Another week of the pandemic has ended with continued improvement in COVID-19 case counts in the U.S. and in many places worldwide. This week we look at cases in children, new publications for schools, scientific articles and case reports, and vaccine updates. But, above all we hope you are safe not only from COVID-19, but also from the harsh winter weather the country is experiencing.
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1) Children and the B117 Variant
In December 2020, the BMJ published a question and answer session with information from the UK’s New and Emerging Respiratory Virus Threats Advisory Group (NERVTAG). At the time, U.K. case counts were climbing and there was a visible increase in pediatric illness. The question “are children more susceptible to the new variant?” was posed and the answer given, yes. Preliminary data showed an increase in pediatric case counts that was higher than what was seen in adults at the time. The theory was that the virus had mutated to allow it to infect children with the same veracity as adults. This week, a new study published in the journal Lancet reviewed pediatric data from a single hospital in London. They compared hospitalizations of children from March 1 -May 31, 2020 and Nov 1, 2020-Jan 19, 2021. They found an increase in the total number of children hospitalized (from 20 to 60), while adult hospitalizations increased “about a third”. Although case counts were higher, disease severity was not. They concluded there was “no evidence of more severe disease having occurred in children and young people during the second wave, suggesting that infection with the B.1.1.7 variant does not result in an appreciably different clinical course to the original strain. ” It is welcome news for countries with increasing levels of the B117 variant .
2) CDC and School Opening
Late last week, the CDC published it’s Operational Strategy for K-12 Schools. The new system replaces previous recommendations published by the CDC in September 2020. Although the recommendations have received considerable criticism, they continue to encourage decision making based on local community conditions, school conditions, and stakeholder input. Beyond that, the framework provides some helpful information:
- The 5 indicator level has been reduced to 4 levels – low, moderate, substantial, and high
- Indicator levels are based upon either total new cases per 100,000 in the past 7 days OR percent of NAATs that are positive over the past 7 days (NAAT is a test category that encompasses PCR but not rapid antigen tests)
- Low and moderate transmission levels come with a recommendation to keep schools open, while substantial and high transmission levels come with hybrid and virtual school recommendations, respectively
- Recommendations reinforced the need for testing of symptomatic and exposed students, teachers, and staff. They also supported decisions by some schools to conduct weekly screening testing.
- Recommendation to consider giving high priority to teachers in early phases of vaccine distribution, but not to make this a requirement of reopening.
- Recommendation to continue social distancing and mask use even when local transmission is low, and when teachers have been vaccinated
- Publication of the CDC’s COVID-19 Integrated County View, allowing easy access to local transmission data
Additionally, the CDC made several strong statements in support of schools, including:
- “It is critical for schools to open as safely and as soon as possible, and remain open, to achieve the benefits of in-person learning and key support services.”
- “In short, success in preventing the introduction and subsequent transmission of SARS-CoV-2 in schools is connected to and facilitated by preventing transmission in communities.”
- “K-12 schools should be the last settings to close after all other mitigation measures in the community have been employed, and the first to reopen when they can do so safely.This implies that schools should be prioritized for reopening and remaining open for in-person instruction over nonessential businesses and activities.“
- “Schools that are open for in-person instruction (either fully open or hybrid) may decide to remain open even at high (red) levels of community transmission.”
- “A decision to remain open should involve considerations for further strengthening mitigation strategies and continuing to monitor cases to reassess decisions. This should be driven by a “classroom-first” approach; in-person instruction should be prioritized over extracurricular activities including sports and school events, a common source of school transmission, to minimize risk of transmission in schools and protect in-person learning.”
A summary of the phased mitigation published by the CDC can be found here. The full version, published online and regularly updated, can be found here. Overall, the guidelines are strongly supportive of schools and teachers. They also provide a framework while overtly stating that schools can choose to ignore them or modify them based upon local variance and community support. Overall, they serve as a good foundation for a reopening program, and are similar to guidelines for schools already published by several states.
3) COVID-19 and the NFL
The CDC published a report of the NFL’s experience with COVID-19. The report details the mitigation strategies the NFL utilized at the start of the season, and the subsequent modifications made as their experience with transmission improved. The NFL used aggressive contact tracing, a strict mitigation protocol, and Kinexon proximity devices. Despite these measures, they experienced a mid season outbreak. After reviewing all available proximity device data and contact tracing, they concluded that transmission occurred even when total exposure time was < 15 minutes. Based on that, they intensified their protocol but also added considerations for mask use/adequacy (both parties, mask type, etc) AND ventilation. Ultimately, they reduced transmission by performing the following:
- Intensive protocol focused on environmental change
- Increased personal protection
- Avoidance of high-risk interactions such as vehicle sharing, eating in the same room or common areas
- Expansion of the components of contact tracing to incorporate high-risk contact designations
- Accounting for mask adequacy in contact tracing
- Accounting for ventilation in contact tracing (indoor vs outdoor)
The CDC concluded that “although the protocols implemented by the NFL were resource-intensive, strategies such as accounting for specific characteristics of the close contact, in addition to time and duration, and creation of an intensive protocol are applicable to other settings, including essential workplaces, long-term care facilities, and schools.”
4) Reinfection with South African Variant
A case study was published this week in the journal Clinical Infectious Disease. It details the French case of a 58 yo male with only a history of asthma who was infected with COVID-19 four months prior to becoming infected a second time. The first infection is reported to have been mild. The second one led to admission to the ICU and placement on a ventilator. Also, the second infection was confirmed to be due to the South African variant. Unfortunately, the variant of the virus responsible for his first infection is not known. This report is only one case, but suggests that prior infection does not guarantee immunity against the South African variant, even in people with healthy immune systems.
5) Is the B117 (UK) Variant More Lethal In Adults ?
A report from the UK published Feb 12th attempts to summarize their experience to date with the nw B117 variant. The publication examines multiple studies across the UK in attempt to draw conclusions about the severity of the B117 variant compared to the original strain. Though there were conflicting findings and limitations to the data sets from multiple studies, the report concluded:
“Based on these analyses, it is likely that infection with VOC (variant of concern) B.1.1.7 is associated with an increased risk of hospitalisation and death compared to infection with non-VOC viruses.”
A new publications in the journal Cell this week also suggests that antibodies from people who have recovered from COVD or received the Pfizer or AstraZenica vaccines may be less effective at neutralizing the B117 variant.
6) Pfizer Vaccine and B1351
A publication in the New England Journal of Medicine this week suggests that the Pfizer vaccine may be less effective against the B1351 variant. The study tested human serum from 15 vaccinated people. Similar findings were published about the Moderna vaccine earlier in the year (see Jan. 29th newsletter, item #4). Although these laboratory tests are helpful, the clinical application (real world performance) remains unclear.
7) AstraZeneca Authorization by the WHO
This week the WHO authorized the AstraZeneca COVID vaccine, granting it emergency use authorization. The vaccine can now officially become a part of the United Nations backed COVAX effort, with over 180 countries participating. A good summary about why this matters appeared in Axios. Yesterday, the White House announced the U.S. will be contributing $2 billion to the COVAX effort with an additional $2 billion over the next 2 years.
8) Israel Confirms Pfizer Vaccine Efficacy
An HMO in Israel, Clatit, publicized its survey results of over 1.2 million people living in Israel, half of whom have received the Pfizer vaccine. They found the vaccine reduced symptomatic COVID infections by 94%, confirming Pfizer’s published trial data. Israel leads the world in the percentage of its population that has been vaccinated, currently reported at 70 per 100 people.
9) WHO working to define Long-COVID
The WHO reports that it assembled a group of patients, clinicians, and other stakeholders to study “post-COVOD-19 condition”, also known as “long COVID”. They hope to develop a definition for the condition which currently includes a multitude of symptoms that may persist after infection with COVID-19.
10) PTSD and COVID-19
Anxiety and PTSD are well known complications of numerous illnesses including stroke, heart attacks, and almost any disease requiring ICU treatment or extended hospitalization. A new study published in the Journal of the American Medical Association, Psychiatry. In the study, 381 patients who recovered from COVID were assessed for post traumatic stress disorder (PTSD). Patients has a mean hospitalization duration of 18 days. Results showed that 115 (30%) met criteria for PTSD. Of those patients, 40 people (34%) reported a prior history of psychiatric illness, and 72 (62%) had persistent medical symptoms post-COVID. This study highlights the continued impact of COVID and prolonged hospitalization on patients who recover.
11) Are We Nearing Herd Immunity?
An opinion piece appeared in the WSJ yesterday, written by Dr. Makary from the Johns Hopkins School of Medicine and Bloomberg School of Public Health. He makes the argument that the U.S. may be closer to herd immunity than experts claim. The lack of good data on antibody or T Cell immunity in the general public remains a stumbling block. However, Dr. Makary makes a coherent case for natural immunity being at least partly responsible for the continued decrease in cases nationwide. His prediction is that the virus will be at negligible levels by April. I certainly hope that is the case.
12) FDA and Fraudulent COVID Products
The FDA is now publishing a list of letters to “firms for selling fraudulent products with claims to prevent, treat, mitigate, diagnose or cure coronavirus disease 2019 (COVID-19). ” The list is published online and continuously updated. The same website includes a link for anyone to report a website that they believe is illegally selling human drugs, animal drugs, medical devices, biological products, foods, dietary supplements or cosmetics.