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1.
J Allergy Clin Immunol ; 150(2): 302-311, 2022 Aug.
Article in English | MEDLINE | ID: covidwho-1945361

ABSTRACT

BACKGROUND: Whether children and people with asthma and allergic diseases are at increased risk for severe acute respiratory syndrome virus 2 (SARS-CoV-2) infection is unknown. OBJECTIVE: Our aims were to determine the incidence of SARS-CoV-2 infection in households with children and to also determine whether self-reported asthma and/or other allergic diseases are associated with infection and household transmission. METHODS: For 6 months, biweekly nasal swabs and weekly surveys were conducted within 1394 households (N = 4142 participants) to identify incident SARS-CoV-2 infections from May 2020 to February 2021, which was the pandemic period largely before a vaccine and before the emergence of SARS-CoV-2 variants. Participant and household infection and household transmission probabilities were calculated by using time-to-event analyses, and factors associated with infection and transmission risk were determined by using regression analyses. RESULTS: In all, 147 households (261 participants) tested positive for SARS-CoV-2. The household SARS-CoV-2 infection probability was 25.8%; the participant infection probability was similar for children (14.0% [95% CI = 8.0%-19.6%]), teenagers (12.1% [95% CI = 8.2%-15.9%]), and adults (14.0% [95% CI = 9.5%-18.4%]). Infections were symptomatic in 24.5% of children, 41.2% of teenagers, and 62.5% of adults. Self-reported doctor-diagnosed asthma was not a risk factor for infection (adjusted hazard ratio [aHR] = 1.04 [95% CI = 0.73-1.46]), nor was upper respiratory allergy or eczema. Self-reported doctor-diagnosed food allergy was associated with lower infection risk (aHR = 0.50 [95% CI = 0.32-0.81]); higher body mass index was associated with increased infection risk (aHR per 10-point increase = 1.09 [95% CI = 1.03-1.15]). The household secondary attack rate was 57.7%. Asthma was not associated with household transmission, but transmission was lower in households with food allergy (adjusted odds ratio = 0.43 [95% CI = 0.19-0.96]; P = .04). CONCLUSION: Asthma does not increase the risk of SARS-CoV-2 infection. Food allergy is associated with lower infection risk, whereas body mass index is associated with increased infection risk. Understanding how these factors modify infection risk may offer new avenues for preventing infection.


Subject(s)
Asthma , COVID-19 , Hypersensitivity , Adolescent , Adult , Asthma/epidemiology , COVID-19/epidemiology , Child , Humans , Hypersensitivity/epidemiology , Prospective Studies , Risk Factors , SARS-CoV-2
2.
Child Obes ; 2022 Jul 19.
Article in English | MEDLINE | ID: covidwho-1937619

ABSTRACT

Background: Societal changes during the COVID-19 pandemic may affect children's health behaviors and exacerbate disparities. This study aimed to describe children's health behaviors during the COVID-19 pandemic, how they vary by sociodemographic characteristics, and the extent to which parent coping strategies mitigate the impact of pandemic-related financial strain on these behaviors. Methods: This study used pooled data from 50 cohorts in the Environmental influences on Child Health Outcomes Program. Children or parent proxies reported sociodemographic characteristics, health behaviors, and parent coping strategies. Results: Of 3315 children aged 3-17 years, 49% were female and 57% were non-Hispanic white. Children of parents who reported food access as a source of stress were 35% less likely to engage in a higher level of physical activity. Children of parents who changed their work schedule to care for their children had 82 fewer min/day of screen time and 13 more min/day of sleep compared with children of parents who maintained their schedule. Parents changing their work schedule were also associated with a 31% lower odds of the child consuming sugar-sweetened beverages. Conclusions: Parents experiencing pandemic-related financial strain may need additional support to promote healthy behaviors. Understanding how changes in parent work schedules support shorter screen time and longer sleep duration can inform future interventions.

3.
J Med Internet Res ; 24(6): e33981, 2022 06 20.
Article in English | MEDLINE | ID: covidwho-1910867

ABSTRACT

BACKGROUND: Telehealth for emergency stroke care delivery (telestroke) has had widespread adoption, enabling many hospitals to obtain stroke center certification. Telehealth for pediatric emergency care has been less widely adopted. OBJECTIVE: Our primary objective was to determine whether differences in policy or certification requirements contributed to differential uptake of telestroke versus pediatric telehealth. We hypothesized that differences in financial incentives, based on differences in patient volume, prehospital routing policy, and certification requirements, contributed to differential emergency department (ED) adoption of telestroke versus pediatric telehealth. METHODS: We used the 2016 National Emergency Department Inventory-USA to identify EDs that were using telestroke and pediatric telehealth services. We surveyed all EDs using pediatric telehealth services (n=339) and a convenience sample of the 1758 EDs with telestroke services (n=366). The surveys characterized ED staffing, transfer patterns, reasons for adoption, and frequency of use. We used bivariate comparisons to examine differences in reasons for adoption and use between EDs with only telestroke services, only pediatric telehealth services, or both. RESULTS: Of the 442 EDs surveyed, 378 (85.5%) indicated use of telestroke, pediatric telehealth, or both. EDs with both services were smaller in bed size, volume, and ED attending coverage than those with only telestroke services or only pediatric telehealth services. EDs with telestroke services reported more frequent use, overall, than EDs with pediatric telehealth services: 14.1% (45/320) of EDs with telestroke services reported weekly use versus 2.9% (8/272) of EDs with pediatric telehealth services (P<.001). In addition, 37 out of 272 (13.6%) EDs with pediatric telehealth services reported no consults in the past year. Across applications, the most frequently selected reason for adoption was "improving level of clinical care." Policy-related reasons (ie, for compliance with outside certification or standards or for improving ED performance on quality metrics) were rarely indicated as the most important, but these reasons were indicated slightly more often for telestroke adoption (12/320, 3.8%) than for pediatric telehealth adoption (1/272, 0.4%; P=.003). CONCLUSIONS: In 2016, more US EDs had telestroke services than pediatric telehealth services; among EDs with the technology, consults were more frequently made for stroke than for pediatric patients. The most frequently indicated reason for adoption among all EDs was related to clinical care.


Subject(s)
Emergency Medical Services , Stroke , Telemedicine , Child , Emergency Service, Hospital , Humans , Referral and Consultation , Stroke/therapy
4.
Pediatrics ; 2022 Jun 30.
Article in English | MEDLINE | ID: covidwho-1910742

ABSTRACT

BACKGROUND AND OBJECTIVES: Experts hypothesized increased weight gain in children associated with the COVID-19 pandemic, potentially due to closures of schools and recreational facilities with consequent reduction of physical activity and dietary changes. Our objective was to evaluate whether the rate of change of child BMI increased during the COVID-19 pandemic compared to pre-pandemic years. METHODS: The study population of 1996 children ages 2-19 years with at least one BMI measure before and during the COVID-19 pandemic was drawn from 38 pediatric cohorts across the US participating in the ECHO-wide Cohort Study. We modelled change in BMI using linear mixed models adjusting for age, sex, race, ethnicity, maternal education, income, baseline BMI category, and type of BMI measure. Data collection and analysis was approved by the local IRB of each institution or by the central ECHO IRB. RESULTS: BMI increased during the COVID-19 pandemic compared to previous years (0.24 higher annual gain in BMI during the pandemic compared to previous years, 95% CI 0.02, 0.45). Children with BMI in the obese range compared to the healthy weight range were at higher risk for excess BMI gain during the pandemic, while children in higher-income households were at decreased risk of BMI gain. CONCLUSIONS: One effect of the COVID-19 pandemic is an increase in annual BMI gain during the COVID-19 pandemic compared with the three prior years among children in our national cohort. This increased risk among US children may worsen a critical threat to public health and health equity.

5.
Prehosp Emerg Care ; : 1-7, 2022 May 23.
Article in English | MEDLINE | ID: covidwho-1819704

ABSTRACT

BACKGROUND: The COVID-19 pandemic disrupted access to routine in-person prenatal care, potentially leading to higher risk of out-of-hospital deliveries. Unplanned out-of-hospital deliveries pose a substantial risk of morbidity and mortality for pregnant patients and newborns. Our objective was to determine the change in rate of emergency medical services (EMS)-attended out-of-hospital deliveries during the COVID-19 pandemic. We hypothesized that COVID-19-related stay-at-home orders were associated with a higher rate of out-of-hospital deliveries during the initial wave of COVID-19. METHODS: We conducted an interrupted time series analysis using the 2019 and 2020 National EMS Information System datasets. We included 9-1-1 scene activations for patients 12-50 years old with out-of-hospital deliveries who were treated and transported by EMS. We calculated the weekly rate of deliveries per 100,000 EMS emergency activations each year overall, and for each census division. The interruption modeled was the enactment of stay-at-home orders, with March 25-31 selected as when most orders had been enacted. We fit ordinary least squares regression models with Newey-West standard errors to adjust for autocorrelation, testing for a change in level and slope overall and by census division. RESULTS: A total of 10,778 out-of-hospital deliveries were included, 58% (n = 6,254) in 2020. The mean weekly rate of out-of-hospital deliveries in 2019 was 29.4 per 100,000 activations (95% CI: 28.4 to 30.4) versus 33.0 (95% CI: 31.8 to 34.1) in 2020. There was an immediate increase of 6.3 deliveries per 100,000 activations (95% CI: 3.3 to 9.3) after the week of March 25-31, with a subsequent decrease of 0.3 deliveries per 100,000 per week after (95% CI: -0.4 to -0.2). There were also statistically significant immediate increases in out-of-hospital deliveries after March 25-31 in the New England, East North Central, West South Central, and Mountain divisions. CONCLUSION: EMS-attended out-of-hospital deliveries remained rare during the COVID-19 pandemic, but there was an immediate increase during the initial wave of the pandemic with evidence of geographic variation. Large-scale disruptions in the health care system may result in increases in uncommon patient presentations to EMS.

6.
Adv Ther ; 39(1): 178-192, 2022 01.
Article in English | MEDLINE | ID: covidwho-1813867

ABSTRACT

Since 1955, the only available H1 antihistamines for intravenous administration have been first-generation formulations and, of those, only intravenously administered (IV) diphenhydramine is still approved in the USA. Orally administered cetirizine hydrochloride, a second-generation H1 antihistamine, has been safely used over-the-counter for many years. In 2019, IV cetirizine was approved for the treatment of acute urticaria. In light of this approval, this narrative review discusses the changing landscape of IV antihistamines for the treatment of histamine-mediated conditions. Specifically, IV antihistamines will be discussed as a treatment option for acute urticaria and angioedema, as premedication to prevent infusion reactions related to anticancer agents and other biologics, and as an adjunct treatment for anaphylaxis and other allergic reactions. Before the development of IV cetirizine, randomized controlled trials of IV antihistamines for these indications were lacking. Three randomized controlled trials have been conducted with IV cetirizine versus IV diphenhydramine in the ambulatory care setting. A phase 3 trial of IV cetirizine 10 mg versus IV diphenhydramine 50 mg was conducted in 262 adults who presented to the urgent care/emergency department with acute urticaria requiring antihistamines. For the primary efficacy endpoint, defined as change from baseline in a 2-h patient-rated pruritus score, non-inferiority of IV cetirizine to IV diphenhydramine was demonstrated (score - 1.6 vs - 1.5, respectively; 95% CI - 0.1, 0.3). Compared with IV diphenhydramine, IV cetirizine demonstrated fewer adverse effects including less sedation, a significantly shorter length of stay in the treatment center, and fewer returns to the treatment center at 24 and 48 h. Similar findings were demonstrated in another phase 2 acute urticaria trial and in a phase 2 trial assessing IV cetirizine for pretreatment for infusion reactions in the oncology/immunology setting. IV cetirizine is associated with similar patient outcomes, fewer adverse effects, and increased treatment center efficiency than IV diphenhydramine.


Subject(s)
Cetirizine , Urticaria , Administration, Intravenous , Adult , Cetirizine/adverse effects , Diphenhydramine/adverse effects , Histamine H1 Antagonists/adverse effects , Humans , Urticaria/chemically induced , Urticaria/drug therapy
7.
J Am Geriatr Soc ; 70(7): 1918-1930, 2022 07.
Article in English | MEDLINE | ID: covidwho-1807168

ABSTRACT

BACKGROUND: Older adults represent a disproportionate share of severe COVID-19 presentations and fatalities, but we have limited understanding of the differences in presentation by age and the association between less typical emergency department (ED) presentations and clinical outcomes. METHODS: This retrospective cohort study used the RECOVER Network registry, a research collaboration of 86 EDs in 27 U.S. states. We focused on encounters with a positive nasopharyngeal swab for SARS-CoV-2, and described their demographics, clinical presentation, and outcomes. Sequential multivariable logistic regressions examined the strength of association between age cohort and outcomes. RESULTS: Of 4536 encounters, median patient age was 55 years, 49% were women, and 34% were non-Hispanic Black persons. Cough was the most common presenting complaint across age groups (18-64, 65-74, and 75+): 71%, 67%, and 59%, respectively (p < 0.001). Neurological symptoms, particularly altered mental status, were more common in older adults (2%, 11%, 26%; p < 0.001). Patients 75+ had the greatest odds of ED index visit admission of all age groups (adjusted odds ratio [aOR] 6.66; 95% CI 5.23-8.56), 30-day hospitalization (aOR 7.44; 95% CI 5.63-9.99), and severe COVID-19 (aOR 4.26; 95% CI 3.45-5.27). Compared to individuals with alternate presentations and adjusting for age, patients with typical symptoms (fever, cough and/or shortness of breath) had similar odds of ED index visit admission (aOR 1.01; 95% CI 0.81-1.24), potentially higher odds of 30-day hospitalization (aOR 1.23; 95% CI 1.00-1.53), and greater odds of severe COVID-19 (aOR 1.46; 95% CI 1.12-1.90). CONCLUSIONS: Older patients with COVID-19 are more likely to have presentations without the most common symptoms. However, alternate presentations of COVID-19 in older ED patients are not associated with greater odds of mechanical ventilation and/or death. Our data highlights the importance of a liberal COVID-19 testing strategy among older ED patients to facilitate accurate diagnoses and timely treatment and prophylaxis.


Subject(s)
COVID-19 , Aged , COVID-19/epidemiology , COVID-19 Testing , Cohort Studies , Cough/epidemiology , Emergency Service, Hospital , Female , Humans , Male , Prevalence , Retrospective Studies , SARS-CoV-2
8.
Am J Clin Nutr ; 115(4): 1123-1133, 2022 Apr 01.
Article in English | MEDLINE | ID: covidwho-1774329

ABSTRACT

BACKGROUND: Vitamin D may have a role in immune responses to viral infections. However, data on the association between vitamin D and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and coronavirus disease 2019 (COVID-19) severity have been limited and inconsistent. OBJECTIVE: We examined the associations of predicted vitamin D status and intake with risk of SARS-CoV-2 infection and COVID-19 severity. METHODS: We used data from periodic surveys (May 2020 to March 2021) within the Nurses' Health Study II. Among 39,315 participants, 1768 reported a positive test for SARS-CoV-2 infection. Usual vitamin D intake from foods and supplements were measured using a semiquantitative, pre-pandemic food-frequency questionnaire in 2015. Predicted 25-hydroxyvitamin D [25(OH)D] concentration were calculated based on a previously validated model including dietary and supplementary vitamin D intake, UV-B, and other behavioral predictors of vitamin D status. RESULTS: Higher predicted 25(OH)D concentrations, but not vitamin D intake, were associated with a lower risk of SARS-CoV-2 infection. Comparing participants in the highest quintile of predicted 25(OH)D concentrations with the lowest, the multivariable-adjusted OR was 0.76 (95% CI: 0.58, 0.99; P-trend = 0.04). Participants in the highest quartile of UV-B (OR: 0.76; 95% CI: 0.66, 0.87; P-trend = 0.002) and UV-A (OR: 0.76; 95% CI: 0.66, 0.88; P-trend < 0.001) also had a lower risk of SARS-CoV-2 infection compared with the lowest. High intake of vitamin D from supplements (≥400 IU/d) was associated with a lower risk of hospitalization (OR: 0.51; 95% CI: 0.29, 0.91; P-trend = 0.04). CONCLUSIONS: Our study provides suggestive evidence on the association between higher predicted circulating 25(OH)D concentrations and a lower risk of SARS-CoV-2 infection. Greater intake of vitamin D supplements was associated with a lower risk of hospitalization. Our data also support an association between exposure to UV-B or UV-A, independently of vitamin D and SARS-CoV-2 infection, so results for predicted 25(OH)D need to be interpreted cautiously.


Subject(s)
COVID-19 , Vitamin D Deficiency , Humans , SARS-CoV-2 , Vitamin D , Vitamins
9.
West J Emerg Med ; 22(6): 1262-1269, 2021 Oct 26.
Article in English | MEDLINE | ID: covidwho-1761083

ABSTRACT

INTRODUCTION: Coinfection with severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) and another virus may influence the clinical trajectory of emergency department (ED) patients. However, little empirical data exists on the clinical outcomes of coinfection with SARS-CoV-2 METHODS: In this retrospective cohort analysis, we included adults presenting to the ED with confirmed, symptomatic coronavirus 2019 who also underwent testing for additional viral pathogens within 24 hours. To investigate the association between coinfection status with each of the outcomes, we performed logistic regression. RESULTS: Of 6,913 ED patients, 5.7% had coinfection. Coinfected individuals were less likely to experience index visit or 30-day hospitalization (odds ratio [OR] 0.57; 95% confidence interval [CI], 0.36-0.90 and OR 0.39; 95% CI, 0.25-0.62, respectively). CONCLUSION: Coinfection is relatively uncommon in symptomatic ED patients with SARS-CoV-2 and the clinical short- and long-term outcomes are more favorable in coinfected individuals.


Subject(s)
COVID-19/therapy , Coinfection/virology , Emergency Service, Hospital/statistics & numerical data , Hospitalization/statistics & numerical data , Adult , Aged , Aged, 80 and over , COVID-19/epidemiology , COVID-19/mortality , Coinfection/epidemiology , Female , Humans , Male , Middle Aged , Retrospective Studies , SARS-CoV-2 , Severity of Illness Index
10.
J Emerg Med ; 62(6): 716-724, 2022 06.
Article in English | MEDLINE | ID: covidwho-1700394

ABSTRACT

BACKGROUND: COVID-19 has been associated with increased risk of thromboembolism in critically ill patients. OBJECTIVE: We sought to examine the association of SARS-CoV-2 test positivity and subsequent acute vascular thrombosis, including venous thromboembolism (VTE) or arterial thrombosis (AT), in a large nationwide registry of emergency department (ED) patients tested with a nucleic acid test for suspected SARS-CoV-2. METHODS: The RECOVER (Registry of Potential COVID-19 in Emergency Care) registry includes 155 EDs across the United States. We performed a retrospective cohort study to produce odds ratios (ORs) for COVID-19-positive vs. COVID-19-negative status as a predictor of 30-day VTE or AT, adjusting for age, sex, active cancer, intubation, hospital length of stay, and intensive care unit (ICU) care. RESULTS: Comparing 14,056 COVID-19-positive patients with 12,995 COVID-19-negative patients, the overall 30-day prevalence of VTE events was 1.4% vs. 1.3%, respectively (p = 0.44, χ2). Multivariable analysis identified that testing positive for SARS-CoV-2 status was negatively associated with both VTE (OR 0.76; 95% confidence interval [CI] 0.61-0.94) and AT (OR 0.51; 95% CI 0.32-0.80), whereas intubation, ICU care, and age 50 years or older were positively associated with both VTE and AT. CONCLUSIONS: In contrast to other reports, results from this large, hetereogenous national sample of ED patients tested for SARS-CoV-2, showed no association between vascular thrombosis and COVID-19 test positivity.


Subject(s)
COVID-19 , Thrombosis , Venous Thromboembolism , Ambulatory Care , COVID-19/diagnosis , COVID-19/epidemiology , Female , Humans , Male , Middle Aged , Retrospective Studies , SARS-CoV-2/isolation & purification , Symptom Assessment , Thrombosis/epidemiology , Venous Thromboembolism/epidemiology
11.
J Telemed Telecare ; : 1357633X211070725, 2022 Jan 24.
Article in English | MEDLINE | ID: covidwho-1648418

ABSTRACT

BACKGROUND: With the rapid increase in telehealth use during the COVID-19 pandemic, concerns have been raised about the potential for exacerbating existing healthcare disparities in marginalized populations. While eliminating barriers such as transportation and time constraints, telehealth may introduce barriers related to technology access. With little known about the patient experience accessing telehealth during the COVID-19 pandemic, this study seeks to understand the barriers and facilitators to telehealth use as well as interventions that may address them. METHODS: We conducted qualitative interviews with parents of pediatric patients of a primary care clinic in a diverse community during the study period of March-May 2021. The interviews explored barriers and facilitators to telehealth during the COVID-19 pandemic. Interviews were balanced across language (Spanish and English) as well as across visit type (in-person vs. telehealth). Recruitment, collection of demographic information, and interviews were conducted by telephone. The conversations were recorded and transcribed. Once thematic saturation was achieved, the data were analyzed using a modified grounded theory approach. RESULTS: Of the 33 participants, 17 (52%) spoke English and 16 (48%) spoke Spanish. A total of 17 (52%) had experienced a telehealth encounter as their first visit during the study period while 16 (48%) had an in-person visit. Five themes were identified: (1) a recognition of differences in technological knowledge and access, (2) situational preferences for telehealth versus in-person visits, (3) avoidance of COVID-19 exposure, (4) convenience, and (5) change over time. English-speaking patients expressed greater ease with and a preference for telehealth, while Spanish-speaking participants expressed more technological difficulty with telehealth and a preference for in-person visits. Suggested interventions included informational tutorials such as videos before the visit, technical support, and providing families with technological devices. CONCLUSION: In this study, we examined patient and family perspectives on pediatric telehealth during the COVID-19 pandemic. Implementation of the suggested interventions to address barriers to telehealth use is essential to prevent further exacerbation of health disparities already experienced by marginalized populations.

12.
J Clin Pharmacol ; 62(6): 777-782, 2022 06.
Article in English | MEDLINE | ID: covidwho-1589060

ABSTRACT

Angiotensin-converting enzyme inhibitor (ACEI) and angiotensin receptor blocker (ARB) drugs may modify risk associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Therefore, we assessed whether baseline therapy with ACEIs or ARBs was associated with lower mortality, respiratory failure (noninvasive ventilation or intubation), and renal failure (new renal replacement therapy) in SARS-CoV-2-positive patients. This retrospective registry-based observational cohort study used data from a national database of emergency department patients tested for SARS-CoV-2. Symptomatic emergency department patients were accrued from January to October 2020, across 197 hospitals in the United States. Multivariable analysis using logistic regression evaluated end points among SARS-CoV-2-positive cases, focusing on ACEIs/ARBs and adjusting for covariates. Model performance was evaluated using the c statistic for discrimination and Cox plotting for calibration. A total of 13 859 (99.9%) patients had known mortality status, of whom 2045 (14.8%) died. Respiratory failure occurred in 2485/13 880 (17.9%) and renal failure in 548/13 813 (4.0%) patients with available data. ACEI/ARB status was associated with a 25% decrease in mortality odds (odds ratio [OR], 0.75; 95%CI, 0.59-0.94; P = .011; c = .82). ACEIs/ARBs were not significantly associated with respiratory failure (OR, 0.89; 95%CI, 0.78-1.06; P = .206) or renal failure (OR, 0.75; 95%CI, 0.55-1.04; P = .083). Adjusting for covariates, baseline ACEI/ARB was associated with 25% lower mortality in SARS-CoV-2-positive patients. The potential mechanism for ACEI/ARB mortality modification requires further exploration.


Subject(s)
COVID-19 , Renal Insufficiency , Respiratory Insufficiency , Angiotensin Receptor Antagonists/therapeutic use , Angiotensin-Converting Enzyme Inhibitors/therapeutic use , Antiviral Agents/therapeutic use , COVID-19/drug therapy , Female , Humans , Male , Renal Insufficiency/drug therapy , Respiratory Insufficiency/drug therapy , Retrospective Studies , SARS-CoV-2
13.
PLoS One ; 16(3): e0248438, 2021.
Article in English | MEDLINE | ID: covidwho-1574763

ABSTRACT

OBJECTIVES: Accurate and reliable criteria to rapidly estimate the probability of infection with the novel coronavirus-2 that causes the severe acute respiratory syndrome (SARS-CoV-2) and associated disease (COVID-19) remain an urgent unmet need, especially in emergency care. The objective was to derive and validate a clinical prediction score for SARS-CoV-2 infection that uses simple criteria widely available at the point of care. METHODS: Data came from the registry data from the national REgistry of suspected COVID-19 in EmeRgency care (RECOVER network) comprising 116 hospitals from 25 states in the US. Clinical variables and 30-day outcomes were abstracted from medical records of 19,850 emergency department (ED) patients tested for SARS-CoV-2. The criterion standard for diagnosis of SARS-CoV-2 required a positive molecular test from a swabbed sample or positive antibody testing within 30 days. The prediction score was derived from a 50% random sample (n = 9,925) using unadjusted analysis of 107 candidate variables as a screening step, followed by stepwise forward logistic regression on 72 variables. RESULTS: Multivariable regression yielded a 13-variable score, which was simplified to a 13-point score: +1 point each for age>50 years, measured temperature>37.5°C, oxygen saturation<95%, Black race, Hispanic or Latino ethnicity, household contact with known or suspected COVID-19, patient reported history of dry cough, anosmia/dysgeusia, myalgias or fever; and -1 point each for White race, no direct contact with infected person, or smoking. In the validation sample (n = 9,975), the probability from logistic regression score produced an area under the receiver operating characteristic curve of 0.80 (95% CI: 0.79-0.81), and this level of accuracy was retained across patients enrolled from the early spring to summer of 2020. In the simplified score, a score of zero produced a sensitivity of 95.6% (94.8-96.3%), specificity of 20.0% (19.0-21.0%), negative likelihood ratio of 0.22 (0.19-0.26). Increasing points on the simplified score predicted higher probability of infection (e.g., >75% probability with +5 or more points). CONCLUSION: Criteria that are available at the point of care can accurately predict the probability of SARS-CoV-2 infection. These criteria could assist with decisions about isolation and testing at high throughput checkpoints.


Subject(s)
COVID-19/diagnosis , COVID-19/epidemiology , Emergency Service, Hospital/trends , Adult , Aged , Clinical Decision Rules , Coronavirus Infections/diagnosis , Cough , Databases, Factual , Decision Trees , Emergency Service, Hospital/statistics & numerical data , Female , Fever , Humans , Male , Mass Screening , Middle Aged , Registries , SARS-CoV-2/pathogenicity , United States/epidemiology
15.
Lancet Diabetes Endocrinol ; 9(5): 276-292, 2021 05.
Article in English | MEDLINE | ID: covidwho-1531931

ABSTRACT

BACKGROUND: A 2017 meta-analysis of data from 25 randomised controlled trials (RCTs) of vitamin D supplementation for the prevention of acute respiratory infections (ARIs) revealed a protective effect of this intervention. We aimed to examine the link between vitamin D supplementation and prevention of ARIs in an updated meta-analysis. METHODS: For this systematic review and meta-analysis, we searched MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, Web of Science, and the ClinicalTrials.gov registry for studies listed from database inception to May 1, 2020. Double-blind RCTs of vitamin D3, vitamin D2, or 25-hydroxyvitamin D (25[OH]D) supplementation for any duration, with a placebo or low-dose vitamin D control, were eligible if they had been approved by a research ethics committee, and if ARI incidence was collected prospectively and prespecified as an efficacy outcome. Studies reporting results of long-term follow-up of primary RCTs were excluded. Aggregated study-level data, stratified by baseline 25(OH)D concentration and age, were obtained from study authors. Using the proportion of participants in each trial who had one or more ARIs, we did a random-effects meta-analysis to obtain pooled odds ratios (ORs) and 95% CIs to estimate the effect of vitamin D supplementation on the risk of having one or more ARIs (primary outcome) compared with placebo. Subgroup analyses were done to estimate whether the effects of vitamin D supplementation on the risk of ARI varied according to baseline 25(OH)D concentration (<25 nmol/L vs 25·0-49·9 nmol/L vs 50·0-74·9 nmol/L vs >75·0 nmol/L), vitamin D dose (daily equivalent of <400 international units [IU] vs 400-1000 IU vs 1001-2000 IU vs >2000 IU), dosing frequency (daily vs weekly vs once per month to once every 3 months), trial duration (≤12 months vs >12 months), age at enrolment (<1·00 years vs 1·00-15·99 years vs 16·00-64·99 years vs ≥65·00 years), and presence versus absence of airway disease (ie, asthma only, COPD only, or unrestricted). Risk of bias was assessed with the Cochrane Collaboration Risk of Bias Tool. The study was registered with PROSPERO, CRD42020190633. FINDINGS: We identified 1528 articles, of which 46 RCTs (75 541 participants) were eligible. Data for the primary outcome were obtained for 48 488 (98·1%) of 49 419 participants (aged 0-95 years) in 43 studies. A significantly lower proportion of participants in the vitamin D supplementation group had one or more ARIs (14 332 [61·3%] of 23 364 participants) than in the placebo group (14 217 [62·3%] of 22 802 participants), with an OR of 0·92 (95% CI 0·86-0·99; 37 studies; I2=35·6%, pheterogeneity=0·018). No significant effect of vitamin D supplementation on the risk of having one or more ARIs was observed for any of the subgroups defined by baseline 25(OH)D concentration. However, protective effects of supplementation were observed in trials in which vitamin D was given in a daily dosing regimen (OR 0·78 [95% CI 0·65-0·94]; 19 studies; I2=53·5%, pheterogeneity=0·003), at daily dose equivalents of 400-1000 IU (0·70 [0·55-0·89]; ten studies; I2=31·2%, pheterogeneity=0·16), for a duration of 12 months or less (0·82 [0·72-0·93]; 29 studies; I2=38·1%, pheterogeneity=0·021), and to participants aged 1·00-15·99 years at enrolment (0·71 [0·57-0·90]; 15 studies; I2=46·0%, pheterogeneity=0·027). No significant interaction between allocation to the vitamin D supplementation group versus the placebo group and dose, dose frequency, study duration, or age was observed. In addition, no significant difference in the proportion of participants who had at least one serious adverse event in the vitamin supplementation group compared with the placebo group was observed (0·97 [0·86-1·07]; 36 studies; I2=0·0%, pheterogeneity=0·99). Risk of bias within individual studies was assessed as being low for all but three trials. INTERPRETATION: Despite evidence of significant heterogeneity across trials, vitamin D supplementation was safe and overall reduced the risk of ARI compared with placebo, although the risk reduction was small. Protection was associated with administration of daily doses of 400-1000 IU for up to 12 months, and age at enrolment of 1·00-15·99 years. The relevance of these findings to COVID-19 is not known and requires further investigation. FUNDING: None.


Subject(s)
Respiratory Tract Infections/diet therapy , Respiratory Tract Infections/prevention & control , Vitamin D/administration & dosage , Dietary Supplements , Humans , Randomized Controlled Trials as Topic , Treatment Outcome
16.
Vaccines (Basel) ; 9(11)2021 Nov 09.
Article in English | MEDLINE | ID: covidwho-1512740

ABSTRACT

Pursuing vaccinations against COVID-19 brings hope to limit the spread of SARS-CoV-2 and remains the most rational decision under pandemic conditions. However, it does not come without challenges, including temporary shortages in vaccine doses, significant vaccine inequity, and questions regarding the durability of vaccine-induced immunity that remain unanswered. Moreover, SARS-CoV-2 has undergone evolution with the emergence of its novel variants, characterized by enhanced transmissibility and ability to at least partially evade neutralizing antibodies. At the same time, serum antibody levels start to wane within a few months after vaccination, ultimately increasing the risk of breakthrough infections. This article discusses whether the administration of booster doses of COVID-19 vaccines is urgently needed to control the pandemic. We conclude that, at present, optimizing the immunity level of wealthy populations cannot come at the expense of low-income regions that suffer from vaccine unavailability. Although the efficiency of vaccination in protecting from infection may decrease over time, current data show that efficacy against severe disease, hospitalization, and death remains at a high level. If vaccine coverage continues at extremely low levels in various regions, including African countries, SARS-CoV-2 may sooner or later evolve into variants better adapted to evade natural and vaccine-induced immunity, ultimately bringing a global threat that, of course, includes wealthy populations. We offer key recommendations to increase vaccination rates in low-income countries. The pandemic is, by definition, a major epidemiological event and requires looking beyond one's immediate self-interest; otherwise, efforts to contain it will be futile.

17.
Acad Emerg Med ; 28(9): 1012-1018, 2021 09.
Article in English | MEDLINE | ID: covidwho-1494375

ABSTRACT

OBJECTIVE: Facilities that process and package meat for consumer sale and consumption (meatpacking plants) were early sites of coronavirus disease 2019 (COVID-19) outbreaks. The aim of this study was to characterize the association between meatpacking plant exposure and clinical outcomes among emergency department (ED) patients with COVID-19 symptoms. METHODS: This was a retrospective cohort study of patients presenting to a single ED, from March 1 to May 31, 2020, who had: 1) symptoms consistent with COVID-19 and 2) a COVID-19 test performed. The primary outcome was COVID-19 positivity, and secondary outcomes included hospital admission from the ED, ventilator use, intensive care unit (ICU) admission, hospital length of stay (LOS; <48 or ≥48 h), and mortality. RESULTS: Patients from meatpacking plants were more likely to be Black or Hispanic than the ED patients without this occupational exposure. Patients with a meatpacking plant exposure were more likely to test positive for COVID-19 (adjusted relative risk [aRR] = 2.37, 95% confidence interval [CI] = 1.59 to 3.53) but had similar rates of hospital admission (aRR = 0.94, 95% CI = 0.82 to 1.07) and hospital LOS (aRR = 0.76, 95% CI = 0.45 to 1.23). There was no significant difference in ventilator use among patients with meatpacking and nonmeatpacking plant exposure (8.2% vs. 11.1%, p = 0.531), ICU admissions (4.1% vs. 12.0%, p = 0.094), and mortality (2.0% vs. 4.1%, p = 0.473). CONCLUSIONS: Workers in meatpacking plants in Iowa had a higher rate of testing positive for COVID-19 but were not more likely to be hospitalized for their illness. These patients were disproportionately Black and Hispanic.


Subject(s)
COVID-19 , Farmers , Emergency Service, Hospital , Hospital Mortality , Humans , Intensive Care Units , Retrospective Studies , SARS-CoV-2
18.
J Acquir Immune Defic Syndr ; 88(4): 406-413, 2021 12 01.
Article in English | MEDLINE | ID: covidwho-1494140

ABSTRACT

BACKGROUND: There is a need to characterize patients with HIV with suspected severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). SETTING: Multicenter registry of patients from 116 emergency departments in 27 US states. METHODS: Planned secondary analysis of patients with suspected SARS-CoV-2, with (n = 415) and without (n = 25,306) HIV. Descriptive statistics were used to compare patient information and clinical characteristics by SARS-CoV-2 and HIV status. Unadjusted and multivariable models were used to explore factors associated with death, intubation, and hospital length of stay. Kaplan-Meier curves were used to estimate survival by SARS-CoV-2 and HIV infection status. RESULTS: Patients with both SARS-CoV-2 and HIV and patients with SARS-CoV-2 but without HIV had similar admission rates (62.7% versus 58.6%, P = 0.24), hospitalization characteristics [eg, rates of admission to the intensive care unit from the emergency department (5.0% versus 6.3%, P = 0.45) and intubation (10% versus 13.3%, P = 0.17)], and rates of death (13.9% versus 15.1%, P = 0.65). They also had a similar cumulative risk of death (log-rank P = 0.72). However, patients with both HIV and SARS-CoV-2 infections compared with patients with HIV but without SAR-CoV-2 had worsened outcomes, including increased mortality (13.9% versus 5.1%, P < 0.01, log-rank P < 0.0001) and their deaths occurred sooner (median 11.5 versus 34 days, P < 0.01). CONCLUSIONS: Among emergency department patients with HIV, clinical outcomes associated with SARS-CoV-2 infection are not worse when compared with patients without HIV, but SARS-CoV-2 infection increased the risk of death in patients with HIV.


Subject(s)
COVID-19/complications , Emergency Service, Hospital/statistics & numerical data , HIV Infections/complications , COVID-19/therapy , COVID-19/virology , Female , Humans , Length of Stay , Male , Middle Aged , Risk Factors , SARS-CoV-2/isolation & purification , Survival Analysis , Treatment Outcome , United States
19.
J Am Coll Emerg Physicians Open ; 2(4): e12502, 2021 Aug.
Article in English | MEDLINE | ID: covidwho-1312727

ABSTRACT

OBJECTIVE: Given the variability in crisis standards of care (CSC) guidelines during the COVID-19 pandemic, we investigated the racial and ethnic differences in prioritization between 3 different CSC triage policies (New York, Massachusetts, USA), as well as a first come, first served (FCFS) approach, using a single patient population. METHODS: We performed a retrospective cohort study of patients with intensive care unit (ICU) needs at a tertiary hospital on its peak COVID-19 ICU census day. We used medical record data to calculate a CSC score under 3 criteria: New York, Massachusetts with full comorbidity list (Massachusetts1), and MA with a modified comorbidity list (Massachusetts2). The CSC scores, as well as FCFS, determined which patients were eligible to receive critical care under 2 scarcity scenarios: 50 versus 100 ICU bed capacity. We assessed the association between race/ethnicity and eligibility for critical care with logistic regression. RESULTS: Of 211 patients, 139 (66%) were male, 95 (45%) were Hispanic, 23 (11%) were non-Hispanic Black, and 69 (33%) were non-Hispanic White. Hispanic patients had the fewest comorbidities. Assuming a 50 ICU bed capacity, Hispanic patients had significantly higher odds of receiving critical care services across all CSC guidelines, except FCFS. However, assuming a 100 ICU bed capacity, Hispanic patients had greater odds of receiving critical care services under only the Massachusetts2 guidelines (odds ratio, 2.05; 95% CI, 1.09 to 3.85). CONCLUSION: Varying CSC guidelines differentially affect racial and ethnic minority groups with regard to risk stratification. The equity implications of CSC guidelines require thorough investigation before CSC guidelines are implemented.

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