Global updates

Background

• New variants of COVID-19 such as the United Kingdom B.1.1.7 variant and the New York B.1.526 make up a majority of new cases Covid cases see in major cities like New York City.

• The Big question regarding these strains is whether they will be able to break through the existing COVID-19 vaccines produced by Moderna and Pfizer.

• This case series studies two patients who suffered vaccine breakthrough after complete SARS-CoV-2 vaccination.

Methods:

• 417 and vaccinated employees of the Darnel Rockerfeller University were enrolled in this study

• Two employees subsequently developed COVID-19 symptoms at least two weeks after their second dose.

• Patient histories were collected and Saliva samples were used to detect viral load and variant characteristics.

Results:

• Patient 1 demonstrated E484K and DG14G mutation, and Patient 2 demonstrated D614G and S477N Mutations.

• Patient 1's serum demonstrated high titers of neutralizing antibodies, consistent with a vaccine response.

• Further testing demonstrated that patient serum was able to recognize the E484K mutant and B1.526 variant, but was unable to prevent breakthrough infection

Discussion:

• Demonstration of new COVID varients to breakthrough neutralizing antibodies provided by vaccination has been demonstrated here and elsewhere in the literature with variants such as the South Africa Variant.

• While previous COVID-19 vaccination provides some resistance to new COVID strains, it may not prevent breakthrough infection in all cases.

• Continued effort to enforce layers of mitigation is crucial in bringing this pandemic to an end.

Conclusions and Limitations:

• This study is a relatively small case report including two patients.

• Extensive workup was conducted on only one patient, and relevant literature detailing similar cases was cited.

• This study highlights the importance of maintaining high vigilance after vaccination. Continued efforts are crucial in the prevention of the proliferation and selection for new resistant mutations.

Background

• New South Wales (NSW), which has 8 million residents, and other jurisdictions appear to have successfully suppressed COVID-19 transmission after rapid escalation of cases in March 2020

• First four cases in NSW were identified in Sydney in late January, all linked to Wuhan outbreak; infected people were isolated and their contacts quarantined, and no transmission linked to these cases was detected

• Travel from China into Australia was restricted on Feb. 1; next new cases in NSW were detected in late February, linked to travelers from Iran and their contacts; as international spread increased, people returning from overseas travel, especially to the U.S. and Western Europe, represented most cases

• In late March, another upswing in cases occurred resulting from infections acquired on cruise ships

New South Wales Government Efforts

• The NSW government based their response on previous pandemic planning informed by SARS and H1N1

• On Jan. 21, the NSW Ministry of Health opened its Public Health Emergency Operations Centre to coordinate case finding, contact tracing, outbreak control, communications, and other actions; staff were drawn from health services, government agencies, universities, and former employees, and over 150 contact tracers were hired

• State Health Emergency Operations Centre was opened to help the state’s 17 local health districts build critical care and emergency department capacity, establish testing clinics, and coordinate the supply of PPE

• The NSW Ministry of Health produced online content and webinars to educate medical providers and others

Australian Government Efforts

• The Communicable Disease Network Australia and its parent organization, the Australian Health Protection Principle Committee (AHPPC), led committees that met daily to review surveillance data and models of projected cases and made recommendations

• The AHPPC advises a national cabinet (with prime minister and first minister of each state/territory) which creates policies, recommends legislation, and implements COVID-19-related laws

• The Australian government has increasingly tightened border-control policies starting Feb. 1; by Mar. 15, entry was restricted to all foreigners

• This was followed by mandatory 14-day quarantine in hotels for residents returning from overseas, closing of borders between some jurisdictions, and bans on gatherings and nonessential travel, all enforced by police

• Most office work and studying is done from home; food outlets restricted to take-away services

• Special attention has been given to increasing testing capacity and broadening access to testing; NSW has one of the highest rates of testing worldwide

• To strengthen contract-tracing efforts, the Australian government launched the app COVIDSafe, which uses Bluetooth to identify close contacts of people infected with COVID-19

Current State and Conclusions

• Current lull in cases in NSW; cases have fallen from 212 on Mar. 27 (peak) to 1 on May 3

• Success may be attributed to Australia’s ability to close its borders, consistent national COVID-19 policies, regular communication with citizens, effective identification and isolation of cases, quarantine of exposed people, and citizens’ compliance with social distancing guidelines

Background

• The province of Bergamo has been the area of Italy most affected by COVID-19 (11,113 confirmed cases and 2932 deaths from COVID-19 as of April 26, 2020)

• Delays in recognizing and isolating patients infected with SARS-CoV-2 and in protecting other patients, healthcare providers, and the community allowed for rapid spread of the virus

• Province not locked down until Mar. 8, two weeks after first documented cases at small hospital in Alzano Lombardo on Feb. 23

• Many who fell ill with COVID-19 were admitted to ASST-Papa Giovanni XXIII, overwhelming hospital capacity and forcing major reorganization led by a crisis team established on Feb. 23

Adaptations Made by ASST-Papa Giovanni XXIII hospital

• Infectious disease unit reconfigured to treat only COVID-19 patients; other patients redistributed or discharged when possible

• Separate COVID-19 units were created in several hospital departments

• On Mar. 28, 498 of 779 beds were occupied by COVID-19 patients; 92 admitted to ICUs and 12 to subintensive critical care

• 25% of staff doctors were redistributed to COVID-19 units at beginning of outbreak, which increased to 70% in the following weeks; all hospital personnel received peer education on COVID-19 management

• ICUs reorganized to increase dedicated COVID-19 beds after exponential growth of cases in first two weeks of outbreak

• By Mar. 9, 49 patients in ICU required mechanical ventilation; 14 ventilators were relocated from operating theaters and 29 additional ventilators were donated; difficult decisions in assigning ventilators to patients were made using a cumulative patient score that took into account the urgency of each patient’s need and the patient’s chance of benefiting from treatment

• Most elective surgeries and transplants were cancelled

• Two of 28 operating theaters remained opened for urgent general and cardiac surgeries

• Of the first 510 COVID-19 patients admitted, 30% died; after several weeks, total hospital mortality dropped from an average of 17-18 (peak of 19) deaths per day to 2 deaths per day, similar to prehospital mortality rate of 2.5 deaths per day on average

Lessons Learned

• All healthcare workers in hospitals, nursing homes, and the community should have been tested for COVID-19 and isolated if they returned a positive test, even if asymptomatic. Clinicians were overlooked in initial identification and isolation efforts of COVID-19 infected people, and complete personal protective equipment was not readily available; 19 doctors in the Bergamo province, all directly involved in the care of COVID-19 patients and aged between 62-74, died, though none worked at ASST-Papa Giovanni XXIII.

• An urgent and decisive regionwide lockdown should have been implemented. This could have helped reduce the number of cases, prevented hospitals from becoming overwhelmed, and limit deaths in the province.

• Africa has so far been largely spared the kind of impact that has thrown China, the United States, and Europe into chaos.

• As of April 13, there were about 14,000 confirmed cases on the African continent, as compared with 160,000 in Italy and more than 560,000 in the United States.

• Despite the slow arrival of Covid-19, a storm is building, and the 1.2 billion people living in Africa are at tremendous risk.

• Most African countries remain woefully unprepared for what’s coming.

• Other obstacles include people living together in close quarters and without access to clean running water

• winter is coming to the Southern Hemisphere, where most of Africa lies, and some experts worry that drier, colder weather may increase viral activity.

• The biggest advantage is time. Heads of state, ministries of health, hospitals, clinics, and community health organizations are taking immediate action.

• Although current estimates suggest a mortality rate of around 2.3%, mortality rates are higher among those who are hospitalized.

• Besides variation in mortality rates among hospitalized and non-hospitalized COVID-19 patients, the fatality ratios may also vary by location. For example, the case fatality rate ranged from 5.8% in Wuhan to 0.7% in the rest of China, with the adjusted case fatality rate in mainland China was 1.4%. The geographical variations in mortality may also be due to the population’s characteristics such as underlying comorbidities or age distribution. For example, in Italy, where the median age of patients with COVID-19 infection is 64 years, the estimated case fatality rate was 7.2% in mid-March. In contrast, the estimated case fatality rate in mid-March in South Korea was 0.9%, where the median age of COVID-19 patients was in the 40's.

• Although Individuals at any age can become infected with COVID-19, middle age and older individuals are most commonly affected, with the median age ranging from 49 to 56 years.

• Furthermore, older individuals are more likely to be affected more severely if infected. In a report from the Chinese Center for Disease Control and Prevention, case fatality rates were 8% in those aged 70-79 years and 15% among those 80 years or older, while the case fatality rate among the entire cohort was 2.3%.

• It is important to understand why death rates were so high in Italy to learn how to best prepare and how to plan for optimal actions in other countries.

• Here are some of the factor that contributed to higher death rates in Italy, some of which may be modifiable factors:

1. Italy has the most elderly population in Europe and the second most elderly population in the world after Japan. The median age of people infected with SARS-CoV-2 who are dying in Italy has been 80 years, and the average age of patients requiring critical care support has been 67 years.

2. Italy has a high proportion of patients with history of smoking and high rates of chronic obstructive pulmonary disease and ischemic heart disease. Thus,preparedness for needs of ICU beds and estimates of expected deaths should consider the age structure and chronic diseases of the population served by each health care system.

3. Increased burden of cases that presented themselves to the health care system in Italy.

4. Italy has a highly competent state-run health care system, but it has only a modest number of ICU beds and very few sub-intensive care beds. Overall, 5090 ICU beds (8.4 per 100 000 population) are available in Italy, and 2601 beds in coronary care units (4.3 per 100 000 population), as opposed to much higher numbers (36 ICU beds per 100 000 population) in the United States.

5. High infection rate of medical personnel possibly due to overcrowding. As of March 30, 2020, 8920 medical personnel had been found to be infected in Italy, leading to further loss of capacity for hospitals to respond.

6. Given the little experience in dealing with the new virus, it is unavoidable that some strategic mistakes were made about which patients should be hospitalized. In the winter, hospitals tend to run close to full capacity, with 87% average occupancy in Italy during the flu season. Apparently, many patients with relatively modest symptoms were admitted, and by the time more patients with severe cases started to arrive, there were limited reserves.

Significance

• During the outbreak of COVID-19, the reduction of outdoor activities and social interaction may have been associated with an increase in children’s depressive symptoms (22.6% during the outbreak vs. 17.2% in other investigations) and anxiety symptoms (18.9% during the outbreak).

Background

• More than 180 million students in China were restricted to their homes due to school closure and quarantine regulations. This study investigated depressive and anxiety symptoms among students in Hubei province, China. The study hoped to present data which could help optimize interventions on the mental health of children for stakeholders in all countries affected by COVID-19.

Methods

• A total of 2330 students in grades 2 through 6 in two primary schools in Hubei province were invited to complete a survey between February 28 and March 5, 2020. The survey link was sent to the guardian’s cellular telephone; the students proceeded to the survey after their guardian had consented. Information included sex, school grade, optimism about the epidemic, whether they worried about being infected by COVID-19, and depressive and anxiety symptoms measured by the Children’s Depression Inventory–Short Form (CDI-S) and the Screen for Child Anxiety Related Emotional Disorders, respectively.

Results

• • There was a 76.6% response rate (1784/2330).

  • Students had been restricted to home for a mean of 33.7 days at survey completion.

  • 22.6% of students (403) reported depressive symptoms and 18.9% (337) reported anxiety symptoms.

  • Students in Wuhan had significantly higher CDI-S scores than those in Huangshi, with a greater risk of depressive symptoms.

  • Students who were slightly or not worried about being affected by COVID-19 had significantly lower CDI-S scores than those who were quite worried, with a decreased risk of depressive symptoms.

  • Those who were not optimistic about the epidemic, compared with those who were quite optimistic, had significantly higher CDI-S scores, with an increased risk of depressive symptoms.

  • There was no significant association between demographic characteristics and anxiety symptoms.

Conclusions

• • 22.6% of students reported having depressive symptoms, which is higher than other investigations in primary schools of China (17.2%).

  • 18.9% of students reported anxiety symptoms, which is higher than the prevalence in other surveys.

  • A limitation is that the study could not evaluate whether these outcomes will be long-lasting after the COVID-19 outbreak.

• WHO’s Solidarity Response Fund has now raised more than 194 million dollars from more than 270,000 individuals, corporations and foundations.

• Easing restrictions is not the end of the epidemic in any country.

• Ending the epidemic will require a sustained effort on the part of individuals, communities and governments to continue suppressing and controlling this deadly virus.

• Countries must now ensure they can detect, test, isolate and care for every case, and trace every contact.

• Early data from some studies suggest that a relatively small percentage of the population may have been infected, even in heavily affected areas – not more than 2 to 3 percent.

• One of WHO’s priorities is to work with partners to increase the production and equitable distribution of diagnostics to the countries that need them most.

• The first shipments of these tests will begin next week, through the United Nations Supply Chain we have established with the World Food Program and other partners.

• Solidarity flights continue to ship lifesaving medical supplies across Africa to protect health workers, who are on the frontlines in the effort to save lives and slow the pandemic.

• Over the past week, WHO has been working closely with the World Food Program to deliver masks, goggles, test kits, face shields and other medical equipment to 40 countries.

• Through April and May, WHO intends to ship almost 180 million surgical masks, 54 million N95 masks and more than 3 million protective goggles to countries that need them most.

• So far, more than 100 countries have joined the Solidarity Trial to evaluate therapeutics for COVID-19, and 1200 patients have been randomized from the first 5 countries.

• Refugees and migrants may have specific vulnerabilities due to the conditions of their migratory journeys, limited employment opportunities, overcrowded and poor living and working conditions with inadequate access to food, water, sanitation, and other basic services.

• Many migrants are often excluded from national programs for health promotion, disease prevention, treatment and care, as well as from financial protection schemes for health and social services.

• WHO has established some guidelines for Member States and partners to contribute to the global public health efforts to prevent COVID-19, which calls for the inclusion of refugees and migrants

Here is a summary of the principal guidelines:

1. The right to the enjoyment of the highest attainable standard of physical and mental health: All states have an obligation to protect and promote the right to health for all people on their territory without discrimination

2. Equitable access to health services and nondiscrimination

3. People-centered, inclusive child- and gender-sensitive health systems for refugees and migrant

4. Equal treatment at the workplace

5. Whole-of-government and whole-of-society approaches and partnership: Preparedness, prevention and control of COVID-19 outbreaks in refugee, migrant and host populations should be considered in the context of broader government policy and coordination between national, local and other levels of government and sectors such as health, sanitation, urban planning, workers' organizations and trade unions.

6. Participation and social inclusion of refugees and migrants: refugees and migrants should be involved and engaged in the design of the national and sub-national COVID-19 readiness and response plans, decision-making

WHO’s recommendations for executing the above guidelines are:

1. Identify/map health and isolation facilities available for refugees, migrants and surrounding populations.

2. Enhance capacity to address the determinants of health to ensure effective COVID-19 preparedness and response actions

3. Accelerate progress towards achieving universal health coverage.

4. Improve preparedness and resilience to public health crises, and adapt all-hazards approach in prioritizing the preparedness, prevention and control of COVID-19 for refugees, migrants and host population

5. Strengthen international cooperation on the health of refugees and migrants

6. Prevent human-to-human transmission and reduce mortality and morbidity from COVID-19 among refugee, migrant and their host populations

7. Include refugees and migrants in COVID-19 surveillance and health information systems.

8. Respond to COVID-19 outbreaks in refugee and migrant populations

9. Prepare for a surge in the demand for health-care facilities and their use to ensure the provision of essential services and continuity of care and referrals for refugees and migrants

10. Strengthen community hygiene, particularly in informal urban areas and settlement

11. Increase public health capacity for immigration and border/port health staff.

12. Support measures to improve communication and counter xenophobia

13. Provide culturally and linguistically appropriate, accurate, timely and user-friendly information in accessible formats on the health facilities available for COVID-19 care

14. Identify and work with groups able to communicate well with refugees and migrants.

15. Provide functional basic utilities such as water, sanitation and hand washing facility) by employers for all workers including refugee and migrant workers

• According to a directive given by China’s Ministry of Education’s science and technology department, China has imposed restrictions on publications regarding the origin of COVID-19

  • Studies on the origin of the virus must go through central government officials before being approved

• The paper first goes to the respective university’s academic committee, which then sends it to the Education Ministry’s science and technology department, and from there to a task force under the State Council

  • Once the university hears back from this task force, only then can they publish the paper

• Takeaway: The international research community should be aware that papers surrounding COVID-19 put forth by Chinese researchers will now have been “double-checked” by the Chinese government before their publication

• The three COVID-19 stimulus bills that Congress has passed provide additional funding for hospitals and for free coronavirus testing for the uninsured through Medicaid.

• To date, few specifics on the new policy for covering COVID-19 treatment costs of uninsured patients have been released, but administration officials have said that hospitals would get reimbursed at Medicare rates, which are substantially lower than prices paid by private insurers.

• The administration has not provided any cost estimates for this new policy, other than stating that the funding will come from the $100 billion in the CARES Act.

• Some analyses estimate the total cost to be between $13.9-$41.8 billion.

• Globally, nearly 1.5 million confirmed cases of COVID-19 have now been reported to WHO, and more than 92,000 deaths.

• In the past week, there has been a slowing in some of the hardest-hit countries in Europe.

• However, there has been an alarming acceleration in other countries.

• In Africa, we are seeing the spread of the virus to rural areas.

• Some countries are already planning the transition out of stay-at-home restrictions. Lifting restrictions too quickly could lead to a deadly resurgence.

• WHO is working with affected countries on strategies for gradually and safely easing restrictions.

• In some countries, there are reports of more than 10 percent of health workers being infected.

  • Evidence shows that some health workers are being infected outside health facilities, in their homes or communities.

  • However, the evidence also shows that when health workers wear personal protective equipment the right way, infections can be prevented.

• Within health facilities, common problems are the late recognition of COVID-19, or lack of training or inexperience in dealing with respiratory pathogens.

• The new United Nations Supply Chain Task Force will coordinate and scale up the procurement and distribution of personal protective equipment, lab diagnostics and oxygen to the countries that need it most.

  • The associated costs will be substantial. The WFP estimates it will need approximately $280 million, simply to cover the costs of storing and moving supplies. The costs of procuring supplies will be much greater.

  • WHO urges donors to support this vitally important system and calls on all donors to support the World Food Programme.

• Chief among the world’s most vulnerable people are refugees and migrants.

• The COVID-19 crisis puts these groups at enormous risk since the appalling conditions of migrant camps are fertile for infectious disease outbreaks, and with extreme overcrowding, physical distancing is impossible.

• There are millions of refugees and migrants in camps and detention centers worldwide.

• Resettlement procedures have been suspended by the UN.

• 34 countries hosting substantial refugee populations have seen local transmission of SARS-CoV-2.

• 80% of refugees live in low-income and middle-income countries, the sites of the expected fourth wave of COVID-19 behind China, Europe, and the USA. Already, these settings have weak health-care systems, scarce protective equipment, and poor testing and treatment capacity. They need enormous global support to prepare for an impending crisis.

• 92% of the public report engaging in social distancing such as cancelling travel and avoiding large gatherings – up from 59% a few weeks ago.

• 4 in 10 (39%) Americans say they lost a job or income due to the coronavirus, including most part-time workers and nearly half of parents and those paid hourly or by the job.

• As COVID-19 cases climb and job losses mount, 45% of the public say their mental health is suffering, up from 32% a few weeks ago.

• 57% of adults are worried they could expose themselves to coronavirus because they can’t afford to stay home from work – up from 35% a few weeks ago.

• More than 1 million confirmed cases of COVID-19 have now been reported to WHO, including more than 50,000 deaths.

• The restrictions many countries have put in place to protect health are taking a heavy toll on the income of individuals and families, and the economies of communities and nations.

• If countries rush to lift restrictions too quickly, the virus could resurge and the economic impact could be even more severe and prolonged.

• Several countries are suspending user fees and providing free testing and care for COVID-19, regardless of a person’s insurance, citizenship, or residence status.

• Suspending user fees should be supported with measures to compensate providers for the loss of revenues.

• As people are asked to stay at home, the risk of intimate partner violence is likely to increase.

• Women in abusive relationships are more likely to be exposed to violence, as are their children, as family members spend more time in close contact, and families cope with additional stress and potential economic or job losses.

• WHO calls on countries to include services for addressing domestic violence as an essential service that must continue during the COVID-19 response.

• New York: In New York City, governor Andrew Cuomo warned state residents to expect a high death rate through July.

  • Mayor Bill de Blasio has warned that city hospitals are in dire need of millions of masks, hundreds of thousands of gowns and hundreds of ventilators, and could run out of supplies by April 5.

• New Jersey: Seven hospitals in New Jersey reached capacity Wednesday and were forced to divert COVID-19 patients to other hospitals.

• CDC Considers Recommending Everyone Wear a Mask in Public: The Centers for Disease Control and Prevention is reconsidering its advisory that people should not wear masks — advice that was initially aimed at preventing a run on personal protective equipment, which is already in short supply.

• Philippines: In the Philippines, authoritarian President Rodrigo Duterte ordered soldiers to shoot to kill residents if they resist a strict lockdown on the island of Luzon.

• Italy: In Italy, COVID-19 deaths have topped 13,000, but The Wall Street Journal reports Italy’s true toll is far higher because the country can’t spare the resources to test every dead body. U.S.

  • Vice President Mike Pence said models predict the United States faces a trajectory of COVID-19 deaths similar to Italy’s.

Reviewed by Fatemeh Sadeghifar on 4/3/20.

• Over the past 5 weeks, there has been a near exponential growth in the number of new cases.

• The number of deaths has more than doubled in the past week. In the next few days, we will reach 1 million confirmed cases, and 50 thousand deaths.

• WHO has called on governments to put in place social welfare measures to ensure vulnerable people have food and other life essentials during this crisis.

  • For developing countries that might struggle to implement social welfare programs, debt relief is essential to enable them to take care of their people and avoid economic collapse.

• 74 countries have either joined or are in the process of joining the Solidarity trial, which is comparing four drugs and drug combinations as a potential treatment for COVID-19.

  • As of 4/1, more than 200 patients had been randomly assigned to one of the study arms.

Reviewed by Fatemeh Sadeghifar on 4/1/20.

• The large number of COVID-19 cases in Italy poses a serious threat to the Italian national health system. The Italian Government introduced mitigation measurements on March 9 and March 11, 2020, to drastically limit social interactions and prevent virus diffusion.

• Projections before March 8, predicted more than 30,000 cases by March 15, 2020. Real data suggest a slight deviation from those predictions, with a recorded number of 24,747 cases by March 15,2020, suggesting that measures introduced by March 11, 2020, began reducing the number of new cases within 3–4 days.

Reviewed by Fatemeh Sadeghifar on 3/31/20.

• A new public charge rule went into effect on February 24, 2020, stating that “aliens are inadmissible to the United States if they are unable to care for themselves without becoming public charges.”

• On the day of its implementation, there were 14 cases of Covid-19 in the United States. Now, with more than 30,000 U.S. cases confirmed, the following message is found on the U.S. Citizen and Immigration Services (USCIS) Public Charge web page: “USCIS encourages all those, including aliens, with symptoms that resemble Coronavirus Disease 2019 (Covid-19) (fever, cough, shortness of breath) to seek necessary medical treatment or preventive services. Such treatment or preventive services will not negatively affect any alien as part of a future Public Charge analysis.”

Reviewed by Fatemeh Sadeghifar on 3/30/20.