Etiology of Acute Febrile Illness in the Peruvian Amazon as determined by modular formatted quantitative PCR: A Protocol for RIVERA, a Health Facility-Based Case-Control Study (preprint)

Background: The study of the etiology of acute febrile illness (AFI) has historically been designed as a prevalence of pathogens detected from a case series. This strategy has an inherent unrealistic assumption that all pathogen detection allows for causal attribution, despite known asymptomatic carriage of the principal causes of acute febrile illness in most low- and middle-income countries (LMICs). We designed a semi-quantitative PCR in a modular format to detect bloodborne agents of acute febrile illness that encompassed common etiologies of AFI in the region, etiologies of recent epidemics, etiologies that require an immediate public health response and additional pathogens of unknown endemicity.  We then designed a study that would delineate background levels of transmission in the community in the absence of symptoms to provide corrected estimates of attribution for the principal determinants of AFI. Methods: A case-control study of acute febrile illness in patients ten years or older seeking health care in Iquitos, Loreto, Peru, was planned. Upon enrollment, we will obtain blood, saliva, and mid-turbinate nasal swabs at enrollment with a follow-up visit on day 21-28 following enrollment to attain vital status and convalescent saliva and blood samples, as well as a questionnaire including clinical, socio-demographic, occupational, travel, and animal contact information for each participant. Whole blood samples are to be simultaneously tested for 32 pathogens using TaqMan array cards. Mid-turbinate samples will be tested for SARS-CoV-2, Influenza A and Influenza B. Conditional logistic regression models will be fitted treating case/control status as the outcome and with pathogen-specific sample positivity as predictors to attain estimates of attributable pathogen fractions for AFI. Discussion: The modular PCR platforms will allow for reporting of all primary results of respiratory samples within 72 hours and blood samples within one week, allowing for results to influence local medical practice and enable timely public health responses. The inclusion of controls will allow for a more accurate estimate of the importance of specific, prevalent pathogens as a cause of acute illness. Study Registration: Project 1791, Registro de Proyectos de Investigación en Salud Pública (PRISA), Instituto Nacional de Salud, Perú.

Randomized controlled study of a diagnosis and treatment plan for moderate coronavirus disease 2019 that integrates Traditional Chinese and Western Medicine.

OBJECTIVE: To investigate the clinical efficacy and safety of a diagnosis and treatment plan for moderate coronavirus disease 2019 (COVID-19) that integrates traditional Chinese (TCM) and western medicine. METHODS: One hundred twenty patients with moderate COVID-19 were randomized 1∶2 to the control group ( = 40) and experimental group ( = 80). Both groups received conventional western medicine treatment, and the experimental group also received TCM decoction. Over a 2-week period from diagnosis, we observed the time to clinical recovery (TTCR), rate of improvement on lung computed tomography (CT) imaging, time to defervescence, cough remission time, hospital discharge rate, average hospitalization stay, modified Medical Research Council (mMRC) scale score, clinical cure rate, laboratory findings, incidence of progression to severe or critical disease, and adverse events. RESULTS: Among 120 enrolled patients, 108 completed the study. The baseline data did not differ between the experimental and control groups (all > 0.05). After treatment, the TTCR, rate of lung CT imaging improvement, time to defervescence, cough remission time, hospital discharge rate, average hospitalization stay (among discharged patients), mMRC scale score, clinical cure rate, and rates of normal values for laboratory findings were better in the experimental group than in the control group ( < 0.05 or < 0.01). The incidence of progression to severe or critical disease and the incidence of adverse events did not differ between the two groups ( > 0.05). CONCLUSION: The diagnosis and treatment plan integrating Chinese and western medicine showed improved clinical efficacy compared with western medicine alone for patients with moderate COVID-19 and is worthy of clinical promotion and application.

Long-Term Clinical Sequelae and Immunological Features of COVID-19 Survivors: A Cross-Sectional Study in Wuhan, China (preprint)

Objectives: To describe the clinical sequelae and immunological features of COVID-19 survivors who have been discharged from the hospital for 5-8 months. Methods: This study is a cross-sectional study of confirmed COVID-19 patients aged ≥18 years who were discharged from hospitals in Wuhan from January to April 2020. The demographics, clinical features, and laboratory findings of the participants were collected from medical records in the hospital. The participants from the study completed an investigation of clinical sequelae, blood tests, a pulmonary function examination and an unarmed rehabilitation evaluation at Hubei Provincial Hospital of Traditional Chinese & Western Medicine. A group of volunteers who were free of COVID-19 and lived in Wuhan during the outbreak were recruited as the comparison group.Results: The average age of the 574 COVID-19 survivors was 57.7±11.4 years, and 348 (60.6%) survivors were female. The average number of days from the onset of symptoms was 241.79±16.16. The average number of days from discharge was 194.3±14.4. Clinical sequelae were common, including general symptoms (n=321, 55.9%), respiratory symptoms (n=265, 46.2%), digestive symptoms (n=84, 14.6%), nervous symptoms (n=75,13.1%) and psychosocial symptoms (n=201, 35%). A total of 190 (33.7%) survivors reported reduced exercise capacity. Through the results of pulmonary function examination, anomalies were noted in carbon monoxide diffusion capacity (DLCO)% in 110 cases (32.4%), maximal mid-expiratory flow (MMEF)% in 105 cases (30.7%), forced expired flow at 50% of forced vital capacity (FEF 50 )% in 128 cases (37.4%), and forced expired flow at 75% of forced vital capacity (FEF 75 )% in 240 cases (70.2%). The counts of T lymphocyte, CD4+ T lymphocyte counts, CD8+ T lymphocyte counts, B lymphocyte and NK cell in the survival group was significantly lower than that in the comparison group(all P < 0.05).There were 252 (43.9%) survivors whose total T lymphocyte counts had dropped, 260 (45.3%) whose CD4+T lymphocyte counts had dropped, 231 (40.2%) whose CD8+ T lymphocyte counts had dropped, 119 (20.7%) whose B lymphocyte counts had dropped, and 54 (9.4%) whose NK cell counts had dropped. But there were no statistically significant differences in the incidence of lymphocyte subsets reduction between severe and nonsevere groups (all P > 0.05). The T lymphocyte counts, CD4+ T lymphocyte counts and CD8+ T lymphocyte counts of the patients before discharge were significantly higher than those in the early stage of admission (P < 0.025). There were 319 (55.6%) survivors with positive or weakly positive IgG antibodies and 17 (2.9%) survivors with positive or weakly positive IgM antibodies.Conclusion: Even after 5 to 8 months of discharge, many survivors still have clinical sequelae, and some of them have impaired immune function. Therefore, the long-term rehabilitation of COVID-19 survivors remains a concern.Funding Statement: This study was funded by the National Key R&D Plan of China (2020YFC0841600), Guangdong Provincial Key Laboratory of Research on Emergency in TCM (2017B030314176), R&D plan in key areas of Guangdong Province (2020B1111300005), and National Administration of Traditional Chinese Medicine (2020ZYLCYJ05-11).Declaration of Interests: The authors declare that they have no competing interests.Ethics Approval Statement: This study was approved by the ethical committees of Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China (GPHCM; No. BF2020-205-01). All participants signed informed consent forms.

Seroprevalence and epidemiological characteristics of immunoglobulin M and G antibodies against SARS-CoV-2 in asymptomatic people in Wuhan, China (preprint)

Background: The seroprevalence of immunoglobulin M (IgM) and immunoglobulin G (IgG) antibodies against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may be a more reliable approach to detect true infected population, particularly in asymptomatic persons. The seroprevalence of IgG or IgM in people in general has not been well described. We choose a general hospital in Jianghan District in Wuhan, near the Huanan Seafood Wholesale Market, the epicenter of the COVID-19 pandemic in China, to conduct a serological survey, aimed at assessing asymptomatic infections of COVID-19 compared to epidemiological characteristics of people in Wuhan. Methods: We conducted a serological survey of asymptomatic people who were tested in the general hospital using a validated colloidal gold method for IgM and IgG antibodies against SARS-CoV-2. Demographic, clinical, laboratory data and CT imaging findings from March 25 to April 28, 2020 were collected and compared. A total of 18,712 people mainly met the inclusion criteria to be enrolled (89.4%), with a median age of 40 years (range 4-81 years old), including 11,391 males (60.9%) with a median age of 42 years and 7,321 females (39.1%) with a median age of 37 years. The seroprevalence was estimated adjusting for imperfect diagnostic tests and the demographic structure of the population. Results: During the period from 25 March 2020 to 28 April 2020, the seroprevalence of IgG and IgM standardized for age and sex in Wuhan varied between 7.67% and 1.56% for IgG, and between 0.71% and 0.16% for IgM, and showed a downward trend. No significant correlation was observed between the seroprevalence of IgG and the different age groups, although none of the 26 individuals under the age of 19 years tested positive for IgG. The seroprevalence of IgM in different age groups was correlated with age (x2 = 18.496, p= 0.035), with no IgM positivity detected under the age of 24 years old (n = 679). Accounting for test performance and adjusting for the age and sex of the general population, the seroprevalence of IgG and /or IgM was estimated at 2.72% (95% confidence interval [CI]: 2.49-2.95%), with a seroprevalence of 2.05% (1.79-2.31%) for males and 3.41% (2.99-3.83%) for females. The seroprevalence was significantly higher for females than males (x2 = 35.702, p < 0.001), with an odds ratio of 1.36 (95% CI: 1.24-1.48). Based on the census number of the Wuhan population aged 4-81 years old in 2017, using IgG and/or IgM seroprevalence tests, the number of asymptomatic COVID-19-positive individuals aged 4-81 years old was estimated at 217,332 (95% CI: 198,709-235,955) in Wuhan from March 25 to April 28, 2020. A significant difference was seen in the seroprevalence of IgG among people from different geographic areas and different types of workplaces (respectively, x2 = 42.871, p < 0.001 and x2 = 202.43, p < 0.001). Sixty percent of antibody-positive cases came from the top ten work units out of a total of 154 units. Some professions had a higher risk for positive antibody tests. From CT imaging of 1636 participants, the IgG antibody-positive cases had a greater number of abnormalities in CT imaging than IgG-negative cases (30.7% vs 19.7%). Significant differences were seen between test groups of antibody-positive and negative cases of IgG and /or IgM in the percentage of leucocytes, neutrophilic granulocytes and monocytes. Conclusions: The reported number of confirmed patients in Wuhan only represents a small proportion of the total number of infections, and most of the Wuhan population remains susceptible to COVID-19. There were differences in IgG seroprevalence among geographic areas, which were consistent with the spread of the SARS-CoV-2 coronavirus in Wuhan. There was a significant aggregation of asymptomatic infections in individuals from some occupations, and based on CT and laboratory findings, some damage may have occurred in asymptomatic individuals positive for IgG antibody.

Heterogeneity analysis of COVID - 19 clinical phenotype in Wuhan (preprint)

BackgroundSince the outbreak of coronavirus disease 2019 (COVID-19), some studies reported the clinical characteristics of COVID-19 patients in hospital. However, these studies did not investigate the clinical symptoms heterogeneity of COVID-19 patients in the outpatient. This study aimed to describe the heterogeneity of clinical characteristics of outpatient COVID-19 patients.MethodsCOVID-19 patients visiting the respiratory outpatient department of our hospital from January 1st to February 28st 2020 were retrospectively analyzed. Based on the complaints, the patients were classified into four groups including group A (patients without symptoms), group B (patients with fever), group C (patients with respiratory symptoms but without fever), and group D (patients with extra-respiratory symptoms but without fever). The difference of clinical characteristics, basic diseases, laboratory examination of outpatient, characteristics of chest CT imaging among all the groups were analyzed and compared.ResultsA total of 309 COVID-19 patients were included with 126 men and 183 women. The common symptoms included fatigue (59.87%, 95% CI: 54.17-65.38%), loss of appetite (51.13%, 95% CI: 45.41-56.83%), fever (50.81%, 95% CI: 45.09-56.51%), muscle soreness (41.42%, 95% CI:35.88-47.14%), and dry cough (35.28%, 95% CI:29.95-40.89%). The percentages of group A to group D were 2.91%, 50.81%, 18.12%, and 28.16%, respectively. The most common symptoms in Group D included fatigue, loss of appetite, muscle soreness. ConclusionThe heterogeneity of clinical symptoms for COVID-19 patients in the outpatient is significant. We should pay attention to patients without symptoms or those with only extra-respiratory symptoms, who are prone to missed diagnosis.

Analysis of risk factors of severe COVID-19 patients (preprint)

Objective: To explore relevant risk factors for severity of patients diagnosed with novel coronavirus pneumonia (COVID-19). Methods: The clinical data of 292 patients with COVID-19 admitted to Hubei Provincial Hospital of Integrated Chinese & Western Medicine from January 1, 2020 to February 29, 2020 were analyzed retrospectively. Patients were divided into mild or severe group according to the Guidance for Corona Virus Disease 2019 (7th version) released by the Chinese National Health Committee. The clinical data were collected at the time of admission, including demographics, clinical characteristics, laboratory tests, imaging characteristics and outcomes of treatments. We applied univariable and multivariable logistic regression methods to explore the risk factors associated with severity of the disease.Results: The median age of patients in the severe group ((68.19±12.51) years) was significantly older than mild group ((54.14 ± 13.62) years). The male sex was more predominant in severe group (63.45%) than that of mild group (38.1%). There were more smokers (8.97% vs 1.36%) and drinkers (4.14% vs 0%) in severe group than that of mild group. Patients in the severe group had more underlying diseases. Hypertension（48.97% vs 23.81%），coronary heart disease (22.07% vs 1.36%, P<0.0001) , chronic obstructive pulmonary disease (6.21% vs 1.36%), malignant tumor (7.59% vs 2.04%) and chronic kidney disease (3.45% vs 0%) were more frequent in severe group than in mild group. The dyspnea, chest tightness and dry cough were more common in severe group (43.45%, 66.9% and 66.21%) than in mild group (23.13%, 44.22% and 53.74%). Abnormality of chest radiography were more frequent in the severe group, there were more ground glass opacities, consolidation of lung and white lung in the severe cases (88.97%, 44.07% and 46.21%) than in mild cases (78.91%, 19.05% and 2.04%). Patients in the severe group were more likely to receive methylprednisolone, oxygen therapy and mechanical ventilation. Lasso algorithm showed that age, C-reactive protein (CRP), creatine kinase (CK) and α-hydroxybutyrate dehydrogenase (α-HBDB) were independent risk factors for severe COVID-19, but the count of CD4+T lymphocyte was the protective factor. Conclusion: This retrospective study of 292 COVID-19 patients revealed that age, CRP, CK, α-HBDB and the count of CD4+T lymphocyte were independent risk factors for severity of COVID-19. Identifying patients with risk factors at an early stage of the disease are helpful for outcome prediction and clinical management.