H5N1

Why saliva testing for COVID-19 in Canada won't be a panacea for long lineups any time soon

Via CBC News: Why saliva testing for COVID-19 in Canada won't be a panacea for long lineups any time soon. Excerpt:

Canadians in several provinces face long lines for a swab to help diagnose COVID-19 as school and workplaces open. While new testing technologies could help, doctors say they won't be a silver bullet.   

The gold standard swab of the nose or throat can be uncomfortable. In contrast, a key promise of saliva tests is that people could collect saliva themselves so that fewer nurses and other health professionals would be needed at assessment centres, as staffing is one of the factors that can drive up wait times.  

But that ideal won't happen immediately. Currently in Canada, both saliva collection and testing remain a research project that regulators are closely evaluating.   

There are three main barriers to overcome before saliva tests roll out widely.   

Gobs of saliva vary in how fluid they can be, so collecting a high-quality sample can be a challenge even for something as non-invasive as spitting into a cup. The next hurdle for scientists is to get accurate and consistent results on the presence of the virus. Finally, clinicians need to determine how well the test results help them to correctly identify those with the disease.  

Dr. Mel Krajden, medical director of the public health laboratory at the BC Centre for Disease Control, said health professionals face a quandary in finding the best ways to support a return to school, with all of its formative benefits for students, while protecting the oldest people at highest risk for severe consequences from COVID-19, such as grandparents or parents who are vulnerable because they have other health conditions. 

Krajden said in his experience, saliva testing works better with COVID-19 patients in hospital than on people living in the community who've tried it as part of a research project. His Vancouver lab is working on a simpler approach to collection than the traditional nasal swab using a saline gargle that seems to work in older children.  

On Thursday, British Columbia announced it's introducing a new mouth rinse, gargle and spit test for students from kindergarten to Grade 12 to make it easier for children and teenagers to check whether they have COVID-19.  But this new test is only offered to school age kids, and only in B.C. 

"What we need to be thinking through is what is the best mixture of tests and how are they best supplied?" Krajden said. "You want to have the right balance between convenience and sensitivity."

Dr. McCance-Katz, Trump mental health official, accuses media of overblowing dangers of Covid-19

Via CNN: Dr. McCance-Katz, Trump mental health official, accuses media of overblowing dangers of Covid-19. Excerpt:

(CNN)The assistant secretary of the Substance Abuse and Mental Health Services Administration, Dr. Elinore McCance-Katz, accused the media of being dishonest about the coronavirus pandemic and reiterated talking points about Covid-19 that President Donald Trump has pushed for months, including complaints that schools should reopen for in-person learning and that very few children are affected by Covid-19.  

"I just wish that the media would get honest about its coverage of Covid," McCance-Katz told embattled Department of Health and Human Services spokesman Michael Caputo in the HHS "Learning Curve" podcast Friday. "For children this is not a life-threatening illness." 

McCance-Katz, who was appointed to SAMHSA by Trump in 2017, acknowledged that children do get severe symptoms from the virus "in rare cases," but said "with a great, great majority of children this is not a serious illness," something Trump has also repeated for months. 

"And when we put them in school with safety measures in place, why can't they go to school?" she said at one point in the interview. 

Many studies have shown children do get Covid-19 and do die from it. They also can spread the virus to others. The American Academy of Pediatrics says more than 500,000 children have been diagnosed with the infection. 

"So, lost in all of this response to Covid and nonstop 24/7 horrors of Covid and if you can't find something to talk about, it appears to me they make things up. It just does," McCance-Katz said at another point in the interview, referring to media coverage of the pandemic. 

McCance-Katz also expressed dismay with the way states have tried to handle the surging pandemic. 

"There was no agreement to this nonstop restriction and quarantining and isolation and taking away anything that makes people happy," she said. "You can't go to a movie. You can't go to a football game." 

McCance-Katz, a psychiatrist with a Yale doctorate in infectious disease epidemiology, argued at one point that the shutdown last spring was too severe. 

"I'm going to say it," she said. "We shut down the entire country before the virus, in my opinion, had a chance to get around the entire country. ... We used a sledgehammer when I think we needed a scalpel." 

She contended the shutdown itself, not the pandemic, actually killed thousands. 

"When you shut down an entire healthcare system, when you do that, you want to talk about the vulnerabilities, the obesity, the diabetes, the cardiovascular disease, the pulmonary diseases that puts you at greater risk for morbidity and mortality from Covid, but you take away the people's ability to get any health care," she said. 

"All you're doing is making certain that if they do become infected, it's going to have the maximum possible negative effect on them and it will end in death for thousands -- which is what we're seeing, and it's just awful." 

McCance-Katz argued that getting the economy and schools reopened is integral for Americans' mental health.

Bill Gates on COVID-19, vaccines and global health

Via The New York Times: Bill Gates on Coronavirus, Vaccines and Global Health. Excerpt:

On Monday, the Bill and Melinda Gates Foundation released the fourth of its annual Goalkeeper reports, which track the slow but steady progress the world has made toward more than a dozen health-related goals set forth by the United Nations in 2015.

This year’s was unrelentingly grim. The coronavirus pandemic has scorched away years of work: More families are in dire poverty, malnutrition is increasing, far fewer children are getting immunized. 

The assessment comes as the United States, stung harder by the virus than any other country, is retreating from the global health stage and seems focused primarily on saving itself. Could it ever return to its role as the world’s leader in both competence and generosity? In an interview with The New York Times, Mr. Gates devoted a half-hour to explaining why he was optimistic that it would. 

“It’s my disposition,” he said. “Plus, I’ve got to call these people up and make the pitch to them that this really makes sense — and I totally, totally believe it makes sense.”

By “these people,” he was referring to leading figures in the White House and Congress, whom he has personally lobbied to do “this”: namely, add an extra $4 billion to the fiscal stimulus package now under debate in Congress so that poor countries can get Covid-19 vaccines.  

Ultimately his goal is far more ambitious: to double American foreign aid from less than 0.25 percent of gross domestic product to 0.5 percent or more. He sees the pandemic as an opportunity to do that. 

“As they say,” he added cheerily, “the U.S. government — after it’s tried every other thing — does the right thing.” 

As he did in Silicon Valley while battling competitors and antitrust regulators, Mr. Gates can calculate his chances of success with a ruthless logic. That has rarely been as true as it is now, as a once-in-a-century pandemic devastates the impoverished countries where he focuses his giving.  

The damage has been wrought less by the virus — so far it has killed much smaller percentages of the populations of Asia and Africa than of the Americas and Western Europe — than by the economic impact, which has been far greater in countries where people and governments “have no spare reserves to draw on,” Mr. Gates said. 

The collapse of tourism, declines in remittances from relatives working abroad, the shutdown of ports, mines and oil wells, school closings and new stresses on fragile health care systems have all created enormous suffering. 

Not since 1870 have so many countries been in recession at once, according to the Goalkeeper report. Between 1990 and 2020, the percentage of the world’s population living in extreme poverty, which is now defined as living on less than $2 a day, shrank to less than 7 percent from 37 percent. In just the past few months, 37 million people have fallen back below the line, the report estimated.  

“The longer the pandemic lasts, the worse its economic scars will be,” it added.

No masks, no distancing: Schools in Denmark defy COVID-19 — with success so far

Via CBC News: No masks, no distancing: Schools in Denmark defy COVID-19 — with success so far. Excerpt:

Every seat in Jens Rodgaard's Grade 5 class is full — there is no physical distance at all.   

When a student raises their hand with a question, Rodgaard is by their side in an instant and leans in to help. 

"You have to be around them and help them, help them with spelling, help them make choices, and for proper teaching we can't do that with the distance," said Rodgaard. 

Students must sanitize their hands every time they enter the school and the grades aren't supposed to mingle with each other. But there isn't a mask in sight.   

This is what Phase 2 of school reopening looked like at Alholm public school in Copenhagen, Denmark, this week, a month into the second semester.  

"Right now we are trying to make things as normal as possible, [to] not scare any kids," said Rodgaard, who has taught at Alholm for 28 years. 

The school's goal is to make the experience of education as normal as possible during the COVID-19 pandemic.

Other schools have more rules in place. At this stage, Denmark is allowing each school to come up with its own COVID-19 safety plans. 

Right now, the country's strategy of containing the coronavirus seems to be working. Countries around the world, including Canada, have looked at the Danish model in designing their own school plans. 

Hygiene standard was 'first priority' 

Denmark wasn't hit by COVID as badly as other countries in Europe, like Italy and Spain, but it nonetheless went into lockdown in March. When the government started removing restrictions, it prioritized opening schools over bars and restaurants. The rules were strict at the time amid concerns there would be outbreaks.

"Our first priority was to ensure that the hygiene standard was good," said Alholm headmaster Soren Vith, who said the school followed all the government-mandated protocols back in Phase 1 of reopening. 

Extra teachers were hired so classes could be divided into three groups, breaks were staggered, each class was assigned to specific toilets and, when possible, learning was done outside.

As Covid-19 cases soar in Spain, new school year comes too soon for some

Via France24: As Covid-19 cases soar in Spain, new school year comes too soon for some. Excerpt:

With coronavirus cases surging as a new school year begins, many Spanish parents are refusing to send their children back to class despite the threat of sanctions. 

"You have your whole life to learn, but if you lose your health, that's it," says Aroa Miranda, a 37-year-old mother-of-two who won't send her boys to school this week when term resumes in the coastal town of Castellon de la Plana.  

Like its European neighbours, Spain is reopening schools this month despite the rapid spread of the virus, with the country counting the highest number of new infections on the continent. 

"Going back to school is being treated like an experiment, we're like guinea pigs," said Miranda, who is about to take her three-year-old off the nursery school list, which is voluntary at his age.  

"For my eight-year-old, I will pretend he's ill so I don't have to send him to school." 

Although masks are obligatory in school for anyone aged six and over and social distancing measures have been put in place, she doesn't think it's enough.  

"If I can't meet with more than 10 people in my home, I don't understand why my son has to be in class with 25 children," she railed. "This is an absurd safety risk." 

'Risk-free doesn't exist' 

For weeks now, there have been a growing number of protests and petitions across Spain to demand better health and safety measures in schools. 

An international Ipsos poll in July found most Spanish parents would back limiting the number of days children are in school, with one in four preferring to wait four to six months before sending them back.

Symptomatic and asymptomatic viral shedding in pediatric patients infected with SARS-CoV-2

An editorial in JAMA Pediatrics: Symptomatic and Asymptomatic Viral Shedding in Pediatric Patients Infected With Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). Excerpt:

Since the global emergence and spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), initial attention appropriately focused on severely affected adults, who represent the highest proportion of symptomatic infections. However, as the pandemic has evolved, a significant effect on children has also become evident. Data from multiple affected countries have corroborated that children are clearly susceptible to infection and may develop severe primary and unique secondary inflammatory complications of infection, including multisystem inflammatory syndrome of children.

However, the vast majority of infected children have mild or unrecognized disease, and this population may play important epidemiologic roles by potentiating spread of infection through communities and/or boosting herd immunity. Only small numbers of children have been included in prior studies focused on kinetics of viral shedding in the setting of symptomatic or asymptomatic SARS-CoV-2 infection. To our knowledge, no prior studies have systematically focused on the frequency of asymptomatic infection in children or the duration of symptoms and viral shedding in both asymptomatic and symptomatic children. 

Han and colleagues provide data accumulated from 22 centers throughout South Korea that address this important knowledge gap. The unique structure of the South Korean public health system facilitated large-scale testing, aggressive contact tracing and testing, and isolation/direct observation of asymptomatic or mildly symptomatic children in designated health care facilities (rather than home quarantine). This structure allowed for the sequential observation, testing (median testing interval of every 3 days), and comparison of 91 asymptomatic, presymptomatic, and symptomatic children with mild to moderate upper and lower respiratory tract infection, identified primarily by contact tracing from laboratory-proven cases.  

The first important take-home point from this study is that not all infected children have symptoms, and even those with symptoms are not necessarily recognized in a timely fashion. A major strength of this study is the inclusion of asymptomatic children (20 of 91 [22%]), presymptomatic children (18 of 91 [20%]), and symptomatic children (53 of 91 [58%]). Most symptomatic infected children had experienced symptoms a median (range) of 3 (1-28) days prior to being diagnosed by testing, despite the fact that they were presumably under closer scrutiny by nature of being identified as a known contact. 

Presymptomatic children remained symptom free for a median (range) of 2.5 (1-25) days before exhibiting any symptoms, despite detectable virus. Only a minority of children (6 [7%]) were identified as infected by testing performed concurrent with onset of their symptoms. This highlights the concept that infected children may be more likely to go unnoticed either with or without symptoms and continue on with their usual activities, which may contribute to viral circulation within their community. 

The authors’ inclusion of asymptomatic patients in the study is particularly important and has rarely been addressed in the pediatric population. Interestingly, this study aligns with adult data in which up to 40% of adults may remain asymptomatic in the face of infection. The true burden of unrecognized asymptomatic disease is still not known but is emerging as both viral molecular testing as well as antibody testing to establish seroprevalence have become more broadly available and applied. Application of these methodologies to specifically characterize the pediatric population is sorely needed. 

In the absence of test-based strategies for social reentry or the ability to aggressively perform contact tracing, asymptomatic infected individuals remain undetected and not isolated. The study by Han et al13 corroborates that children are no exception. In this study, the authors estimate that 85 infected children (93%) would have been missed using a testing strategy focused on testing of symptomatic patients alone. 

A surveillance strategy that tests only symptomatic children will fail to identify children who are silently shedding virus while moving about their community and schools. In regions where use of face masks is not widely accepted or used by the general public, asymptomatic carriers may serve as an important reservoir that may facilitate silent spread through a community.

Preventing and mitigating SARS-CoV-2 transmission — four overnight camps, Maine, June–August 2020

Via MMWR: Preventing and Mitigating SARS-CoV-2 Transmission — Four Overnight Camps, Maine, June–August 2020. The summary:

What is already known about this topic?  

Nonpharmaceutical interventions (NPIs) have been shown to decrease spread of communicable disease. Data on the effectiveness of NPIs on the prevention and mitigation of SARS-CoV-2 transmission among children and adolescents in congregate settings are limited. 

What is added by this report?  

During the 2020 summer camp season, four Maine overnight camps with 1,022 attendees from 41 states and international locations implemented a multilayered prevention and mitigation strategy that was successful in identifying and isolating three asymptomatic COVID-19 cases and preventing secondary transmission.  

What are the implications for public health practice? 

Understanding successful interventions to prevent and mitigate SARS-CoV-2 transmission in overnight camps has important implications for similar congregate settings such as day camps and schools with the same age range.

Clinical characteristics of children and young people admitted to hospital with covid-19 in United Kingdom

Via The BMJ: Clinical characteristics of children and young people admitted to hospital with covid-19 in United Kingdom: prospective multicentre observational cohort study. The abstract:

Objective To characterise the clinical features of children and young people admitted to hospital with laboratory confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in the UK and explore factors associated with admission to critical care, mortality, and development of multisystem inflammatory syndrome in children and adolescents temporarily related to coronavirus disease 2019 (covid-19) (MIS-C).  

Design Prospective observational cohort study with rapid data gathering and near real time analysis. 

Setting 260 hospitals in England, Wales, and Scotland between 17 January and 3 July 2020, with a minimum follow-up time of two weeks (to 17 July 2020).  

Participants 651 children and young people aged less than 19 years admitted to 138 hospitals and enrolled into the International Severe Acute Respiratory and emergency Infections Consortium (ISARIC) WHO Clinical Characterisation Protocol UK study with laboratory confirmed SARS-CoV-2.  

Main outcome measures Admission to critical care (high dependency or intensive care), in-hospital mortality, or meeting the WHO preliminary case definition for MIS-C. 

Results Median age was 4.6 (interquartile range 0.3-13.7) years, 35% (225/651) were under 12 months old, and 56% (367/650) were male. 57% (330/576) were white, 12% (67/576) South Asian, and 10% (56/576) black. 42% (276/651) had at least one recorded comorbidity. 

A systemic mucocutaneous-enteric cluster of symptoms was identified, which encompassed the symptoms for the WHO MIS-C criteria. 18% (116/632) of children were admitted to critical care. On multivariable analysis, this was associated with age under 1 month (odds ratio 3.21, 95% confidence interval 1.36 to 7.66; P=0.008), age 10-14 years (3.23, 1.55 to 6.99; P=0.002), and black ethnicity (2.82, 1.41 to 5.57; P=0.003). Six (1%) of 627 patients died in hospital, all of whom had profound comorbidity. 

11% (52/456) met the WHO MIS-C criteria, with the first patient developing symptoms in mid-March. Children meeting MIS-C criteria were older (median age 10.7 (8.3-14.1) v 1.6 (0.2-12.9) years; P<0.001) and more likely to be of non-white ethnicity (64% (29/45) v 42% (148/355); P=0.004). Children with MIS-C were five times more likely to be admitted to critical care (73% (38/52) v 15% (62/404); P<0.001). 

In addition to the WHO criteria, children with MIS-C were more likely to present with fatigue (51% (24/47) v 28% (86/302); P=0.004), headache (34% (16/47) v 10% (26/263); P<0.001), myalgia (34% (15/44) v 8% (21/270); P<0.001), sore throat (30% (14/47) v (12% (34/284); P=0.003), and lymphadenopathy (20% (9/46) v 3% (10/318); P<0.001) and to have a platelet count of less than 150 × 109/L (32% (16/50) v 11% (38/348); P<0.001) than children who did not have MIS-C. No deaths occurred in the MIS-C group. 

Conclusions Children and young people have less severe acute covid-19 than adults. A systemic mucocutaneous-enteric symptom cluster was also identified in acute cases that shares features with MIS-C. This study provides additional evidence for refining the WHO MIS-C preliminary case definition. Children meeting the MIS-C criteria have different demographic and clinical features depending on whether they have acute SARS-CoV-2 infection (polymerase chain reaction positive) or are post-acute (antibody positive).

Children and COVID-19: State-level data report

A news release from the American Academy of Pediatrics: Children and COVID-19: State-Level Data Report.

State-level reports are the best publicly available data on child COVID-19 cases in the United States. The American Academy of Pediatrics and the Children’s Hospital Association are collaborating to collect and share all publicly available data from states on child COVID-19 cases (definition of “child” case is based on varying age ranges reported across states; see report Appendix for details and links to all data sources).  

On August 20, the age distribution of reported COVID-19 cases was provided on the health department websites of 49 states, New York City, the District of Columbia, Puerto Rico, and Guam. While children represented only 9.3% of all cases in states reporting cases by age, over 442,000 children have tested positive for COVID-19 since the onset of the pandemic.

A smaller subset of states reported on hospitalizations and mortality by age, but the available data indicated that COVID-19-associated hospitalization and death is uncommon in children.  

At this time, it appears that severe illness due to COVID-19 is rare among children. However, states should continue to provide detailed reports on COVID-19 cases, testing, hospitalizations, and mortality by age so that the effects of COVID-19 on children’s health can be documented and monitored. 

Summary of Findings Reported on 8/20/20: 

(Note: Data represent cumulative counts since states began reporting) 

Cumulative Number of Child COVID-19 Cases* 

• 442,785 total child COVID-19 cases reported, and children represented 9.3% (442,785/4,766,825) of all cases  

• Overall rate: 583 cases per 100,000 children in the population 

Change in Child COVID-19 Cases, 8/6/20 – 8/20/20 

• 74,160 new child cases reported from 8/6-8/20 (358,469 to 432,629), a 21% increase in child cases over 2 weeks 

Testing (9 states reported)* 

• Children made up between 4%-12.1% of total state tests, and between 3.2%-17.8% of children tested were tested positive 

Hospitalizations (21 states and NYC reported)* 

• Children were 0.4%-4.6% of total reported hospitalizations, and between 0.2%-8.6% of all child COVID-19 cases resulted in hospitalization 

Mortality (45 states and NYC reported)* 

• Children were 0%-0.3% of all COVID-19 deaths, and 21 states reported zero child deaths  

 • In states reporting, 0%-0.7% of all child COVID-19 cases resulted in death  

*Note: Data represent cumulative counts since states began reporting; All data reported by state/local health departments are preliminary and subject to change; ^ In making this 2-week comparison, the count excludes Alabama due to change in definition of child case as of 8/13; see full report.

Pediatric SARS-CoV-2: Clinical presentation, infectivity, and immune responses

Via The Journal of Pediatrics: Pediatric SARS-CoV-2: Clinical Presentation, Infectivity, and Immune Responses. The abstract:

Objectives 

As schools plan for re-opening, understanding the potential role children play in the coronavirus infectious disease 2019 (COVID-19) pandemic and the factors that drive severe illness in children is critical. 

Study design: Children ages 0-22 years with suspected severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection presenting to urgent care clinics or being hospitalized for confirmed/suspected SARS-CoV-2 infection or multisystem inflammatory syndrome in children (MIS-C) at Massachusetts General Hospital (MGH) were offered enrollment in the MGH Pediatric COVID-19 Biorepository. Enrolled children provided nasopharyngeal, oropharyngeal, and/or blood specimens. SARS-CoV-2 viral load, ACE2 RNA levels, and serology for SARS-CoV-2 were quantified. 

Results 

A total of 192 children (mean age 10.2 +/- 7 years) were enrolled. Forty-nine children (26%) were diagnosed with acute SARS-CoV-2 infection; an additional 18 children (9%) met criteria for MIS-C. Only 25 (51%) of children with acute SARS-CoV-2 infection presented with fever; symptoms of SARS-CoV-2 infection, if present, were non-specific. Nasopharyngeal viral load was highest in children in the first 2 days of symptoms, significantly higher than hospitalized adults with severe disease (P = .002). Age did not impact viral load, but younger children had lower ACE2 expression (P=0.004). IgM and IgG to the receptor binding domain (RBD) of the SARS-CoV-2 spike protein were increased in severe MIS-C (P<0.001), with dysregulated humoral responses observed. 

Conclusion 

This study reveals that children may be a potential source of contagion in the SARS-CoV-2 pandemic in spite of milder disease or lack of symptoms, and immune dysregulation is implicated in severe post-infectious MIS-C.