COVID-19 Scan for Dec 15, 2020

News brief

UK trial finds no benefit from azithromycin in hospital COVID-19 patients

Investigators with the United Kingdom's RECOVERY trial reported yesterday that a preliminary analysis of data from the azithromycin arm of the trial showed the antibiotic had no impact on clinical outcomes in hospitalized COVID-19 patients.

In the trial, which was conducted among COVID-19 patients at 176 National Health Service hospitals, 2,582 patients were randomized to receive 500 milligrams of azithromycin, an antibiotic, once daily and compared with 5,182 patients who received usual care. Patients entered the study an average of 8 days after onset of symptoms. The primary outcome was 28-day mortality, and the results, which were not peer-reviewed, were published on medRxiv, a preprint server.

Preliminary analysis of the data showed that 496 patients who received azithromycin (19%) and 997 patients allocated to usual care (19%) died within 28 days (rate ratio, 1.00; 95% confidence interval, 0.90 to 1.12; P = 0.99). Investigators also found no evidence of beneficial effects on the risk to progression to mechanical ventilation or length of hospital stay.

Azithromycin is one of several treatments for COVID-19 being tested in the RECOVERY trial, under the theory that it could reduce lung inflammation.

"Our results show very clearly that for patients hospitalised with COVID-19 azithromycin is not an effective treatment," Peter Horby, MD, PhD, chief investigator for the trial and a professor of emerging infectious diseases and global health at the University of Oxford, said in a press release. "While that is disappointing, it is nonetheless an important result that will guide clinical care around the world."

The investigators concluded that azithromycin should be used in COVID-19 patients only when antimicrobials are clearly indicated.
Dec 14 medRxiv study
Dec 14 RECOVERY trial press release

High risk of death, readmission found after hospitalization for COVID-19

A JAMA study yesterday of veterans hospitalized for COVID-19 found that the first 10 days after hospitalization are the most dangerous for patients, with a 40% to 60% higher risk of death or readmission compared with similar patients treated for pneumonia or heart failure.

A research team from the University of Michigan and Veterans Administration (VA) Ann Arbor Healthcare System compared outcomes for 2,179 veterans hospitalized for COVID-19 and discharged from 132 US VA hospitals from Mar 1 to Jul 1 with nearly 5,300 similar patients hospitalized for non–COVID-19 pneumonia and heart failure during the same period.

All but 5% of the patients were male, and half were black, both of which represent groups at high risk of severe COVID-19. Overall, 18.5% of COVID-19 patients died during their hospital stay.

The researchers found a 43% higher risk of readmission or death for patients with COVID-19 in the first 10 days after discharge compared with similar patients with non–COVID-19 pneumonia (hazard ratio [HR], 1.43; 95% confidence interval [CI], 1.09 to 1.87) and a 62% higher risk compared with similar patients with heart failure (HR, 1.62; 95% CI, 1.31 to 2.01). Overall, 9% of discharged VA COVID-19 patients died and 20% required readmission—most often for COVID-19 complications and sepsis, or an extreme reaction to infection—in the 60 days after hospital discharge.

"The study suggests a need for special vigilance in the first days after discharge," lead author John P. Donnelly, PhD, said in a University of Michigan news release.

"Unfortunately, this is yet more evidence that COVID-19 is not 'one and done,'" coauthor Theodore J. Iwashyna, MD, PhD, said in the news release. "For many patients, COVID-19 seems to set off cascades of problems that are every bit as serious as those we see in other diseases. But too little of our healthcare response—and too little research—is designed to help these patients as they continue for days, weeks, even months to recover from COVID-19."

The study authors advocate for better discharge plan design, communication, and post-hospital care.
Dec 14 JAMA study
Dec 14 University of Michigan news release

Low risk of severe COVID-19 noted for young kids

A French study in Pediatrics today reports a low risk of severe COVID-19 for children less than 3 months old and points to low blood oxygen levels and high levels of inflammatory proteins as reliable predictors of severe disease in children.

Researchers conducted a surveillance study of 60 hospitals—representing 38.5% of French children hospitalized with SARS-CoV-2. They identified 397 infected children hospitalized from Feb 15 to Jun 1, including 385 children with reverse-transcription polymerase chain reaction (RT-PCR)–confirmed infection and 12 diagnosed via characteristic chest CT-scan lesions. Severe disease was defined as the need for ventilatory or hemodynamic support—efforts to restore blood volume and flow to improve oxygen delivery.

Although infants less than 3 months old were the main group requiring hospitalization in this study (37% of all cases), only 3% had severe disease. Nearly all (92%) of these infants presented with a fever, and the authors noted that hospitalization was a precaution for possible bacterial infection for most of them.

"The use of a rapid test at the bedside to identify SARS-CoV-2 would be helpful to improve the care of these children in pediatric emergency departments," the authors wrote.

Excluding children with multisystem inflammatory syndrome—a severe COVID-19 complication—and those hospitalized for reasons unrelated to SARS-CoV-2, only 11% of children overall had severe disease (23 of 306), 6 of whom died. While 29% of children in the study had comorbidities, including compromised immune function or chronic respiratory or cardiac diseases, these were not associated with severe disease.

"Our findings suggested that the rate of severe forms was the lowest in very young children and was the highest for children ≥ 10 years," the authors wrote.

In addition to age greater than 10 years (odds ratio [OR], 3.4; 95% confidence interval [CI], 1.1 to 10.3), other independent risk factors were low blood oxygen at admission (OR, 8.9; 95% CI, 2.6 to 29.7; P = 0.0004) and elevated levels of the inflammatory marker C-reactive protein (OR, 6.6; 95% CI, 1.4 to 27.5; P = 0.012). The authors suggest that monitoring these clinical markers could help identify children at higher risk for increased surveillance and support.
Dec 15 Pediatrics study

News Scan for Dec 15, 2020

News brief

First CWD case in wild deer in Ohio triggers mandatory sampling

A sample from a white-tailed deer in Wyandot County, Ohio, tested positive for chronic wasting disease (CWD) Dec 10, according to the Ohio Department of Natural Resources (ODNR) yesterday, the first in a wild deer in the state. A Daily Record report from May says there have been 21 cases of CWD at three captive deer farms in Ohio since 2015.

The new CWD case triggers enhanced surveillance within a 10-mile radius of the harvesting site, which was private property. Additionally, for the rest of the hunting season, which closes next Feb 7, deer samples will be mandated from all harvests in the county's Killdeer Plains Wildlife Area.

CWD is a fatal, neurologic disease affecting the cervid family, which includes deer, elk, and moose. The cause, misfolded prions, are transmitted through body fluids, environmental contamination, and antler velvet. No case has yet been reported in humans.

Ohio hunters can submit samples via authorized taxidermists, like this case, or through authorized processors, DNR drop off sites, or direct arrangements with the Department of Agriculture's Animal Disease Diagnostic Laboratory.
Dec 14 ODNR notice

Black children with severe sepsis have 19% higher death rates

Black children under age 21 with severe sepsis have 19% increased adjusted odds of death compared with white children, finds a study published yesterday in The Lancet Child & Adolescent Health. Hospital stays were also longer for black and Hispanic children (10 days) than white children (8) or children with other racial backgrounds such as Asian and Native American (8).

The researchers analyzed health records for 9,816 children with severe sepsis as reported by the 2016 Kids' Inpatient Database. Overall, the mortality rate was 14.6%, with 18.4% case mortality in black patients, 16.0% in patients with other ethnicities/racial backgrounds, 13.7% in Hispanic patients, and 13.4% in white patients. Despite the higher mortality percentage in children of "other" backgrounds, they had only a 3% increased adjusted likelihood of mortality compared with white patients. Hispanic patients actually had a 4% decreased adjusted likelihood of death.

Across the United States, the greatest disparities for black death rates were in the South (adjusted odds ratio [AOR], 1.30; 95% confidence interval [CI], 1.04 to .62) and the West (AOR, 1.58; 95% CI, 1.05 to 2.38).

"The results bear witness to a reality that Black children (and their parents) in the USA already know: when other factors are accounted for, they are still more likely than their White counterparts to die, in this case from sepsis," writes Katherine Peeler, MD, a Harvard pediatrician, in a commentary in the same journal. "It is imperative that further research begin to understand why such disparities exist to inform efforts to mitigate them."

Previous studies found that black adults and uninsured patients have higher mortality rates for sepsis, and while this study also found the racial disparity, the AOR between privately and publicly insured children was statistically insignificant. For the 7.7% of children whose payer category was no charge, self-pay, or other, their death rate was 30% higher than for those with public or private insurance.
Dec 14 Lancet Child Adolesc Health study
Dec 14 Lancet Child Adolesc Health commentary

More high-path avian flu confirmed in France, Netherlands, Taiwan

France and Taiwan reported more highly pathogenic avian flu outbreaks in poultry involving different strains, and the Netherlands reported more H5N8 in captive birds, according to the latest notifications from the World Organization for Animal Health (OIE).

France reported three more H5N8 outbreaks in poultry, which affected commercial farms in three departments: Vendee, Deux-Sevres, and Landes, all in the west. The events began on Dec 10 and Dec 11, and, taken together, the virus killed 820 of 14,297 susceptible birds.

In other European developments, France also reported H5N8 in a wild goose found sick on Nov 30 in Morbihan department, and the Netherlands reported another H5N8 detection, this time in captive gamebirds in North Holland province, where the outbreak began on Nov 12, killing two birds.

Taiwan reported four more outbreaks involving H5N5 in poultry, two at slaughterhouses and two on commercial goose farms. The outbreaks began from Nov 13 to Nov 23, and the virus killed 1,450 of 2,918 total susceptible birds.
Dec 14 OIE report on H5N8 in France
Dec 14 OIE report on H5N8 in French wild birds
Dec 14 OIE report on H5N8 in Dutch wild birds
Dec 15 OIE report on H5N5 in Taiwan