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Use of “normal” risk to improve understanding of dangers of covid-19 – BMJ

Accumulating data on deaths from covid-19 show an association with age that closely matches the “normal” risk we all face. Explaining risk in this way could help people understand and manage their response, says David Spiegelhalter

As covid-19 turns from a societal threat into a matter of risk management, it is vital that the associated risks are understood and clearly communicated.1 But these risks vary hugely between people, and so finding appropriate analogues is a challenge. Although covid-19 is a complex multisystem disease that can cause prolonged illness, here I focus solely on the risks of dying from covid-19 and explore the use of “normal” risk—the risk of death from all causes each year—as an aid to transparent communication.

  • General population: the risk of catching and then dying from covid-19 during 16 weeks of the pandemic was equivalent to experiencing around 5 weeks extra “normal” risk for those over 55, decreasing steadily with age, to just 2 extra days for schoolchildren
  • Over 55 who are infected with covid-19: additional risk of dying is slightly more than the “normal” risk of death from all other causes over one year, and less for under 55s.

https://www.bmj.com/content/370/bmj.m3259

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Neurologic Complications in Children Hospitalized With Influenza Infections – ​​​​The Pediatric Infectious Disease Journal

Background:
Influenza infection is a common cause of respiratory disease and hospitalization in children. Neurologic manifestations of the infection have been increasingly reported and may have an impact on the severity of the disease. The aim of this study is to describe neurologic events in pediatric patients hospitalized with influenza and identify associated risk factors.

Methods:
Retrospective cohort study which included all hospitalized patients with microbiologic confirmation of influenza disease over 4 epidemic seasons, focusing on neurologic complications. Demographic, laboratory and clinical data, as well as past history, were recorded. Descriptive and analytic statistical study was performed using SPSS and R statistical software.

Results:
Two hundred forty-five patients were included. Median age was 21 months (interquartile range, 6–57) and 47.8% had a previous underlying condition. Oseltamivir was administered to 86% of patients, median hospitalization was 4 days (interquartile range, 3–6), and pediatric intensive care unit admission rate 8.9%. Twenty-nine patients (11.8%) developed neurologic events, febrile seizures being the most frequent, followed by nonfebrile seizures and encephalopathy. Status epilepticus occurred in 4 children, and 69.6% of seizures recurred. Patients with a previous underlying condition were at greater risk of developing a neurologic complication [odds ratio (OR), 4.55; confidence interval (CI), 95% 1.23–16.81). Male sex (OR, 3.21; CI 95%, 1.22–8.33), influenza B virus (OR, 2.82; CI 95%, 1.14–7.14) and neurologic events (OR, 3.34; CI 95%, 1.10–10.19) were found to be risk factors for pediatric intensive care unit admission.

Conclusions:
A significant proportion of influenza-related hospitalized patients develop neurologic complications, especially seizures which may be prolonged or recurrent. Previous underlying conditions pose the greatest risk to neurologic events, which increase disease severity.

https://journals.lww.com/pidj/Fulltext/2020/09000/Neurologic_Complications_in_Children_Hospitalized.5.aspx

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COVID-19 – research evidence summaries – Royal College of Paediatrics and Child Health

Are children as likely as adults to acquire COVID-19?

Emerging evidence suggests that children may be less likely to acquire the disease. This is supported in countries that have undertaken widespread community testing, where lower case numbers in children than adults have been found.4 14 44 45 Between 16 January and 3 May 2020, 35,200 children in England were swabbed for SARS-CoV-2 and 1408 (4%) were positive. Children under 16 years old accounted for only 1.1% of positive cases.

Can children transmit the virus?

The importance of children in transmitting the virus is difficult to establish, particularly because of the number of asymptomatic cases, but there is some evidence that their role in transmitting the virus is limited…

https://www.rcpch.ac.uk/resources/covid-19-research-evidence-summaries#transmission

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Comparison of Clinical Features of COVID-19 vs Seasonal Influenza A and B in US Children – JAMA

No statistically significant differences in the rates of hospitalization, admission to the intensive care unit, and mechanical ventilator use between children with COVID-19 and those with seasonal influenza.

Question  What are the similarities and differences in clinical features between coronavirus disease 2019 (COVID-19) and seasonal influenza in US children?

Findings  In this cohort study of 315 children with COVID-19 and 1402 children with seasonal influenza, there were no statistically significant differences in the rates of hospitalization, admission to the intensive care unit, and mechanical ventilator use between the 2 groups. More patients with COVID-19 than with seasonal influenza reported fever, diarrhea or vomiting, headache, body ache, or chest pain at the time of diagnosis.

Meaning  The findings suggest that prevention of both COVID-19 and seasonal influenza in US children is prudent and urgent for the well-being of this population.

https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2770250

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Diagnosing COVID-19 infection: the danger of over-reliance on positive test results – medRxiv

Unlike previous epidemics, in addressing COVID-19 nearly all international health organizations and national health ministries have treated a single positive result from a PCR-based test as confirmation of infection, even in asymptomatic persons without any history of exposure. This is based on a widespread belief that positive results in these tests are highly reliable. However, data on PCR-based tests for similar viruses show that PCR-based testing produces enough false positive results to make positive results highly unreliable over a broad range of real-world scenarios. This has clinical and case management implications, and affects an array of epidemiological statistics, including the asymptomatic ratio, prevalence, and hospitalization and death rates. Steps should be taken to raise awareness of false positives, reduce their frequency, and mitigate their effects. In the interim, positive results in asymptomatic individuals that haven’t been confirmed by a second test should be considered suspect.

https://www.medrxiv.org/content/10.1101/2020.04.26.20080911v3

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16 Possible Factors for Sweden’s High Covid Death Rate among the Nordics –

What accounts for Sweden’s high Covid death rate among the Nordics? One factor could be Sweden’s lighter lockdown. But we suggest 15 other possible factors. Most significant are: (1) the “dry-tinder” situation in Sweden (we suggest that this factor alone accounts for 25 to 50% of Sweden’s Covid death toll); (2) Stockholm’s larger population; (3) Sweden’s higher immigrant population; (4) in Sweden immigrants probably more often work in the elderly care system; (5) Sweden has a greater proportion of people in elderly care; (6) Stockholm’s “sport-break” was a week later than the other three capital cities; (7) Stockholm’s system of elderly care collects especially vulnerable people in nursing homes. Other possible factors are: (8) the Swedish elderly and health care system may have done less to try to cure elderly Covid patients; (9) Sweden may have been relatively understocked in protective equipment and sanitizers; (10) Sweden may have been slower to separate Covid patients in nursing homes; (11) Sweden may have been slower to implement staff testing and changes in protocols and equipage; (12) Sweden elderly care workers may have done more cross-facility work; (13) Sweden might have larger nursing homes; (14) Stockholmers might travel more to the Alpine regions; (15) Sweden might be quicker to count a death “a Covid death.” We give evidence for these other 15 possible factors. It is plausible that Sweden’s lighter lockdown accounts for but a small part of Sweden’s higher Covid death rate.

https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3674138

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Exposure to common cold coronaviruses can teach the immune system to recognize SARS-CoV-2 – MedicalXpress

  • Your immune system’s ‘memory’ T cells keep track of the viruses they have seen before.
  • New study led by scientists at La Jolla Institute for Immunology (LJI) shows that memory helper T cells that recognize common cold coronaviruses also recognize matching sites on SARS-CoV-2, the virus that causes COVID-19.
  • Having a strong T cell response, or a better T cell response may give you the opportunity to mount a much quicker and stronger response.
  • 40%-60% of people never exposed to SARS-CoV-2 had T cells that reacted to the virus showing that their immune systems recognized the virus.
  • This finding turned out to be a global phenomenon and was reported in people from the Netherlands, Germany, the United Kingdom and Singapore.
  • This discovery suggests that fighting off a common cold coronavirus can induce cross-reactive T cell memory against SARS-CoV-2.

https://medicalxpress.com/news/2020-08-exposure-common-cold-coronaviruses-immune.html

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Preliminary report on surgical mask induced deoxygenation during major surgery – PubMed (2008)

Abstract
Objectives: This study was undertaken to evaluate whether the surgeons’ oxygen saturation of hemoglobin was affected by the surgical mask or not during major operations.

Methods: Repeated measures, longitudinal and prospective observational study was performed on 53 surgeons using a pulse oximeter pre and postoperatively.

Results: Our study revealed a decrease in the oxygen saturation of arterial pulsations (SpO2) and a slight increase in pulse rates compared to preoperative values in all surgeon groups. The decrease was more prominent in the surgeons aged over 35.

Conclusions: Considering our findings, pulse rates of the surgeon’s increase and SpO2 decrease after the first hour. This early change in SpO2 may be either due to the facial mask or the operational stress. Since a very small decrease in saturation at this level, reflects a large decrease in PaO2, our findings may have a clinical value for the health workers and the surgeons.

https://pubmed.ncbi.nlm.nih.gov/18500410/

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Association of contact to small children with mild course of COVID-19 – medRxiv

It is known that severe COVID-19 cases in small children are rare. If a childhood-related infection would be protective against severe course of COVID-19, it would be expected that adults with intensive and regular contact to small children also may have a mild course of COVID-19 more frequently. To test this hypothesis, a survey among 4,010 recovered COVID-19 patients was conducted in Germany. 1,186 complete answers were collected. 6.9% of these patients reported frequent and regular job-related contact to children below 10 years of age and 23.2% had own small children, which is higher than expected. In the relatively small subgroup with intensive care treatment (n=19), patients without contact to small children were overrepresented. These findings are not well explained by age, gender or BMI distribution of those patients and should be validated in other settings.

https://www.medrxiv.org/content/10.1101/2020.07.20.20157149v1

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A country level analysis measuring the impact of government actions, country preparedness and socioeconomic factors on COVID-19 mortality and related health outcomes – The Lancet

Lockdowns may reduce the peak of transmission and recovery rates but not the number of critical cases or overall mortality.

Lastly, government actions such as border closures, full lockdowns, and a high rate of COVID-19 testing were not associated with statistically significant reductions in the number of critical cases or overall mortality.

…full lockdowns and early border closures may lessen the peak of transmission, and thus prevent health system overcapacity, which would facilitate increased recovery rates.

https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(20)30208-X/fulltext

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Masking lack of evidence with politics – CEBM

This recent crop of trials added 9,112 participants to the total randomised denominator of 13,259 and showed that masks alone have no significant effect in interrupting the spread of ILI or influenza in the general population, nor in healthcare workers.

The small number of trials and lateness in the pandemic cycle is unlikely to give us reasonably clear answers and guide decision-makers. This abandonment of the scientific modus operandi and lack of foresight has left the field wide open for the play of opinions, radical views and political influence.

https://www.cebm.net/covid-19/masking-lack-of-evidence-with-politics/

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Treatment with hydroxychloroquine, azithromycin, and combination in patients hospitalized with COVID-19 – International Journal of Infectious Diseases

  • As of May 27, 2020 there are over 1,678,843 confirmed cases of COVID-19 claiming more than 100,000 lives in the Unites States. Currently there is no known effective therapy or vaccine.
  • According to a protocol-based treatment algorithm, among hospitalized patients, use of hydroxychloroquine alone and in combination with azithromycin was associated with a significant reduction in-hospital mortality compared to not receiving hydroxychloroquine.
  • Findings of this observational study provide crucial data on experience with hydroxychloroquine therapy, providing necessary interim guidance for COVID-19 therapeutic practice.

https://www.ijidonline.com/article/S1201-9712(20)30534-8/fulltext

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Why no-one can ever recover from COVID-19 in England – a statistical anomaly – CEBM

Here, it seems that PHE regularly looks for people on the NHS database who have ever tested positive, and simply checks to see if they are still alive or not. PHE does not appear to consider how long ago the COVID test result was, nor whether the person has been successfully treated in hospital and discharged to the community. Anyone who has tested COVID positive but subsequently died at a later date of any cause will be included on the PHE COVID death figures.

By this PHE definition, no one with COVID in England is allowed to ever recover from their illness. A patient who has tested positive, but successfully treated and discharged from hospital, will still be counted as a COVID death even if they had a heart attack or were run over by a bus three months later.

https://www.cebm.net/covid-19/why-no-one-can-ever-recover-from-covid-19-in-england-a-statistical-anomaly/

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Preventing a covid-19 pandemic – BMJ

A randomized placebo-controlled trial in children showed that flu shots increased fivefold the risk of acute respiratory infections caused by a group of noninfluenza viruses, including coronaviruses. (Cowling et al, Clin Infect Dis 2012;54:1778) From Table 3, vaccine recipients had 20 noninfluenza virus-positive ARIs and 19 virus-negative ARIs; non-recipients had 3 noninfluenza virus-positive ARIs and 14 virus-negative ARIs. These figures yield an odds ratio of 4.91 (CI 1.04 to8.14).

Such an observation may seem counterintuitive, but it is possible that influenza vaccines alter our immune systems non-specifically to increase susceptibility to other infections; this has been observed with DTP and other vaccines. (Benn et al, Trends in Immunology, May 2013) There are other immune mechanisms that might also explain the observation.

https://www.bmj.com/content/368/bmj.m810/rr-0

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Coronavirus Disease 2019 (COVID-19) Testing – CDC

A positive test result shows you may have antibodies from an infection with the virus that causes COVID-19. However, there is a chance a positive result means that you have antibodies from an infection with a virus from the same family of viruses (called coronaviruses), such as the one that causes the common cold.

Regardless of whether you test positive or negative, the results do not confirm whether or not you are able to spread the virus that causes COVID-19. 

https://www.cdc.gov/coronavirus/2019-ncov/testing/serology-overview.html

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An Outbreak of Common Colds at an Antarctic Base after Seventeen Weeks of Complete Isolation – JSTOR (1973)

17-week perfect Antarctic quarantine and someone still contracted a coronavirus.

https://www.jstor.org/stable/3862013?seq=1

Commentary by Professor Michael Levitt:

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Masks are neither effective nor safe: A summary of the science – Colleen Huber (NMD)

A review of the peer-reviewed medical literature examines impacts on human health, both immunological, as well as physiological.  The purpose of this paper is to examine data regarding the effectiveness of facemasks, as well as safety data.  The reason that both are examined in one paper is that for the general public as a whole, as well as for every individual, a risk-benefit analysis is necessary to guide decisions on if and when to wear a mask.

https://www.primarydoctor.org/masks-not-effect

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Advice on the use of masks in the context of COVID-19 – WHO

Transmission:

According to the current evidence, COVID-19 virus is primarily transmitted between people via respiratory droplets and contact routes. Droplet transmission occurs when a person is in close contact (within 1 metre) with an infected person and exposure to potentially infective respiratory droplets occurs.

N95 vs medical masks:

Meta-analyses in systematic literature reviews have reported that the use of N95 respirators compared with the use of medical masks is not associated with any statistically significant lower risk of the clinical respiratory illness outcomes or laboratory-confirmed influenza or viral infections.

Wearing masks by the general public:

There is limited evidence that wearing a medical mask by healthy individuals in households, in particular those who share a house with a sick person, or among attendees of mass gatherings may be beneficial as a measure preventing transmission.

At present, there is no direct evidence (from studies on COVID-19 and in healthy people in the community) on the effectiveness of universal masking of healthy people in the community to prevent infection with respiratory viruses, including COVID-19.

At the present time, the widespread use of masks by healthy people in the community setting is not yet supported by high quality or direct scientific evidence and there are potential benefits and harms to consider.

https://www.who.int/publications/i/item/advice-on-the-use-of-masks-in-the-community-during-home-care-and-in-healthcare-settings-in-the-context-of-the-novel-coronavirus-(2019-ncov)-outbreak

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Interim Guidance for the Use of Masks to Control Seasonal Influenza Virus Transmission – CDC

Persons who are diagnosed with influenza…should remain at home until the fever is resolved for 24 hours…and the cough is resolving to avoid exposing other members of the public. If such symptomatic persons cannot stay home during the acute phase of their illness, consideration should be given to having them wear a mask in public places when they may have close contact with other persons. 

No recommendation can be made at this time for mask use in the community by asymptomatic persons, including those at high risk for complications, to prevent exposure to influenza viruses.

https://www.cdc.gov/flu/professionals/infectioncontrol/maskguidance.htm

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Robust T cell immunity in convalescent individuals with asymptomatic or mild COVID-19 – bioRxiv

“[R]oughly twice as many people have developed T-cell immunity compared with those who we can detect antibodies in.

SARS-CoV-2-specific memory T cells will likely prove critical for long-term immune protection against COVID-19. We systematically mapped the functional and phenotypic landscape of SARS-CoV-2-specific T cell responses in a large cohort of unexposed individuals as well as exposed family members and individuals with acute or convalescent COVID-19. Acute phase SARS-CoV-2-specific T cells displayed a highly activated cytotoxic phenotype that correlated with various clinical markers of disease severity, whereas convalescent phase SARS-CoV-2-specific T cells were polyfunctional and displayed a stem-like memory phenotype. Importantly, SARS-CoV-2-specific T cells were detectable in antibody-seronegative family members and individuals with a history of asymptomatic or mild COVID-19. Our collective dataset shows that SARS-CoV-2 elicits robust memory T cell responses akin to those observed in the context of successful vaccines, suggesting that natural exposure or infection may prevent recurrent episodes of severe COVID-19 also in seronegative individuals.

https://www.biorxiv.org/content/10.1101/2020.06.29.174888v1.full