To those of us on the actual front lines of health care, the depth and extent of misinformation is mind boggling. I get into discussions online and it never ceases to amaze me how pervasive misinformation is.
I spent much of my career in teaching hospitals. Getting the best information is crucial. When you are a medical school faculty member you have to be sure the information you are sharing with medical student and resident physicians is factually correct.
How do we do that? Well, in most medical schools we rely on an online clinical decision support tool known as UPTODATE. This tool is the king of the hill as a reliable reference for quality information. The guest editors of UPTODATE are the world’s foremost authorities in their field. Each is required to maintain a topic summary in their identified areas of expertise and to update that summary in real time as new quality data is published. With UPTODATE, physicians always have the latest information at their finger tips.
So here is the latest from UPTODATE on COVID:
Evidence is growing that physical fitness confers benefit in those infected with COVID-19. In a retrospective, nationwide study performed in South Africa of over 65,000 people participating in a physical activity rewards program, those with high physical activity levels (>150 minutes/week) suffered substantially lower morbidity from complications of COVID-19 infection than those with low physical activity levels (<60 minutes/week). Patients with high activity levels prior to becoming infected experienced lower rates of hospitalization, intensive care unit admission, mechanical ventilation, and death. These findings emphasize the importance of maintaining exercise programs during the pandemic.
Persistent symptoms following acute COVID-19 infection (eg, long COVID) are common. Recent evidence suggests that the prevalence of persistent symptoms may vary depending on the COVID-19 variant. In an observational study including over 97,000 vaccinated individuals in the United Kingdom, subsequent infection with the Omicron variant was associated with a lower risk of developing persistent symptoms compared with Delta (4.5 versus 10.8 percent). Findings were consistent regardless of the interval between vaccination and infection. However, methodologic issues (eg, self-reporting through an electronic "app" and shorter duration of follow-up for Omicron versus Delta patients) limit the interpretation of these findings, and further research is needed.
A longer recovery course is expected in patients with COVID-19 who require hospitalization; however, patients who never require hospitalization also often report prolonged and persistent symptoms. In a recent study that compared the presence of persistent symptoms in patients with mild COVID-19 with symptoms in controls who had no history or serologic evidence of previous COVID-19, a higher proportion of patients with COVID-19 had two persistent symptoms at five months (55 versus 13 percent). Most symptoms (i.e., fatigue, dyspnea, parosmia, and concentration impairment) were similar to previous reports. Patients recovering from COVID-19 also had a shorter six-minute walk distance (560 versus 590 meters) and a lower quality of life. No significant differences were found in routine laboratory and rheumatologic tests, inflammatory or immunologic markers, pulmonary function tests, echocardiography, neurocognitive testing, or serologic tests for SARS-CoV-2. Further data are needed to improve our understanding of the cause of persistent symptoms in patients recovering from mild COVID-19.
Based upon limited data suggesting a potential benefit, awake pronation has been used as a strategy to avoid intubation in patients with acute hypoxemic respiratory failure due to COVID-19. However, two recent trials in this population did not find a difference in intubation rates, length of stay, or mortality with awake pronation versus standard of care . As an example, in one of the trials, the intubation rate with pronation was 34 versus 41 percent (hazard ratio 0.81, 95% CI 0.59-1.12). While pronation was associated with higher levels of oxygen support on day 5, the clinical significance of this is uncertain given the lack of difference at subsequent timepoints. Because there were methodologic issues with these studies and the imprecise effect estimates suggest that a benefit cannot be ruled out, we continue to suggest awake pronation in this population until further data become available.
As of June 2022, the US Food and Drug Administration (FDA) has authorized BNT162b2 (Pfizer COVID-19 vaccine) and mRNA-1273 (Moderna COVID-19 vaccine) for use in children 6 months and older. Trials in children 6 months to 11 years have demonstrated that these vaccines, given at lower doses, elicit neutralizing immune responses comparable to those in adolescents and adults following standard doses . Vaccination also reduces the risk of symptomatic COVID-19 in these populations, although the estimates of effect vary, in part because of different variants prevalent during the trials. There were no cases of vaccine-associated myocarditis in the trials; the precise risk is uncertain but is expected to be lower than that seen in older individuals. We agree with recommendations from the Centers for Disease Control and Prevention to give BNT162b2 or mRNA-1273 to children ages 6 months to 11 years.
COVID-19 is a hypercoagulable state, and thromboprophylaxis with low molecular weight (LMW) heparin is appropriate during hospitalization. The intensity of anticoagulation (prophylactic versus therapeutic dosing) is individualized based on the patient's thrombotic and bleeding risks. UpToDate contributors generally suggest therapeutic dose LMW heparin for medical inpatients who are not critically ill (non-intensive care unit [ICU]), consistent with new guidelines from the American Society of Hematology and National Institutes of Health. Individuals in the ICU and those hospitalized with another illness who are incidentally found to be infected with SARS-CoV-2 are generally treated with prophylactic dose LMW heparin. Many factors influence the degree of hypercoagulability, including viral variants, underlying medical conditions, and available therapies.
For individuals with COVID-19 and risk factors for progression to severe disease, nirmatrelvir-ritonavir reduces the risk of hospitalization. However, "rebound" COVID-19 (recrudescent symptoms with a return of positive rapid antigen testing) has been reported in some patients several days after initial improvement and conversion to negative testing following completion of treatment. There are no reports of severe disease in such circumstances, and consistent with guidance from the United States Centers for Disease Control and Prevention, we do not repeat treatment with nirmatrelvir-ritonavir (or any other COVID-19-specific therapy) in these patients. Individuals who develop rebound COVID-19 following nirmatrelvir-ritonavir treatment should restart the isolation period.
The monoclonal antibody combination tixagevimab-cilgavimab is a potential option for pre-exposure prophylaxis against COVID-19 for certain immunocompromised individuals who may not benefit maximally from vaccination and for those who have a contraindication to vaccination. In a placebo-controlled, randomized trial of over 5000 unvaccinated adults, a single dose of tixagevimab-cilgavimab reduced the risk of symptomatic infection by 77 percent. Overall, serious adverse event rates were similar to those with placebo. However, among individuals with cardiovascular risk, severe cardiac events were rare but more frequent with tixagevimab-cilgavimab. For those who meet eligibility criteria, we individualize the decision to use tixagevimab-cilgavimab, taking into account risk of exposure and severe disease, underlying comorbidities, and patient preference.
Croup has increasingly been recognized as a manifestation of COVID-19 in young children, particularly during the Omicron surge. It is unclear whether the severity of illness or response to treatment differs between COVID-19-associated croup and other viral croup etiologies. The largest case series included 75 children with COVID-19-associated croup. Most patients were treated with dexamethasone (97 percent); 37 percent of patients received racemic epinephrine. A large majority of patients (88 percent) responded well and were discharged from the emergency department. Among patients requiring hospitalization, most required repeated doses of racemic epinephrine and dexamethasone; four children required intensive care. No patients required invasive ventilation or died. These findings suggest that most patients with COVID-19-related croup can be successfully managed with standard croup therapies.
In the United States, the Food and Drug Administration authorized and the Centers for Disease Control and Prevention (CDC) recommends a second booster dose of an mRNA COVID-19 vaccine (given at least four months after the first) for individuals who are >50 years old or are ≥12 years old and have certain immunocompromising conditions . The CDC also indicates that a second booster dose with an mRNA vaccine is an option for any individual who received Ad26.COV2.S (Janssen/Johnson and Johnson) for both the primary and booster doses. Vaccine effectiveness following a primary series and single booster dose appears to wane, and observational studies suggest that a second booster dose is associated with increased protection against severe COVID-19 and death.
In April 2022, the US Food and Drug Administration (FDA) expanded approval for remdesivir treatment of COVID-19 to include children ≥28 days of age who weigh ≥3 kg . Indications include hospitalization and, for outpatients, mild to moderate COVID-19 with a high risk of progression to severe disease. The FDA based approval on clinical trials in adults and a single-arm, open-label study in 53 hospitalized children ≥28 days of age, in which remdesivir was associated with improvement in clinical status. We make decisions about the use of remdesivir in children with SARS-CoV-2 infection on a case-by-case basis.
In the United States, the US Food and Drug Administration recently authorized a breathalyzer that can detect exhaled volatile organic compounds specific to SARS-CoV-2 infection. The contraption is the size of a small suitcase and returns results in approximately three minutes. Compared with polymerase chain reaction on nasopharyngeal swab in asymptomatic and symptomatic individuals, sensitivity and specificity of the breathalyzer were 91 and 99 percent. More detailed performance data, as well as other information such as cost, are necessary to inform the optimal role of this device in COVID-19 diagnosis.
Symptoms of upper respiratory tract infection (URI) are the most common manifestations of nonsevere COVID-19, although the relative frequency of each symptom may vary by viral variant. In an observational study evaluating the reported clinical symptoms of over 63,000 confirmed COVID-19 cases between two time periods (during Delta variant predominance and Omicron variant predominance), nasal congestion, headache, sneezing, and sore throat were the most common presenting symptoms . Sore throat was more common and alteration or loss of smell was less common during the time period of Omicron predominance. As new variants emerge, the predominant URI symptoms of COVID-19 may continue to change.
Accumulating evidence supports the efficacy of high-titer convalescent plasma for the treatment of outpatients with nonsevere COVID-19. In a new trial that randomly assigned 1181 outpatients with nonsevere COVID-19 (80 percent unvaccinated) to receive high-titer convalescent plasma or control plasma within nine days of symptom onset, the risk of hospitalization was lower in the convalescent plasma group (2.9 versus 6.3 percent) . Pneumonia was more common with control plasma, and three deaths all occurred in the control group. Although other effective therapies are available for nonsevere COVID-19, high-titer convalescent plasma administered early in the disease course has a role for treating individuals at high risk of disease progression who lack access to these other therapies.
The acute cardiovascular (CV) complications of COVID-19 have been well described, but few studies have examined the association between COVID-19 and long-term CV outcomes. In a study that recorded the one-year incidence of CV disease among nearly 5.8 million United States veterans, patients who had COVID-19 had an increased risk of major adverse CV events (all-cause mortality, stroke, or myocardial infarction) at one year when compared with those who did not have COVID-19 (adjusted hazard ratio 1.55) . In addition, patients with more severe COVID-19 were more likely to develop CV disease than those who had less severe COVID-19. While no direct causal mechanism has been established between COVID-19 and CV disease, patients with COVID-19 may have a higher risk of long-term CV outcomes.
In February 2022, the Centers for Disease Control and Prevention updated their recommendations on mask-wearing, which now depend on the estimated COVID-19 community levels, a combined measure of local case counts, new COVID-19 hospital admissions, and the percent of staffed inpatient beds occupied by patients with COVID-19. At low community levels, masks are optional; at medium levels, individuals who are immunocompromised or otherwise at risk for severe disease should consider wearing masks for personal protection, and their close contacts should wear them in their presence; at high levels, all individuals should wear masks in indoor public settings. Masks are also recommended on public transportation, in health care settings, and for all persons who have suspected or documented COVID-19 or exposure to SARS-CoV-2, regardless of community level.
With predominance of the Omicron (B.1.1.529) SARS-CoV-2 variant in the United States, weekly COVID-19 hospitalization rates among children reached an all-time high in January 2022 (7.1 per 100,000 population). Hospitalization rates were particularly high (15.6 per 100,000 population) in children age 0 to 4 years, who are not eligible for vaccination. Despite increased rates of hospitalization, the proportion of children and adolescents requiring intensive care or invasive mechanical ventilation was lower with Omicron than earlier circulating strains. Greater proportions of unvaccinated than fully vaccinated adolescents had COVID-19 as the primary reason for hospitalization (70 versus 41 percent) and required intensive care (30 versus 16 percent), highlighting the benefits of vaccination.
Vaccination of nursing home (NH) staff against COVID-19 has lagged behind resident vaccination but impacts resident outcomes when community transmission is high. In a study of over 12,000 NHs, among facilities with the lowest versus highest staff vaccination coverage, there were an estimated 1.6 additional COVID-19 cases and 0.19 COVID-19-related deaths per hundred beds in counties with the highest prevalence of COVID-19. Efforts to improve staff acceptance of COVID-19 vaccination should continue to be a priority in the NH setting.
In December 2021, the United States Centers for Disease Control and Prevention (CDC) updated recommendations on home isolation for individuals with SARS-CoV-2 infection and post-exposure precautions in the community. For select immunocompetent patients with infection (eg, those who are asymptomatic; those with mild, improving infection), the duration of isolation was reduced from 10 to 5 days, followed by strict mask-wearing when around others for another 5 days. Following exposure, people should monitor for symptoms and wear masks when around others for 10 days; those not up-to-date on vaccination should quarantine at home for the first 5 days. Additional details on the role of testing and other restrictions during the post-infection or post-exposure period, as well as updated recommendations for quarantine and isolation for healthcare personnel can be found on the CDC website.
In solid organ transplant recipients, a third dose of a COVID-19 mRNA vaccine appears to improve the immune response; however, many have a weak response even after three prior doses. Data from three independent case series suggest that a fourth dose of an mRNA vaccine may increase antibody levels in some of these patients . In the largest of these studies, approximately half of the 92 kidney transplant recipients who received a fourth dose mounted an appropriate serologic response (antispike IgG titer >143 binding antibody units); however, similarly robust responses were not seen across all studies. Among patients who did not respond to previous doses, the likelihood of response to additional doses was low. Administration of more than three doses of mRNA vaccine is not routinely performed; for patients who are unable to respond to multiple vaccine doses, other strategies may be required to achieve immunity.
So there you have it. Quality information not the junk you find online from dubious doctors or political programs on TV disguised as news.