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November 6th, 2020


The elections have consumed much of the media attention this week. However, there have been some significant developments in the COVID-19 world. As always, if you were forwarded this newsletter and would like to receive it in your inbox weekly, you may subscribe here.

1) New York State Travel Advisory Changes

Starting Nov. 4th, the State of New York mandatory quarantine has changed. Travelers are now allowed to “test out” of quarantine by following a two test process over the span of 7 days. Testing begins three days before flying. Here is the language from the governor’s website :

For travelers who were in another state for more than 24 hours:

  • Travelers must obtain a test within three days of departure from that state.
  • The traveler must, upon arrival in New York, quarantine for three days.
  • On day 4 of their quarantine, the traveler must obtain another COVID test. If both tests comes back negative, the traveler may exit quarantine early upon receipt of the second negative diagnostic test.

For travelers who were in another state for less than 24 hours:

  • The traveler does not need a test prior to their departure from the other state, and does not need to quarantine upon arrival in New York State.
  • However, the traveler must fill out our traveler form upon entry into New York State, and take a COVID diagnostic test 4 days after their arrival in New York.

In last week’s newsletter, we discussed the problems with using a test based strategy to end quarantine early. You may read that discussion in section 5, here.  The CDC continues to recommend a full 14 day quarantine after travel. There are a few notable points regarding this new policy:

  • International travelers do not have the option to “test out” and are required to quarantine for the full 14 days.
  • Essential workers are exempt, but the New York State list of exempt employees is not as long as the federal government’s list. Teachers are not listed as essential workers on the governor’s website.
  • The new testing protocol does not specify test type, suggesting that rapid testing is an acceptable method for the “test out” protocol.

2) False Positive Antigen Tests

The FDA released a formal statement regarding the likelihood of false positive COVID-19 antigen test results. It includes a discussion of the difference between specificity of a test and the positive predictive value. These are two statistical measurements that are used to characterize the utility of a test. The specificity of a test represents how well a test correctly identifies negative results while sensitivity represents how well is correctly identifies positive results. However, these numbers alone do not tell us how well a test performs when disease levels change. For that calculation, we take into account the prevalence of a disease and the calculation is called a positive predictive value. So, a test with high specificity used in a population with very low disease will yield a significant number of false positives.

The point of the FDA letter was to educate and alert providers to the higher probability of a test being false positive when there is low transmission in the community, and suggests obtaining confirmatory PCR testing if possible.

3) Does Living With Children Increase Your Risk Of COVID-19?

A new study in pre-publication from the U.K. studied the health records of 24 millions people to see if there was any correlation between living with children and contracting, being hospitalized, or dying from COVID-19. Here were their conclusions:

  • Among 9,157,814 adults ≤65 years, living with children 0-11 years was not associated with increased risks of recorded SARS-CoV-2 infection, COVID-19 related hospital or ICU admission but was associated with reduced risk of COVID-19 death.
  • Living with children aged 12-18 years was associated with a small increased risk of recorded SARS-CoV-2 infection, but not associated with other COVID-19 outcomes (hospitalization or death).
  • Living with children of any age was also associated with lower risk of dying from non-COVID-19 causes. (Most adults living with children were younger)
  • Among 2,567,671 adults >65 years there was no association between living with children and outcomes related to SARS-CoV-2.
  • No consistent changes in risk following school closure was observed.

Within the limitations of a retrospective review of health records, this large study provides further positive evidence for those living with or frequently around children.

4) Children and COVID-19

The American Academy of Pediatrics and the Children’s Hospital Association continue to publish COVID-19 data in children on a weekly basis. The detailed report includes data by state. Recent weeks have shown a significant increase in the total number of cases detected in children, similar to the increase in total cases in adults. The percent of cases in children continue to climb slowly as does the number of childhood cases per 100,000. However, the rate of hospitalizations in children has decreased, and the rate of death has remained very low. It is important to note that these numbers are not zero. There is harm to children from the disease, but thankfully it is very small in comparison to what we are seeing in adults.

5) COVID and Wearable Sensor Data

A new study published in Nature Medicine seeks to determine if information from wearable sensors, like smartwatches, can augment screening questionnaires and improve the detection of COVID-19 symptoms early. The study enrolled over 30,000 participants using a mobile app and the number of people who were ultimately tested was 333. Of those, 279 were negative and 54 positive. The study concludes that the combination of wearable data and screening questions does improve early detection of COVID-19. It is an interesting method to provide passive but continuous screening of a large population between tests.

6) COVID-19 Among Grocery Store Employees

A new study in BMJ Occupational & Environmental Medicine studied exposure risk and mental health in a group of grocery retail workers in the U.S.. 104 workers were enrolled and 21 tested positive for COVID-19, with 16 of those being asymptomatic. The study concluded that a large percentage (76%) were asymptomatic and that being exposed to customers increased the risk of COVID-19 by 5 fold. They also concluded that those employees who were able to maintain social distancing had lower levels of anxiety and depression. It is a small but interesting study to read that adds further evidence of significant asymptomatic infection in the population.

7) COVID in Pregnancy

The CDC reported updated surveillance data on pregnant women hospitalized with COVID-19. Early reports had suggested no increased risk to pregnancy women. However, this large review of data form 400,000 women aged 15–44 years with symptomatic COVID-19 suggests otherwise. They found that pregnant women were more likely to be admitted to an ICU (2.7 fold risk), and more than double the risk of receiving advanced methods of oxygenation (ventilators and ECMO). The increased risk of death was approximately 25% (1.5 vs 1.2 per 1000).  The report concludes “Although the absolute risks for severe COVID-19–associated outcomes among women were low, pregnant women were at significantly higher risk for severe outcomes compared with non-pregnant women”.

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