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Yale- Tulane-Sacred Heart ESF-8 Special US Report - COVID-19 5-1-20

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Contributors are students, faculty, and alumni located in a variety of geographic locations from Yale, Tulane, and Sacred Heart Universities. It provides information gathered from situation reports, government and non-governmental organization, media reporting, and a variety of information sources, verifies and synchronizes the information and provide real-time information products to federal, state, local, nongovernmental and international response organizations.

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Yale- Tulane-Sacred Heart ESF-8 Special US Report - COVID-19 5-1-20

  1. 1. YALE-TULANE-SACRED HEART - ESF-8 SPECIAL US REPORT CORONAVIRUS (COVID-19) AS OF 1 MAY 2020 2320 HRS EDT US FEDERAL GOVERMENT • CORONAVIRUS.GOV • USA.GOV HHS COVID-19 CDC • CDC – COVID-19 NIH • COVID-19 NIOSH • NIOSH CORONAVISUS FEMA • FEMA DOD Coronavirus Response USAF _ COVID-19 NEWS SOURCES • New York Times COVID- 19 Coverage • WASHINGTON POST • Reuters • CNN • Xinhua ASSOCIATION • NACCHO • AMERICAN HOSPITAL ASSOCIATION • NRHA PORTALS, BLOGS, AND RESOURCES • YALE NEWHAVEN HEALTH – COVID-19 • YALE MEDICINE • YALE NEWS _COVID 19 • JOHN HOPKINS UNIVERSITY COVID-19 GLOBAL CASES (CSSE) • COVID-19 SURVEILLANCE DASHBOARD • CIDRAP • H5N1 • VIROLOGY DOWN UNDER BLOG • CONTAGION LIVE • WORLDOMETER • 1POINT3ACRES BACKGROUND WHO • WHO –COVID-19 • ECHO • PAHO AFRO • EMRO • Western Pacific OCHA • ReliefWeb ECDC • European Centre for Disease Prevention and Control CCDC • China Center for Disease Control and Prevention INTERNATIONAL JOUNALS AND ONLINE LIBRARIES • BMJ • Cambridge University Press • Cochrane • Elsevier • JAMA Network • The Lancet 2019-nCoV Resource Centre • New England Journal of Medicine • Oxford University Press • Wiley SITUATION - US GLOBAL CONFIRMED CASES DEATHS RECOVERED 3,127,126 313,792 939,223 UNITED STATES CONFIRMED CASES DEATHS RECOVERED 1,102,703 64,739 164,015 HEALTHCARE INNOVATIONS CONTACT TRACING PROGRESS ON TESTING SOURCE: JOHNS HOPKINS COVID-19 DASHBOARD (AS OF 1 MAY 2020, 1932 HRS EDT) Yale-Tulane-Sacred Heart Planning and Response Network RESEARCH / STUDIES RURAL RESPONSE TO CORONAVIRUS COVID-19 AND INCARCERATION RISK ASSESSMENT RISK TO GENERAL POPULATION RISK TO ELDERLY POPULATION RISK TO HEATHCARE SYSTEM CAPACITY MODERATE VERY HIGH HIGH BLOOD CLOTS AND STROKES RACE FOR A VACCINE There have been over 1 million confirmed cases of COVID-19 and 58,348 deaths reported in the United States. 1 in 5 U.S. deaths from COVID-19 have occurred in nursing homes and other long-term care facilities. SITUATION – NURSING HOMES Yale-Tulane-Sacred Heart - ESF-8 Team will be producing a special report dedicated to COVID and nursing homes On Sunday, 3 May 2020.
  2. 2. BACKGROUND WHERE: WORLDWIDE WHEN: DECEMBER 2019 - CURRENT SITUATION PANDEMIC OUTBREAK – COVID-19 BACKGROUND: At the end of December 2019, Chinese public health authorities reported several cases of acute respiratory syndrome in Wuhan City, Hubei province, China. Chinese scientists soon identified a novel coronavirus as the main causative agent. The disease is now referred to as coronavirus disease 2019 (COVID-19), and the causative virus is called severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). It is a new strain of coronavirus that has not been previously identified in humans. The initial outbreak in Wuhan spread rapidly, affecting other parts of China. The International Health Regulations (IHR) (2005) Emergency Committee on the outbreak of COVID-19 was first convened on 22‒23 January 2020, and subsequently reconvened on 30 January 2020. PUBLIC HEALTH EMERGENCY OF INTERNATIONAL CONCERN (PHEIC) The WHO Director General declared the COVID-19 outbreak to be a public health emergency of international concern (PHEIC) on 30 January 2020. The Emergency Committee provided recommendations to WHO, to China, to all countries and to the global community, on measures to control the outbreak. PANDEMIC On 11 March 2020. WHO declared COVID-19 a pandemic because of the “alarming levels of spread and severity, and by the alarming levels of inaction”. At that time, there were large outbreaks of the virus in Italy, South Korea, and the United States. In the US, the slow rollout of testing and limited testing capacity has crippled response to the disease. The declaration came after a 13-fold rise in the number of cases outside China in the two weeks prior to the declaration. The first known case of COVID-19 in the U.S. was confirmed on January 21, 2020, in a man in his 30s from Washington state, who traveled to Wuhan, is diagnosed with novel coronavirus. On 29 January 2020 the White House Coronavirus Task Force was established.On 31 January 2020 , Secretary azar declares a Public Health Emergency for United States for COVID-19. Travel restriction were put into place for those traveling from China . Later restriction were added for Iran and Europe (29 February 2020). On 26 February 2020 the Centers for Disease Control and Prevention (CDC) confirms the first case of COVID-19 in a patient in California with no travel history to an outbreak area, nor contact with anyone diagnosed with the virus. It's suspected to be the first instance of local transmission in the United States. Oregon, Washington and New York soon report their own cases of possible community transmission. By 17 March 2020 COVID 19 was present in all 50 states. By 27 March, New York City becomes epicenter of coronavirus pandemic in the US. COVID 19 IN THE UNITED STATES EMERGENCY AND MAJOR DISASTER DECLARATIONS AND WHITE HOUSE Several emergency declarations are in effect, including a Public Health Emergency under Section 319 of the Public Health Service Act, declared on January 31 (retroactively dated to January 27); nationwide emergency declarations on March 13 and subsequent major disaster declarations pursuant to the Stafford Act; and a National Emergency declaration pursuant to the National Emergencies Act on March 13, dated to March 1. Waivers are in effect under Section 1135 of the Social Security Act to aid the health care system with surge capacity • President Trump invoked the Defense Production Act (DPA) on March 18 and delegated authority to the Secretary of Health and Human Services (HHS) to prioritize and allocate health and medical resources as needed. • 30 Days to Slow the Spread - The White House has advised Americans to work and engage in schooling from home when possible and to avoid gatherings of 10 or more people, discretionary travel, and restaurants through April 30. • The White House, in collaboration with the Centers for Disease Control and Prevention (CDC), has released guidelines for “OPENING UP AMERICA AGAIN” on 16 April 2020.
  3. 3. SITUATION - UNITED STATES COVID-19 ACTIVITY Different parts of the country are seeing different levels of COVID-19 activity. The United States nationally is nearing the end of the acceleration phase of the pandemic. Many parts of the county have successfully flattened the epi curve but have yet to show an extended period of decline. Others have begun to see a slow decline in cases. However, there still remains states who have not hit their peak. • The greatest number of cases have been recorded in New York, New Jersey, Massachusetts, Illinois, California, Pennsylvania, Michigan,, Florida, Texas, Louisiana and Connecticut. (CDC) • Nationally, visits to outpatient providers and emergency departments (EDs) for illnesses with symptoms consistent with COVID-19 continued to decline and are below baseline in many areas of the country. (CDC) • The overall cumulative COVID-19 associated hospitalization rate is 29.2 per 100,000, with the highest rates in persons 65 years and older (95.5 per 100,000) and 50-64 years (47.2 per 100,000). (CDC) NORTH AMERICA CONFIRMED CASES DEATHS CFR RECOVERED 1,102,703 64,789 5.86% 164,015 RISK ASSESSMENT RISK TO GENERAL POPULATION RISK TO ELDERLY POPULATION RISK TO HEATHCARE SYSTEM CAPACITY MODERATE VERY HIGH HIGH JURISDICTIONS REPORTING CASES: 55 (Total jurisdictions includes 50 states, District of Columbia, Guam, the Northern Mariana Islands, Puerto Rico, and the U.S Virgin Islands.) (CDC) As of April 29, 2020 - This map shows confirmed and probable COVID-19 cases reported by U.S. states, U.S. territories, and the District of Columbia. Each state’s health department reports how much the virus has spread in their community. As the nation looks to restart the economy and recover from the COVID-19 pandemic, reopening entirely will depend on expanded public health testing and contact tracing efforts, sustained healthcare system capacity to respond to new outbreaks, and public compliance with existing and new containment and mitigation efforts. The Association of State and Territorial Health Officials has produced, A Coordinated, National Approach to Scaling Public Health Capacity for Contact Tracing and Disease Investigation which provides a tier approach to contact tracing. They are also offering a free Making Contact: A Training for COVID-19 Contact Tracers. An introductory online course for entry-level COVID- 19 contact tracers, for use by health agencies in rapid training of new contact tracers. The training should be augmented by state/local specific training required to orient individuals to jurisdiction-specific protocols. SOURCE: JOHNS HOPKINS COVID-19 DASHBOARD (AS OF 1 MAY 2020, 1932 HRS EDT)
  4. 4. SITUATION - UNITED STATES NEW VIRUS TREATMENT. The Food and Drug Administration on Friday, 1 May 2020 issued an emergency approval for the antiviral drug remdesivir as a treatment for patients with Covid- 19, the illness caused by the coronavirus. The approval, formally called an emergency use authorization, had been expected following modestly encouraging results from a federal trial, announced on Wednesday. SOURCE: NYT MORE THAN 4,000 WORKERS IN MEATPACKING PLANTS HAVE VIRUS At least 4,193 workers at 115 meatpacking plants in the United States have been infected with the coronavirus, according to a report released Friday by the Centers for Disease Control and Prevention. Twenty of those workers have died, the report said. And the data almost certainly understates the scale of the problem, because not all states with infections at meat plants have reported figures to the C.D.C. WHO HAS EXTENDS ITS DECLARATION OF A GLOBAL HEALTH EMERGENCY. The World Health Organization extended its declaration of a global health emergency on Friday, 1 May 2020. The move comes three months after the organization’s original decision to announce a “public health emergency of international concern” on Jan. 30. At the time, only 98 of the nearly 10,000 cases confirmed had occurred outside China’s borders. But the pandemic continues to grow. More than 3.2 million people around the world have been sickened by the virus and nearly a quarter million have died, according to official counts. Hot spots have moved outside China; there is evidence on six continents of sustained transmission. ON L.A.’S FIRST DAY OF FREE TESTING FOR ALL, NEARLY 10,000 PEOPLE WERE TESTED. Los Angeles became the largest city in the country to offer free testing to anyone, regardless of symptoms, a significant ramping up of testing that officials in California have said is required before tentative steps to open the economy can be taken in the coming weeks. NURSING HOMES WILL FACE FEDERAL INSPECTIONS President Trump announced on 30 April 2020 that the federal government would increase inspections of nursing homes, which have been at the center of the pandemic. The facilities would be required to report cases directly to the Centers for Disease Control and Prevention, with testing data posted online. The inspections will be financed by money from the federal relief packages approved by Congress, Mr. Trump said. Testing data from nursing homes will be posted online, and facilities will be required to report cases to residents and their family members, the president said. Mr. Trump said a commission of industry experts, doctors, scientists, family members and patient advocates would be formed to monitor safety and quality. The New York Times has identified more than 6,400 nursing homes and other long-term care facilities across the United States with coronavirus cases. More than 100,000 residents and staff members at those facilities have contracted the virus, and more than 17,000 have died. That means more than a quarter of the U.S. deaths in the pandemic have been linked to long-term care facilities.
  5. 5. SITUATION – NURSING HOMES Certain conditions at nursing homes can exacerbate the spread of the disease: • Shortages of coronavirus tests • Shortages of or lack of access to personal protective equipment (PPE) such as masks and gowns • Frequent physical contact between residents and staff • Understaffing • Employees who work in multiple facilities, increasing chances for exposure • Chronic problems with infection control that predate coronavirus • Residents sharing rooms • Transfers of residents from hospitals and other settings • These factors make nursing homes potential breeding grounds for viral and bacterial diseases. • The lack of transparency (AARP) The Centers for Medicare & Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC) have issued guidance on reducing the spread of COVID-19 in nursing homes. Facilities have been instructed to: • Strictly limit visitation • Suspend communal dining and group activities for residents • Screen residents daily for fever and other COVID-19 symptoms • Screen anyone entering the building for symptoms and observe flexible sick-leave policies for staff members • Require staff to wear masks The Centers for Medicare and Medicaid Services (CMS) — which regulates nursing homes — announced recently that it will require nursing homes to alert residents, their families and the federal government of new cases, though the details of how that will work are still unclear. • The Coronavirus pandemic has devastated nursing homes across the country. • The Associated Press conducted its own survey in the U.S. and found there had been nearly 11,000 COVID-related nursing home deaths across the country as of April 24. However, just 23 states have been publicly reporting nursing home deaths. States also vary in how and where they are performing tests, and some count only proven cases and not also presumptive ones, leading to significant underestimates of the death toll. • As of April 25, about 77% of Massachusetts nursing homes – 299 of 389 – had at least one case of COVID-19. That percentage will no doubt climb as the state carries out its mandated testing at nursing homes. About one- third of Massachusetts nursing homes reported more than 30 COVID-19 cases each among residents and staff. • Sixty-eight veteran residents who tested positive for the virus have died, officials said Tuesday, and it’s not known whether another person who died had COVID-19. Another 82 residents and 81 employees have tested positive. • Maryland announced Wednesday, 29 April 2020, that it will test all residents and staff at nursing homes for coronavirus, which has spread through 185 facilities, infecting 4,369 and killing 471 patients and staff. • On 17 April 2020, a recent analysis from The Washington Post found that at least 40 percent of nursing homes with known outbreaks in the country have been cited more than once by inspectors in recent years for violating federal standards meant to control the spread of infections. Yale-Tulane-Sacred Heart - ESF-8 Team is producing a special report this weekend dedicated to COVID and nursing homes
  6. 6. Idaho Restaurants, gyms and salons remain closed until phase two, and recreational venues — like nightclubs and movie theaters — are expected to remain shuttered until the summer. Illinois March 21, 2020 – stay at home issued Indiana Is expected to announce whether he will extend the stay-at-home order on May 1. Kansas March 30, 2020 – stay at home issued Kentucky March 26, 2020 – stay at home issued Louisiana March 23, 2020 – stay at home issued Maine Some personal care business open. Restaurant sometime in June Maryland March 30, 2020 – stay at home issued Massachusetts March 24, 2020 – stay at home issued Michigan March 24, 2020 – stay at home issued Minnesota Allowed employees in certain agriculture, industrial and office settings to return to work starting April 27. His office estimated the move would allow as many as 100,000 residents to return to work, while keeping a stay-at-home order in Mississippi Shelter in place expired on April 27. Lifted restrictions on retail stores, which could reopen at limited capacity Missouri Set to expire April 6, 2020 Montana Stay at home expired on April 26 Nevada Stay at home set to expire April 30 Nebraska Plans on opening restaurants 4 May in some areas New Hampshire Stay at home in effect since March 27 and set to expire May 4. New Jersey March 21, 2020 – stay at home issued New Mexico March 24, 2020 – stay at home issued New York March 22, 2020 – stay at home issued North Carolina March 30, 2020 – stay at home issued Ohio March 23, 2020 – stay at home issued Oklahoma Restaurant dining, movie theaters, gyms, houses of worship and sporting venues are expected to reopen statewide — with certain restrictions — starting May 1. Oregon March 23, 2020 – stay at home issued Pennsylvania April 2, 2020 – stay at home issued Puerto Rico March 15, 2020 – stay at home issued Rhode Island March 28, 2020 – stay at home issued South Carolina Started reopening April 20. Stores at 20% capacity Tennessee Reopens starting April 27 Texas All retail stores, restaurants, movie theaters and malls can reopen on May 1, with limited capacity. US Virgin Islands March 25, 2020 – stay at home issued Vermont March 25, 2020 – stay at home issued Virginia March 30, 2020 – stay at home issued Washington March 23, 2020 – stay at home issued Washington, D.C. April 1, 2020 – stay at home issued West Virginia Will lift restrictions on certain businesses starting May 4 while encouraging people to stay at home. Wisconsin Stay at home in effect since March 25 and set to expire May 26. Which States Are Reopening and Which Are Still Shut DownNYT STATES /TERRITORIES WITH A ORDER OR ADVISORY STATE DATE STATES /TERRITORIES WITH A ORDER OR ADVISORY STATE DATE Alabama Retail stores at 50% Alaska Reopened eased restrictions on several kinds of businesses starting April 24. The restart, came with certain requirements Arizona The state’s stay-at-home order is extended to May 15, but outlined a plan for retail stores to begin opening sooner. California March 19, 2020 – stay at home issued Arkansas No stay-at-home order statewide, but other restrictions in place Colorado Stay at home expired on April 26 Connecticut Stay at home in effect since March 23 and set to expire May 20. Delaware March 24, 2020 Florida Stay at home set to expire May 4. allow restaurants and stores to operate at 25 percent capacity starting May 4. The reopening excludes Miami-Dade, Broward and Palm Beach counties, the state’s most populous, which have seen a majority of coronavirus cases. Georgia Reopened Guam April 7, 2020 – stay at home issued Hawaii March 25, 2020 – stay at home issued
  7. 7. PROGRESS ON TESTING IN US NOTE: Data during the gray period of graph are incomplete because of the lag in time between when specimens are accessioned, testing is performed, and results are reported. The range was extended from 4 days to 7 days on March 26. PRIORITIES FOR COVID-19 TESTING (Nucleic Acid or Antigen) CDC; COVID TRACKING) California is the first state to open up testing to asymptomatic individuals in high risk settings NY TO BEGIN COVID-19 TESTING/TRACING PROGRAM IN PARTNERSHIP WITH NJ AND CT • New York's Contact Tracing Program Will Be Done in Coordination with Downstate Region as well as New Jersey and Connecticut • Bloomberg School of Public Health at Johns Hopkins University to Build Online Curriculum and Training Program for Contact Tracers • NYS DOH Will Work with Bloomberg Philanthropies Team to Identify and Recruit Contact Tracer Candidates, Including DOH Staff, Investigators from State Agencies, Hundreds of Downstate Tracers and SUNY and CUNY Students in Medical Fields • Partnership with Vital Strategies' Resolve to Save Lives to Provide Operational and Technical Advising (NY GOVERNOR) AS OF 1532 HRS 1 MAY 2020 6,322,198 TEST RESULTS IN THE US Number of specimens tested for SARS CoV-2 by CDC labs (N= 5,561) and U.S. public health laboratories* (N= 565,288)† HIGH PRIORITY • Hospitalized patients • Healthcare facility workers, workers in congregate living settings, and first responders with symptoms • Residents in long-term care facilities or other congregate living settings, including prisons and shelters, with symptoms • Persons identified through public health cluster and selected contact investigations PRIORITY • Persons with symptoms of potential COVID-19 infection, including: fever, cough, shortness of breath, chills, muscle pain, new loss of taste or smell, vomiting or diarrhea and/or sore throat • Persons without symptoms who are prioritized by health departments or clinicians, for any reason, including but not limited to: public health monitoring, sentinel surveillance, or screening of other asymptomatic individuals according to state and local plans.
  8. 8. CONTACT TRACING KEY CONCEPTS OF CONTACT TRACING Contact tracing is the identification and follow up of people who may have come into contact with an infectious disease. Steps include: 1. Contact Identification: a confirmed case is asked to identify any person they have come into contact with (family, friends, healthcare providers, coworkers) 2. Contact Listing: All contacts listed should be identified and contacted to inform them about their potential exposure to the disease. Contacts should be advised on actions they should take, what kind of follow up to expect, disease prevention, accessing early care, and quarantine or isolation procedures. 3. Contact Follow-Up: Regular follow-up should be conducted with all contacts to monitor for symptoms and test for signs of infection. SOURCE: WHO For COVID-19 Contact Tracing: • Contacts are encouraged to stay home and maintain social distance from others (at least 6 feet) until 14 days after their last exposure, in case they also become ill. They should monitor themselves by checking their temperature 2x daily and watching for cough or shortness of breath. To the extent possible, public health staff should check in with contacts to make sure they are self- monitoring and have not developed symptoms. Contacts who develop symptoms should promptly isolate themselves and notify public health staff. They should be evaluated for infection and potential need for medical care. Contact tracing is a specialized skill that requires: • An understanding of patient confidentiality • Knowledge of the medical terms and principles of exposure, infection, infectious period, potentially infectious interactions, symptoms of disease, pre-symptomatic and asymptomatic infection • Interpersonal, cultural sensitivity, and interviewing skills TOOLS FOR CONTACT TRACING Digital tools are used to: 1. Improve efficiency and accuracy of data management 2. Reduce the burden of data collection and risk of infection by allowing electronic self-reporting 3. Using location data to identify community contacts unknown to the case SOURCE: CDC CONTACT TRACING CAPACITY • The CDC is calling for "very aggressive" contact tracing • Much of the burden falls on state/local health departments who lack the personnel to do extensive tracing • In an effort to expand the workforce, CDC is funding 650 health workers at state health departments to increase contact tracing and testing capacity • Digital technology can act as a force multiplier allowing one worker to reach more people within the community than would normally be possible. • Other federal agencies, like the Census Bureau, Peace Corps and AmeriCorps may be called in to assist with contact tracing In the United States, there have been 3 primary initiatives to develop mobile applications to assist with contact tracing. • Covid-19 Watch • CoEpi: Community Epidemiology in Action • Private Kit: Safe Paths SOURCE: NPR
  9. 9. A 3-TIER APPROACH FOR CONTACT TRACING ESTIMATED NUMBER OF CONTACT TRACERS NEEDED PER STATE FEDERAL 3-TIER PROGRAM: TIER 1: ENTRY LEVEL, “LAY,” AND PARA-PROFESSIONAL CONTACT INVESTIGATORS: Using the experience of China and other countries that have contained COVID-19, it is clear that a cadre of community members, volunteers, and individuals who are quickly trained, including just-in-time training, and oriented to the task of contact tracing, can identify cases and link individuals to public health agencies for follow-up. Local and state health agencies are already supporting basic contact investigation with entry level, rapidly trained individuals including: • Government employees from other agencies that are redeployed to COVID-19 response such as librarians, teachers and school personnel, and other professionals that have experience working in communities. 6 • Community health workers (CHWs), promotors, and other health navigators from the community. • Staff from local community health assets, such as community health center, healthcare coordinators, medical assistants, para-professional home-visitors, and staff from other community-facing programs or city and state agencies. • Staff from local nonprofits, faith communities, community development organizations, etc. • Students and faculty at local academic institutions including schools and programs in public health and schools of nursing, social work, and other allied health professions. • Staff from Public Health Institutes and organizations with which the public health agencies may have staffing arrangements and existing relationships. • Volunteer groups and other local non-government organizations. • Individuals identified through state response volunteer recruitment tools. TIER 2: PROFESSIONAL DISEASE INVESTIGATION SPECIALISTS (DIS) AND DIS SUPERVISOR/TRAINERS: Local and state health agencies currently employ approximately 2,200 DIS professionals or their equivalents (to conduct disease investigations related to STD/STIs, HIV, and TB. A rapid expansion of this profession is needed. Existing DIS professionals can be quickly trained on COVID-19 basics and TIER 3: ADVANCED COVID-19 RESPONSE PROFESSIONALS, INCLUDING EPIDEMIOLOGY/SURVEILLANCE PROFESSIONALS, CLINICAL SPECIALISTS, EPIDEMIC INTELLIGENCE SERVICES OFFICERS, AND CDC COVID-19 CORPS TEAM MEMBERS: Corps team members Local and state public health agencies employee teams of professionals with the clinical and epidemiological expertise to manage outbreaks and make clinical recommendations for individuals being assessed, screened, and isolated. CDC staff are routinely deployed to support local and state agencies as needed to complement existing expertise. The teams may include laboratory professionals, health care professionals, and other resource staff needed to manage response activities and assure critical public health and health care guidance is established and implemented. https://www.astho.org/COVID-19/A-National-Approach-for-Contact-Tracing/ CONTACT TRACING
  10. 10. RESEARCH - CONTACT TRACING Contact Tracing Assessment of COVID-19 Transmission Dynamics in Taiwan and Risk at Different Exposure Periods Before and After Symptom Onset In this study, high transmissibility of COVID-19 before and immediately after symptom onset suggests that finding and isolating symptomatic patients alone may not suffice to contain the epidemic, and more generalized measures may be required, such as social distancing. IMPORTANCE The dynamics of coronavirus disease 2019 (COVID-19) transmissibility are yet to be fully understood. Better understanding of the transmission dynamics is important for the development and evaluation of effective control policies. OBJECTIVE To delineate the transmission dynamics of COVID-19 and evaluate the transmission risk at different exposure window periods before and after symptom onset. OBJECTIVE This prospective case-ascertained study in Taiwan included laboratory- confirmed cases of COVID-19 and their contacts. The study period was from January 15 to March 18, 2020. All close contacts were quarantined at home for 14 days after their last exposure to the index case. During the quarantine period, any relevant symptoms (fever, cough, or other respiratory symptoms) of contacts triggered a COVID-19test. The final follow-up date was April 2, 2020. MAIN OUTCOMES AND MEASURES Secondary clinical attack rate (considering symptomatic cases only) for different exposure time windows of the index cases and for different exposure Settings (such as household, family, and health care). MAIN OUTCOMES RESULT We enrolled 100 confirmed patients, with a median age of 44 years (range, 11-88 years), including 56 men and 44 women. Among their 2761 close contacts, there were 22 paired index-secondary cases. The overall secondary clinical attack rate was 0.7%(95%CI, 0.4%-1.0%). The attack rate was higher among the 1818 contacts whose exposure to index cases started within 5 days of symptom onset (1.0% [95%CI, 0.6%-1.6%]) compared with those who were exposed later (0 cases from 852 contacts; 95%CI, 0%-0.4%). The 299 contacts with exclusive presymptomatic exposures were also at risk (attack rate, 0.7%[95% CI, 0.2%-2.4%]). The attack rate was higher among household (4.6%[95%CI, 2.3%-9.3%]) and nonhousehold (5.3%[95%CI, 2.1%- 12.8%]) family contacts than that in health care or other settings. The attack rates were higher among those aged 40 to 59 years (1.1%[95%CI, 0.6%- 2.1%]) and those aged 60 years and older (0.9%[95%CI, 0.3%-2.6%]). CONCLUSION AND RELEVANCE https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2765641
  11. 11. RESEARCH/STUDIES HOPES RISE FOR CORONAVIRUS DRUG REMDESIVIR Despite conflicting studies, results from largest trial yet show the antiviral speeds up recovery, putting it on track to become a standard of care in the United States An experimental drug — and one of the world’s best hopes for treating COVID-19 — could shorten the time to recovery from coronavirus infection, according to the largest and most rigorous clinical trial of the compound yet. he drug, called remdesivir, interferes with the replication of some viruses, including SARS-CoV-2, which is responsible for the current pandemic. On 29 April, Anthony Fauci, director of the US National Institute of Allergy and Infectious Diseases (NIAID), announced that a clinical trial in more than 1,000 people had showed that those taking remdesivir recovered in 11 days on average, compared with 15 days for those on a placebo. (Nature) DRY SWABBING’ OFFERS A WORKAROUND TO TEST- CHEMICAL SCARCITY Wide-scale genetic testing for SARS-CoV-2 has been hampered, in part, by shortages of the solutions used to store sampling swabs and extract viral RNA from them. To overcome this difficulty, a team led by Lea Starita and Jay Shendure at the University of Washington in Seattle developed a procedure for detecting viral RNA in swabs without the highly sought solutions (S. Srivatsan et al. Preprint at bioRxiv http://doi.org/ds6k; 2020; not peer reviewed before posting). The ‘dry swab, extraction-free’ procedure correctly detected viral RNA in 9 out of 11 samples from people known to have SARS-CoV-2 infections. Conventional extraction methods yielded positive results in only 8 of the 11. The researchers say that their protocol could enable a massive scale-up in the use of self-collected samples for genetic testing at centralized laboratories. HOSPITAL TOILETS CAN BE A HOTSPOT FOR AIRBORNE VIRAL RNA The new coronavirus’s RNA can travel through the air, and might spread by way of small particles exhaled by infected people. Ke Lan at Wuhan University in China and his colleagues tested the concentration of SARS-CoV-2 RNA in aerosols — fine airborne particles — at two hospitals treating people with COVID-19 (Y. Liu et al. Nature https://doi.org/10.1038/s41586-020-2271-3; 2020). The team detected elevated levels of viral RNA in locations such as a small toilet used by patients, and staff changing rooms. No viral RNA was detected in staff rooms after they had been disinfected. Low to undetectable levels were found in the hospitals’ well- ventilated patient wards. The presence of airborne viral RNA suggests that SARS-CoV-2 has the potential to spread by way of aerosols, the researchers say. They suggest that measures such as routine disinfection and better ventilation could help to control the virus’s spread.
  12. 12. HOW IS COVID-19 CAUSING CLOTS? It’s not clear precisely how COVID-19 is causing blood complications and abnormalities. They could be a result of the virus directly attacking blood vessels, or due to a hyperactive inflammatory response to the virus by the patient’s immune system. Lab tests on patients show values of D-dimer–a protein fragment produced when a blood clot dissolves–over 100 times normal levels, suggesting there’s a high number of blood clots that the body is trying to break down. Some patients also exhibit alarmingly high levels of thrombin, an enzyme that causes blood to clot. CONSIDERATIONS • Cardiovascular disease (CVD) is a risk factor for both contracting the virus, as well as developing serious, life-threatening COVID-19 disease. Since CVD increases susceptibility to blood clots/stroke, evidence of blood clots/stroke as a complication and cause of death for COVID-19 offers insight into how/why CVD is associated with rapid onset of life-threatening COVID-19 infection. • Acute respiratory distress disease remains the leading cause of death in patients, but blood complications are close behind. New York state data on the top chronic health problems in those who died with COVID-19 were almost all cardiovascular conditions. Asthma was not among them. • Multiple people who suffered strokes reported they put off going to the hospital when they experienced numbness, slurred speech, etc. due to fear of contracting COVID-19 (many were asymptomatic and unaware they had the virus). Others did not recognize their symptoms as signs of stroke. RECOMMENDATIONS • Facilities should consider giving hospitalized COVID-19 patients small doses of blood thinners upon admission as a preventative measure. • Target prevention efforts towards those with CVD and other conditions with an increased risk for blood clots/abnormalities. • Increase awareness on stroke symptoms & stress importance of seeking immediate medical care. • Invest in research on role of systemic inflammation in the virus’ pathology • https://www.nejm.org/doi/full/10.1056/NEJMc2010472?query=TOC • https://www.nejm.org/doi/full/10.1056/NEJMc2009787 • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7146714/ Doctors in U.S. hospitals are observing unusual cases of blood clotting and stroke in individuals with the SARS-CoV-2 virus. This lends further evidence to a phenomenon documented by doctors since the start of the pandemic in China: COVID-19 appears to produce an alarming number of potentially deadly blood clots, even in otherwise healthy, low-risk and/or asymptomatic people. A doctor at Columbia University Medical Center estimated blood clots were “one of the top three causes of demise and deterioration in covid-19 patients” he was treating. Autopsies have shown some lungs filled with hundreds of tiny clots, rather than evidence of pneumonia and damaged alveoli. This information offers critical insight into how exactly COVID-19 kills, as well as the pathology of the virus. NEW YORK – MAJOR STROKES IN YOUNG PEOPLE WITH COVID-19 Large vessel strokes are emerging as an unanticipated cause of death in COVID-19 patients, especially for those under 50. In New York, several young people admitted for major strokes, who had none of the typical risk factors for stroke, tested positive for the virus. ICU doctors and specialists are also seeing clots in the lungs and renal arteries of COVID-19 patients. ATLANTA – CLOTTING IN ICU & DIALYSIS PATIENTS WITH COVID-19 Doctors throughout Emory University’s health system are seeing abnormal blood clotting in their COVID-19 patients, despite some being put on anticoagulants. Some hospitals were seeing this issue in as many as 20, 30, or 40% of their patients. Clotting is being seen in a ”significant minority” of ICU patients with COVID-19, as well as in COVID-19 patients on dialysis machines (filter out the blood of people with failing kidneys). Doctors are perplexed by this since patients are given blood thinners to prevent clots from occurring as their blood passes through the machine. At Emory’s critical care center, dialysis machines–which almost never clot–are clotting up to four times a day. Blood clots have become so frequent in this hospital, it has five separate teams dedicated solely to investigating clotting in COVID-19 patients. SOURCE: SEATTLE TIMES & NPR STUDIES ON BLOOD CLOTS & STROKE IN COVID-19 PATIENTS Credit: Getty Images CONSIDERATIONS & RECOMMENDATIONS DOCTORS LINK COVID-19 TO BLOOD CLOTS & STROKE
  13. 13. EMERGING ISSUES - MENTAL HEALTH MENTAL HEALTH CONSEQUENCES OF COVID-19 AND SOCIAL DISTANCING The COVID-19 pandemic has brought unprecedented efforts to institute the practice of physical distancing in countries all over the world, resulting in changes in national behavioral patterns and shutdowns of usual day-to-day functioning. While these steps may be critical to mitigate the spread of this disease, they will undoubtedly have consequences for mental health and well- being in both the short and long term. In the context of the COVID-19 pandemic, it appears likely that there will be substantial increases in anxiety and depression, substance use, loneliness, and domestic violence; and with schools closed, there is a very real possibility of an epidemic of child abuse. This concern is so significant that the UK has issued psychological first aid guidance from Mental Health UK. While the literature is not clear about the science of population level prevention, it leads us to conclude that 3 steps can help us proactively prepare for the inevitable increase in mental health conditions and associated consequences of this pandemic. 1. Plan for the inevitability of loneliness and its effects as populations physically and socially isolate and to develop ways to intervene. 2. Use of digital technologies can bridge social distance 3. Place mechanisms for surveillance, reporting, and intervention, particularly, when it comes to domestic violence and child abuse. 4. Bolster our mental health system in preparation for the inevitable challenges precipitated by the COVID-19 pandemic. Stepped care, the practice of delivering the most effective, least resource-heavy treatment to patients in need, and then stepping up to more resource-heavy treatment based on patients’ needs, is a useful approach. The worldwide COVID-19 pandemic, and efforts to contain it, represent a unique threat, and we must recognize the pandemic that will quickly follow it—that of mental and behavioral illness—and implement the steps needed to mitigate it. It will be years before the mental health toll of the COVID-19 pandemic is fully understood, but some early data already paints a bleak picture. A study published March 23 in the medical journal JAMA found that, among 1,257 healthcare workers working with COVID-19 patients in China, 50.4% reported symptoms of depression, 44.6% symptoms of anxiety, 34% insomnia, and 71.5% reported distress. Nurses and other frontline workers were among those with the most severe symptoms. In interviews with TIME, several doctors and nurses said that fighting COVID-19 is making them feel more dedicated to their profession, and determined to push through and help their patients. However, many also admitted to harboring darker feelings. They’re afraid of spreading the disease to their families, frustrated about a lack of adequate protective gear and a sense they can’t do enough for their patients, exhausted as hours have stretched longer without a clear end in sight, and, most of all, deeply sad for their dying patients. SOURCE: TIME MEDICAL WORKERS ARE FACING A MENTAL HEALTH CRISIS SOURCE: JAMA Finding ways to support medical workers’ mental health could be a key component in the fight against COVID-19. Dr. Albert Wu, professor of health policy and management and medicine at the Johns Hopkins Bloomberg School of Public Health, says that evidence from the 2003 SARS outbreak suggests that failing to support healthcare workers in a crisis, including by not providing enough protective gear, can erode their “wellbeing and resilience,” ultimately leading to chronic burnout. Some healthcare workers could leave the profession, be absent more often from work, or develop PTSD, and any preexisting mental health conditions could be exacerbated. Furthermore, healthcare workers are human like the rest of us, and under extreme stress, they could be prone to making mistakes — which could lead to worse outcomes for patients, and further erode doctors’ and nurses’ mental health.
  14. 14. EMERGING ISSUES – ADDICTION AND COVID-19 IMPACT ON INDIVIDUALS SUFFERING FROM SUBSTANCE ABUSE With millions of Americans forced into weeks of extended isolation, several communities have reported a spike in drug overdose deaths, prompting health officials to raise concerns about the safety of those suffering from substance use disorders amid the COVID-19 pandemic. In New York, at least four counties have acknowledged an increase in reported overdoses, including Erie County, where officials saw at least 110 drug overdoses, including 36 deaths, reported since the beginning of March. “I think we need to consider the role that social isolation coupled with non- stop reporting on the pandemic may have on the feelings of desperation and hopelessness among those struggling with substance abuse,” U.S. Attorney for the Western District of New York James Kennedy Jr. said in a statement. It's unclear whether the reports from local officials reflects a broader trend nationwide. The Centers for Disease Control was unable to provide national data on overdose deaths during the coronavirus crisis, but a spokesperson told ABC News its officials are “aware of the concerns involving COVID-19 and drug overdoses and that it could affect some populations with substance use disorders.” In the past year, one in 12 adults in the U.S. had a substance use disorder, according to the Substance Abuse and Mental Health Services Administration (SAMHSA). According to some estimates, alcohol sales were up more than 50% in the last few weeks. As Americans are asked to shelter-in-place, stress from the pandemic is taking its toll on many, which can leave many resorting to alcohol or drugs to help cope. SOURCE: ABC NEWS SOURCE: ABC NEWS Most treatment occurs at outpatient settings. That is, people with SUD go to work, go to school, take medications if needed, attend individual or group therapy, go back home. Large-group gatherings are frequently hosted, such as Alcoholics Anonymous (AA), Narcotics Anonymous (NA) and naloxone (“Narcan”) teachings. All of these activities are associated with a great deal of close interaction with sick or soon-to-be sick people. Social distancing poses unique problems for people experiencing SUD and attempting to achieve or maintain long-term recovery. What Needs to Happen: 1. Screening before arrival 2. Waiting room precautions 3. Guaranteeing and expanding access to medications 4. Revamping group therapy models 5. Implementing teleheath SOURCE: FORBES ADDICTION TREATMENT PREPARATION FOR COVID-19 OUTBREAK
  15. 15. VULNERABLE POPULATIONS: INCARCERATED INDIVIDUALS Incarcerated populations have quickly become one of the most vulnerable populations for COVID-19. The United Nations experts on detention, the World Health Organization and human rights activists have all urged governments to reduce their prisoner populations swiftly. (NY Times) (Guardian) • There are about 740,000 people held in US jails. Jails are so overcrowded there is virtually no possibility to place inmates 6ft apart, and sanitation is often rudimentary. (Guardian) • Analysis found that unless instant action is taken to reduce jail populations, as many as 99,000 more people could die in the US as a result of the virus being contracted behind jail walls (23,000 are projected to succumb behind bars and 76,000 in surrounding communities as a result of inmates spreading the virus upon release). This projection would almost double last month’s White House modeling for COVID-19 Mortality. (Guardian) • Outbreaks in in jails have already begun popping up across the country. On Sunday, there were reports that 1,828 people incarcerated at Marion County Correctional Facility in Ohio, 73% of its total population, tested positive for COVID-19. This is the largest reported source of virus infections (NY Times) but similar reports are coming in from federal and state facilities across the country. (Time) • Some states and jails have made progress in tackling the crisis. Colorado has reduced its jail population by 31% since the pandemic began, Los Angeles county by 25% and Kentucky by 28%. (Guardian) JAILS PRISONS • On March 28, the first inmate in a federal prison died of Covid-19. Since than more than 100 have, and thousands more could if prisons and elected officials do not take steps to protect the incarcerated. (NY Times) • In late March, U.S. Attorney General William Barr ordered officials running federal prisons to “immediately maximize” the release of prisoners to home confinement to prevent the spread of the virus. However, only 1,027 prisoners (about half of 1 percent of the more than 174,000 people federally incarcerated) have been released to home confinement. (Marshall Project) • In four U.S. States prison systems (Arkansas, North Carolina, Ohio and Virginia) 96% of 3,277 inmates who tested positive for the coronavirus were asymptomatic. Despite the high number of asymptomatic cases seen in mass testing, most states are only testing inmates who show symptoms. This means case numbers in State prisons are vastly undercounted and the spread will continue. (NY TIMES) • A 2016 report from the Department of Justice found that 17 percent of medical positions in prison hospitals were unfilled. Releasing high-risk inmates can free up limited resources within the prison health care system to better treat those who remain. (NY Times) • Older incarcerated individuals comprise the fastest growing demographic in the US prison system, many of whom suffer from respiratory problems and heart conditions- making them at increased risk of COVID-19 complications. (NCBI) (The Conversation)
  16. 16. VULNERABLE POPULATIONS: INCARCERATED INDIVIDUALS Over the past few years, a number of state criminal justice systems, including Minnesota’s, have begun using automated, computer algorithm-based risk-need- responsivity (RNR) assessments to help better prepare inmates for release. More accurate than professional judgment and much easier for prison staff to use, these assessments help generate service packages (e.g., substance abuse treatment, job training, mental health services) that mitigate the factors most likely to result in new crimes and convictions. The use of these assessments also promotes public safety by guiding decisions about the appropriate level of community supervision (e.g., probation, parole, half-way houses). In the context of the pandemic, the RNR assessments could be coupled with medical risk assessments to identify individuals who are both “low-risk” for future offense and “high-risk” for COVID-19 due to underlying health conditions (e.g., age, obesity, high blood pressure, diabetes, lung disease). These assessments would offer some assurance to corrections officials, governors and the public that there is sound health justification for release and provide a higher level of confidence that those being released are suitable for community supervision. States might also consider greater reliance on automated risk assessments for pre-trial risk assessments to determine whether an individual accused of a crime requires detention in a jail facility or can be safely monitored in the community pending trial, thus reducing the numbers of people flowing into jails and prisons. THE HILL RNR ASSESSMENTS COULD BE COUPLED WITH MEDICAL RISK ASSESSMENTS TO IDENTIFY INDIVIDUALS WHO ARE BOTH “LOW-RISK” FOR FUTURE OFFENSE AND “HIGH-RISK” FOR COVID-19 ELIMINATING MEDICAL CO-PAYS In most states, incarcerated people are expected to pay $2-$5 co-pays for physician visits, medications, and testing. Because incarcerated people typically earn 14 to 63 cents per hour, these charges are the equivalent of charging a free-world worker $200 or $500 for a medical visit. The result is to discourage medical treatment and to put public health at risk. In 2019, some states recognized the harm and eliminated these co-pays. We’re tracking how states are responding to the COVID-19 pandemic: PRISON POLICY
  17. 17. IMPACTS ON RURAL HEALTH Up until late March, 80 percent of the counties with high prevalence of the coronavirus were home to large urban centers. Now, more than half the counties showing signs of rapid growth are outside metropolitan areas. As the coronavirus outbreak spreads into rural parts of the United States, more people who live far from a hospital are increasingly likely to need one. Rural Americans are older, more prone to underlying conditions like diabetes, heart disease and hypertension, and more likely to smoke — all risk factors that heighten one's vulnerability to the worst symptoms of COVID-19. People in rural regions who are located farther from health care use care less often and generally have worse outcomes. Research shows people are less likely to seek health care, even emergency care, when they need to travel farther to get it, especially when they are more than about 30 minutes from a hospital: (The Hill) (NY Times) CORONAVIRUS IN RURAL AMERICA Disparities between rural communities and urban communities prior to the outbreak of COVID-19 in the U.S. means the disease will be a part of rural communities for a long time to come; with case numbers continuing to rise for weeks. We could eventually see rural areas with a higher per capita burden and a higher ratio of cases to hospital beds: (Princeton) (Daily Yonder)
  18. 18. SOURCE : https://www.av.co/covid-diagnostics @vasudevbailey @zoeguttendorf HEALTHCARE INNOVATIONS TO FIGHT COVID-19
  19. 19. 04.28.20
  20. 20. HEALTHCARE INNOVATIONS TO FIGHT COVID-19 SOURCE : https://www.av.co/covid-diagnostics @vasudevbailey @zoeguttendorfZ
  21. 21. SOURCE : https://www.av.co/covid-diagnostics @vasudevbailey @zoeguttendorfZ HEALTHCARE INNOVATIONS TO FIGHT COVID-19

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