News Scan for Jun 07, 2021

News brief

Trial of rapid respiratory tests finds no reduction in antibiotics

The use of rapid respiratory pathogen (RRP) testing among children with influenza-like illness (ILI) did not reduce antibiotic prescribing, according to a randomized clinical trial published late last week in JAMA Network Open.

The single-center trial, conducted by investigators with the University of Colorado School of Medicine and Children's Hospital Colorado, involved children aged 1 month to 18 years who presented to the emergency department with ILI from Dec 1, 2018, to Nov 30, 2019. All children received a nasopharyngeal swab for RRP testing and were randomized 1:1 to an intervention group, in which the emergency department (ED) clinician and families of children received test results, and a control group that did not. The primary outcome was antibiotic prescribing during the ED visit. Secondary outcomes included antiviral prescribing, ED length of stay, and hospital admission.

The cohort consisted of 908 children, with 452 in the intervention group and 456 in the control group. The median age was 2.1 years, and there were no significant differences in demographic and clinical characteristics between the two groups. Positive RRP test results were obtained for 795 of 931 visits (85%). The most common pathogens were enterovirus (n=295), influenza (180), respiratory syncytial virus (162), and adenovirus (115).

In the intention-to-treat (ITT) intervention group, children were more likely to receive antibiotics (relative risk [RR], 1.3; 95% confidence interval [CI], 1.0 to 1.7), with no significant differences in antiviral prescribing, medical visits, and hospitalization. In a modified ITT analysis, children whose clinician knew the RRP test results were more likely to receive antivirals (RR, 2.6; 95% CI, 1.6 to 4.5) and be hospitalized (RR, 1.8; 95% CI, 1.4 to 2.5) than those whose clinicians did not know the test results, but antibiotic prescribing was not significantly different (RR, 1.1; 95% 0.9 to 1.4).

"The results of this randomized clinical trial show that RRP testing for children with acute respiratory illnesses in an ED setting did not lead to a decrease in antibiotic prescribing," the study authors wrote. "The greatest effect on clinicians' clinical decision-making was appropriate antiviral use for children based on influenza test results, supporting the potential benefit for rapid molecular influenza testing in this setting."
Jun 4 JAMA Netw Open study

WHO formally recommends Johnson & Johnson's Ebola vaccine

The Strategic Advisory Group of Experts (SAGE) on Immunization for the World Health Organization (WHO) formally supports the use of Johnson & Johnson's two-dose Ebola vaccine regimen, Zabdeno (Ad26.ZEBOV) and Mvabea (MVA-BN-Filo), both during outbreaks for individuals at risk for Ebola exposure and before outbreaks for first responders, according to a press release today from Johnson & Johnson.

"Our vision is to stop Ebola outbreaks before they start," Johnson & Johnson said in the release. "Johnson & Johnson accelerated the development of an Ebola vaccine during the 2014 Ebola crisis. Since then, we have sponsored 15 clinical trials across three continents that have demonstrated the regimen to be safe and capable of inducing an immune response."

The announcement comes on the heels of the WHO prequalification of the vaccines in April. The vaccines were developed following the 2014-2016 West African Ebola outbreak and have been used in Rwanda and the Democratic Republic of the Congo since 2018 on an emergency basis during outbreaks in both countries.

Johnson & Johnson said it is now focused on securing national registrations for the vaccine in Ebola-affected countries in Africa. To date, more than 235,000 people have received at least the first dose of the Ebola vaccine, including 190,000 who have been fully vaccinated with both doses.
Jun 4 Johnson & Johnson statement

COVID-19 Scan for Jun 07, 2021

News brief

COVID-19 pandemic linked with worse mental health in teens

In a population study of 13- to 18-year-old Icelandic teens, mental health worsened during the COVID-19 pandemic, according to a study late last week in The Lancet Psychiatry.

The researchers analyzed 59,701 survey responses across two pre-pandemic baselines (2016, 2018) as well as during the pandemic (October 2020) and found that depressive symptoms increased (β 0.57; 95% confidence interval [CI], 0.53 to 0.60) and mental wellbeing worsened (β 0.46; 95% CI, -0.49 to -0.42). The outcomes were significantly worse in girls than in boys (β 4.16 and -1.13, respectively).

Depression was measured with the Symptom Checklist-90, and data showed that symptoms significantly increased over time, with a 3.2% increase between 2016 and 2018 and a 9.5% increase between 2018 and 2020. Similarly, mental wellbeing significantly worsened, with an average decrease of 1.6% between 2016 and 2018 and a 5.4% decrease between 2018 and 2020, according to the Short Warwick Edinburgh Mental Wellbeing Scale.

The researchers also note that, across both sexes, cigarette smoking, e-cigarette smoking, and alcohol intoxication declined by an odds ratio of 2.61, 2.61, and 2.59 in teens 15 to 18, perhaps because of isolation.

"[The] results underline the significance of social relationships in the health and well-being of youth and the importance of nurturing and maintaining strong social support mechanisms in their lives," said coauthor Alfgeir L. Kristjansson, PhD, in a Columbia University press release.

"The pandemic might have exacerbated trends already present in the adolescent population, thereby highlighting the status of adolescents’ mental health," writes Gertrud Sofie Hafstad, PhD, and Else-Maria Augusti, PhD, in a commentary. "Moreover, the present study together with other similar studies shows the importance of closely monitoring indicators of risk and resilience, as it enables timely efforts to mitigate the risk for development of mental disorders during adolescence."
Jun 3 Lancet Psych study and commentary
Jun 3 Columbia University press release

Cancer associated with worse COVID-19 hospitalization outcomes

Hospitalized COVID-19 patients with active cancer are more likely to die than those who have a history of cancer or those who have never received a cancer diagnosis, according to a Cancer study today.

The researchers performed chart reviews on 4,184 COVID-19 patients admitted to the NYU Langone Medical Center from Mar 1 to May 15, 2020, of whom 233 (5.6%) had an active cancer diagnosis and available records and 493 (11.8%) had a history of cancer.

Those with an active diagnosis were more likely to die from COVID-19 (34.3%) than those with a history of cancer (27.6%) or without any cancer (20.0%), data showed. When including intensive care unit (ICU) admission in addition to death, the researchers found that patients with active cancer had higher rates than those without (31.4% vs 39.5%), while no statistically significant relationship was found when comparing active and historical cancer patients.

Although the researchers note that no cancer therapy received within 3 months prior to hospitalization was associated with increased mortality risk, blood-related cancers had the highest mortality risk among cancer types (47.8% vs 28.7%).

Overall, independent risk factors for death were significantly associated with active cancer (odds ratio [OR], 1.89), older age (OR, 1.06), male sex (female vs male OR, 0.70), diabetes (OR, 1.26), morbidly obese body mass index (OR, 1.87), and elevated D-dimer levels, a marker of inflammation (OR, 6.41). While an increased risk was seen in patients with a history of cancer, it was not statistically significant.

"In summary, we found that patients with active cancer had an increased risk of death from COVID-19 independent of age, peak D-dimer levels, and other covariates," write the researchers. "Our finding that both D-dimer levels and active cancer independently predict worse outcomes suggests that cancer likely affects outcomes through mechanisms beyond just its prothrombotic effects."
Jun 7 Cancer study

Increased mucormycosis (black fungus) cases tied to COVID uptick

Mucormycosis (black fungus) cases rose 2.1-fold from September to December 2020 compared with corresponding months the year prior because of underlying COVID-19, according to a study last week in Emerging Infectious Diseases.

Mucormycosis is a fungal infection that causes different symptoms depending on where it manifests. In this study's cohort, most cases of COVID-associated mucormycocis (CAM) were in the rhino-orbital system (58.1%), followed by the rhino-orbito-cerebral (27.2%) and pulmonary systems (7.7%), and the case-fatality rate was 45.7% at 12 weeks.

The study consisted of 287 patients hospitalized from Sep 1 to Dec 31, 2020 in 16 healthcare centers in India, of whom 65.2% had CAM, and the rest had non–COVID-associated mucormycosis. Median time to CAM diagnosis was 18 days. Patients had a mean age of 53.4 years and were mostly men (74.6%), although CAM patients were older (average, 56.9 years) and skewed even more toward men (80.2%). The most common comorbidity was diabetes (62.7%).

The researchers calculated 0.3% CAM prevalence among patients from seven centers with the necessary data, which increased to 1.6% in intensive care unit (ICU) settings. Excluding the number of CAM cases, the researchers add, the number of mucormycosis cases in 2020 would be comparable to those in 2019 (92 vs 112).

Overall, age above 54 years, ICU admission, and Mucorales infection of the pulmonary system or the brain all were independently associated with mortality. The development of late CAM was also associated with hypoxemia due to COVID-19 and inappropriate glucocorticoid use—data showed only 33.6% of CAM patients received steroids at appropriate levels.

Sequential use of antifungal drugs improved survival regardless of where the mucormycosis manifested.

"We found no difference in the risk factors, site of involvement, and outcome of mucormycosis complicating COVID-19 cases compared with non–COVID-19 cases," write the researchers. "Nevertheless, the prevalence of mucormycosis has increased greatly in India, coinciding with the country’s COVID-19 epidemic. Clinicians should be vigilant for mucormycosis in the patients recovering from COVID-19 illness, especially among patients with new or previously diagnosed diabetes mellitus and clinical manifestations of facial or orbital pain or black or blood-stained nasal discharge."
Jun 4 Emerg Infect Dis study