JAMA Editorial (July 14, 2020) JT Brooks, JC Butler, RR Redfield (all authors from CDC), Universal Masking to Prevent SARS-CoV-2 Transmission—The Time Is Now
In this issue of JAMA, Wang et al present evidence that universal masking of health care workers (HCWs) and patients can help reduce transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections.1 In the largest health care system in Massachusetts with more than 75 000 employees, in tandem with routine symptom screening and diagnostic testing of symptomatic HCWs for SARS-CoV-2 infection, leadership mandated a policy of universal masking for all HCWs as well as for all patients. The authors present data that prior to implementation of universal masking in late March 2020, new infections among HCWs with direct or indirect patient contact were increasing exponentially, from 0% to 21.3% (a mean increase of 1.16% per day). However, after the universal masking policy was in place, the proportion of symptomatic HCWs with positive test results steadily declined, from 14.7% to 11.5% (a mean decrease of 0.49% per day). Although not a randomized clinical trial, this study provides critically important data to emphasize that masking helps prevent transmission of SARS-CoV-2…. the public needs consistent, clear, and appealing messaging that normalizes community masking. At this critical juncture when COVID-19 is resurging, broad adoption of cloth face coverings is a civic duty, a small sacrifice reliant on a highly effective low-tech solution that can help turn the tide favorably in national and global efforts against COVID-19.
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Some of the uptick in cases likely related to lack of concern and not using masks
NBC/NY Link: Goldman Sachs Says National Mask Mandate Could Slash Infections, Save Economy From 5% Hit
Briefly noted: G Bommelear et al. Clin Gastroenterol Hepatol; 2020; 18: 1553-60. Oral Curcumin No More Effective Than Placebo in Preventing Recurrence of Crohn’s Disease After Surgery in a Randomized Controlled Trial
- Double-blind randomized controlled trial at 8 referral centers in France, from October 2014 through January 2018, with 62 consecutive patients with CD undergoing bowel resection.
- Patients received azathioprine (2.5 mg/kg) and were randomly assigned to groups given oral curcumin (3 g/day; n = 31) or an identical placebo (n = 31) for 6 months, and were then evaluated by colonoscopy.
- The primary endpoint: postoperative recurrence of CD in each group (Rutgeerts’ index score ≥i2) at month 6
- Postoperative recurrence at 6 months: (Rutgeerts’ index score ≥i2): 58% receiving curcumin vs 68% receiving placebo (P = .60).
- Severe recurrence: 55% receiving Curcumin 55%vs 26% receiving placebo –had a severe recurrence of CD (Rutgeerts’ index score ≥i3) (P = .034).
- Clinical recurrence of CD (CD activity index score >150) at 6 months: 30% with curcumin compared with 45% receiving placebo (P = .80)
My take: Curcumin was ineffective in preventing recurrent post-operative Crohn’s disease
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According to this ranking, U.S. is 58th in the world:
From Health Affairs, Full Text: Community Use Of Face Masks And COVID-19: Evidence From A Natural Experiment Of State Mandates In The US
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NPR interview (5 minutes) with Atul Gawande: How The Widespread Mask Use Could Slow The Coronavirus Pandemic
“NPR’s Mary Louise Kelly talks with Dr. Atul Gawande, a staff writer for the New Yorker, about the efficacy of different face masks and why masks remain essential in dealing with the coronavirus”
Proceedings of the Royal Society A. Published:10 June 2020 https://doi.org/10.1098/rspa.2020.0376 Full Text Link: A modelling framework to assess the likely effectiveness of facemasks in combination with ‘lock-down’ in managing the COVID-19 pandemic
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NY Times article that summarized recent Lancet study: Medical Workers Should Use Respirator Masks, Not Surgical Masks
Original Lancet Study (DK Chu et al. June 1, 2020
https://doi.org/10.1016/S0140-6736(20)31142-9): Physical distancing, face masks, and eye protection to prevent person-to-person transmission of SARS-CoV-2 and
COVID-19: a systematic review and meta-analysis
An excerpt from NY Times article:
The surgical masks used in risky settings like hospitals offer much less protection against the coronavirus, an analysis found…
The results, published on Monday in The Lancet, make it clear that the W.H.O. and the Centers for Disease Control and Prevention should recommend that essential workers like nurses and emergency responders wear N95 masks, not just surgical masks
N95 masks offered 96 percent protection, the analysis found, while the figure for surgical masks was 77 percent. The findings are particularly important as the United States moves to reopen the economy, Dr. Michaels said…
Workers in health care settings are not the only ones at high risk of coronavirus infection: employees in meatpacking plants and some farms are all also at high risk of coronavirus infection and could benefit from N95 masks..
The new analysis also suggests that covering the eyes with face shields, goggles and glasses may provide additional safeguards for health care workers and people in the community.
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The CDC, along with numerous states, are currently using aggregated viral testing that include assays for current infection along with antibody testing that detects prior infections. This muddies the picture on actual current coronavirus cases and makes it more difficult to determine if we are heading in the right direction.
From The Atlantic: ‘How Could the CDC Make That Mistake?’
The Centers for Disease Control and Prevention is conflating the results of two different types of coronavirus tests, distorting several important metrics and providing the country with an inaccurate picture of the state of the pandemic. We’ve learned that the CDC is making, at best, a debilitating mistake: combining test results that diagnose current coronavirus infections with test results that measure whether someone has ever had the virus…
The widespread use of the practice means that it remains difficult to know exactly how much the country’s ability to test people who are actively sick with COVID-19 has improved….
Georgia …has also seen its COVID-19 infections plateau amid a surge in testing. Like Texas, it reported more than 20,000 new results on Wednesday, the majority of them negative. But because, according to The Macon Telegraph, it is also blending its viral and antibody results together, its true percent-positive rate is impossible to know…
On a national scale, they call the strength of America’s response to the coronavirus into question…the portion of tests coming back positive has plummeted, from a seven-day average of 10 percent at the month’s start to 6 percent on Wednesday…The intermingling of viral and antibody tests suggests that some of those gains might be illusory.
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Correction: Today’s earlier blog post has been updated:
- For >1000 [calprotectin], the sensitivity 38%, specificity 100%, PPV 98%, and NPV 92%
- Previously this line started with the following: “For >100”
From NY Times: Why Georgia Isn’t Ready to Reopen
- Georgia’s infection rates have not started to decline
- Georgia has a low testing rate compared to other states
- Georgia’s population rate is vulnerable with increased rates of diabetes and the 4th highest rates of uninsured individuals
A good read from Aaron Carroll/NY Times: How Will We Know When to Reopen the Country?
Here is an excerpt:
Everyone wants to know when we are going to be able to leave our homes and reopen the United States. That’s the wrong way to frame it.
The better question is: “How will we know when to reopen the country?”…
A recent report by Scott Gottlieb, Caitlin Rivers, Mark B. McClellan, Lauren Silvis and Crystal Watson staked out some goal posts.
- Hospitals in the state must be able to safely treat all patients requiring hospitalization, without resorting to crisis standards of care.
- A state needs to be able to test at least everyone who has symptoms.
- The state is able to conduct monitoring of confirmed cases and contacts.
- There must be a sustained reduction in cases for at least 14 days…
These four criteria are a baseline…Until we get a vaccine or effective drug treatments, focusing on these major criteria, and directing efforts toward them, should help us determine how we are progressing locally, and how we might achieve each goal.
Related blog posts/links:
- COVID-19 Projections -IHME Data IHME Link: IHME Website for COVID-19 This post details the projected needs (ventilators, ICU beds) and projected mortality. The site allows one to look at specific states; while NY is expected to peak this week, Georgia is expected to peak in about 18 days.
- How to Do a Colonoscopic Polypectomy and U.S. COVID-19 Tracker NPR: Map: Tracking The Spread Of The Coronavirus In The U.S This tracker details the pandemic in every state.
- How to Protect Healthcare Workers from COVID-19 -Lessons from Hong Kong and Singapore Atul Gawande has a very pertinent article in the New Yorker: Keeping the Coronavirus from Infecting Health-Care Workers
- What is the Current Standard of Care for PPE and Endoscopy Cases? Link to manuscript: COVID-19 in Endoscopy: Time to do more?
- Bill Gates: What We Need to Do Now for COVID-19, False-negative testing & Article Describing 3 Stages of Infection From NY Times: If You Have Coronavirus Symptoms, Assume You Have the Illness, Even if You Test Negative Bill Gates: Here’s how to make up for lost time on covid-19 & article describing 3 stages of infection: COVD-19 Illness in Native and Immunosuppressed States: A Clinical-Therapeutic Staging Proposal
- Allocating Scarce Resources During COVID-19 Pandemic Links CDC Link: Testing for COVID-19 Full Link NEJM 2020 (Ezekial J Emmanuel et al): Fair Allocation of Scarce Medical Resources in the Time of Covid-19. This post also displays some data on sensitivity/specificity of testing
- Iron Injectables Links Financial Times: Coronavirus tracked: the latest figures as the pandemic spreads | Free to read & from Johns Hopkins: COVID19 Caseload & Outcomes Worldwide
- COVID-19: Veneto vs. Lombardy and Georgia’s Part of this Pandemic Link: Harvard Business Review: Lessons from Italy’s Response to Coronavirus & Georgia DPH: COVID-19 Daily Status Report
- “Crushing It” Two More Pediatric Hepatitis C studies Full link from NY Times: How Long Will Coronavirus Live on Surfaces or in the Air Around You? and blog post shows how to properly place PPE
- Ethical Dilemmas and Digestive Symptoms –Common with COVID-19 Full link: NEJM: Facing Covid-19 in Italy — Ethics, Logistics, and Therapeutics on the Epidemic’s Front Line & digestive symptoms ACG: Full Link: ACG Media Statement
- More Advice on Coronavirus for Pediatric GIs: NASPGHAN and CCFA CCFA Guidance for Pediatric Caregivers and Patients —Updates on COVID-19 and IBD
- Autoimmune Hepatitis Outcomes, Grand Rounds on Splenomegaly, Hydroxychloroquine for SARS-CoV-2 & Zantac Warning
- Liver Shorts and COVID-19 Screenshots This post includes Fauci donuts, AJG reference on COVID-19 digestive symptoms, and technology to sterilized used PPE
- COVID-19 Posts: At bottom of post is a NEJM link to video demonstrating need for PPE during intubation – Fluorescent Spray During Intubation and information on how hydroxychloroquine and azithromycin could increase risk for life-threatening arrhythmias