H5N1

Epidemiology of Covid-19 in a long-term care facility in King County, Washington

Via NEJM: Epidemiology of Covid-19 in a Long-Term Care Facility in King County, Washington.

BACKGROUND 

Long-term care facilities are high-risk settings for severe outcomes from outbreaks of Covid-19, owing to both the advanced age and frequent chronic underlying health conditions of the residents and the movement of health care personnel among facilities in a region. 

METHODS 

After identification on February 28, 2020, of a confirmed case of Covid-19 in a skilled nursing facility in King County, Washington, Public Health–Seattle and King County, aided by the Centers for Disease Control and Prevention, launched a case investigation, contact tracing, quarantine of exposed persons, isolation of confirmed and suspected cases, and on-site enhancement of infection prevention and control.  

RESULTS 

As of March 18, a total of 167 confirmed cases of Covid-19 affecting 101 residents, 50 health care personnel, and 16 visitors were found to be epidemiologically linked to the facility. Most cases among residents included respiratory illness consistent with Covid-19; however, in 7 residents no symptoms were documented. Hospitalization rates for facility residents, visitors, and staff were 54.5%, 50.0%, and 6.0%, respectively. The case fatality rate for residents was 33.7% (34 of 101). As of March 18, a total of 30 long-term care facilities with at least one confirmed case of Covid-19 had been identified in King County.  

CONCLUSIONS 

In the context of rapidly escalating Covid-19 outbreaks, proactive steps by long-term care facilities to identify and exclude potentially infected staff and visitors, actively monitor for potentially infected patients, and implement appropriate infection prevention and control measures are needed to prevent the introduction of Covid-19.

Q&A: New York emergency room doctor says it’s just getting 'worse and worse’

Via Caixin Global: Q&A: New York Emergency Room Doctor Says It’s Just Getting 'Worse and Worse’. Note the reference to a doctor becoming reinfected; I haven't heard of that before. Excerpt:

Nineteen shifts in 22 days. 

That’s what New York City emergency room (ER) doctor Calvin Sun has worked since the Covid-19 outbreak began in the city. As a per-diem doctor, Sun works on something like a freelance basis, picking up shifts at whichever hospital in the city has a 10- to 12-hour hole to fill in its ER schedule. This experience has given him a broad perspective about the state of the city’s emergency rooms as New York has become the epicenter of the U.S. outbreak. On Thursday, the day Sun spoke with Caixin, the state of New York recorded 562 deaths from Covid-19. 

Sun described the increasingly desperate-looking situation at New York City ERs, as younger, sicker patients seek treatment in droves even as the local health care system strains under the pressure. Some hospitals are setting up tents outside to handle surging patient numbers, while personal protective equipment (PPE) is in short supply that Sun has been taking donations to keep himself kitted out in “cobbled together” gear. 

This interview has been edited for length and clarity.  

Caixin: When did you start dealing with Covid-19? 

Dr. Calvin Sun: I started working at exactly 7 a.m. on March 8. I was co-leading a trip in Angola up until March 7 at 6 p.m. And then my first shift was 7 a.m. the next morning. So, once I landed, I got immediately straight to work and I haven’t stopped since. 

I think I’ve worked 19 shifts in the last 22 days. So tomorrow will be my 20th shift — I just picked it up five minutes ago because a doctor just got reinfected with Covid-19. And Saturday, I just picked up another shift for another doctor that got infected with Covid-19. 

How many hours can you rest in between shifts? 

I’m a per-diem, so I work however much as I want. I usually do 10- to 12-hour shifts — tomorrow’s is 10 hours, Saturday is nine hours, yesterday’s was 12 hours. But when I go home, I go home — you know, go to sleep.  

How has the situation changed in the past month or so? 

It has just been getting worse and worse. The patients are coming in sicker. They are coming in younger. More patients are coming in. The volume is higher. And more field tents are being set out outside the hospitals to manage the surge capacity. And we’re running low on resources. It was already understaffed and difficult before this pandemic.  

There have been reports of shortages of PPE and medical workers. Have you seen improvement on these fronts?  

Everything is a sign of progress in terms of effort, and trying to fill in the holes … We need to fight this pandemic as a warlike effort, but it’s just that I think there was a difficulty in the supply chain in getting us equipment because the other countries that were (producing) this personal protective equipment were shut down because they were also fighting this pandemic … We’re just doing our best right now by the ingenuity of the people who are staying at home, who are not working. They’re creating masks. They’re trying to give donations. They donating to the right people. And I’m accepting personal private donations. I’m distributing to my friends if I have too much of anything. And yeah, we’re just making a huge effort right now to make sure everyone is adequately protected. 

My PPE is cobbled together for the many different emergency rooms that I work in. I’m lucky — if that’s even a word I can use nowadays — to be per diem, so I have access to different emergency rooms and their equipment. But every emergency room is always lacking something. It’s always something different. But I put something together for myself and have been getting by until my family and loved ones were able to donate something that was a little more comprehensive. 

Are many medical workers getting sick?  

It’s part of the nature of our work that we get sick … Every patient that we take care of — we’re exposed to what they have, and sometimes we get sick.  

This is a little scarier because we’re getting sick with a virus that we know very little about. And it kills people very quickly. Unlike cancer or heart attacks — more people die from those — but people die in a more drawn out setting — a few heart attacks a day. But with Covid-19, you get infected really, really quickly because it is so contagious … It’s like, McDonald’s sells 2.5-3 billion hamburgers every year. That’s a lot, but they can handle it, right? But imagine you drive up to a McDonald’s and ask for 50,000 burgers in one day. That’s going to overwhelm the system, and that’s what we’re dealing with right now.

How are the emergency rooms operating right now?

Just because you have a quarantine doesn’t mean the rates of heart attacks are less. Maybe (there is) less trauma because there are fewer people outside, but every now and then I still get the occasional motor vehicle accident that comes into the emergency room, and we have to take care of them too. And when they come in, they may get exposed to Covid-19 just simply because a lot of our emergency rooms are structured as one giant room where patients are separated by curtains. Instead of every patient getting their own rooms. We just don’t have that space in a place like New York City.

What are you thinking every time you go to a shift?

It is scary. You’re battling a virus that you don’t know, that’s an invisible enemy, that’s very infectious — and you can bring that home.

I can imagine it being daunting for anyone in our shoes to rush, you know, into a burning building, fighting a fire that you cannot see. Inhaling all that smoke. Not adequately protected — naked — as the building is about to collapse on you. And your job is to try to get everyone outside of this burning building before it completely collapses, but you’re also trapped inside. That’s how I usually feel.

But personally, I’m trained for this … Disaster medicine is my thing … But I can’t speak on behalf of my colleagues who may not have signed up for things like that and may not be interested in that area of emergency medicine. So, it is something that a lot of us are adjusting to.

Italian doctors’ fatalities reach tragic levels as they fight COVID-19 in overburdened hospitals

Via The Globe and Mail, a report by Eric Reguly: Italian doctors’ fatalities reach tragic levels as they fight COVID-19 in overburdened hospitals. Excerpt, with my bolding:

In Italy they’re known as the Camici Bianchi – the White Coats – and they’re falling in the line of duty in tragic numbers. 

The White Coats are the doctors who have died treating COVID-19 patients in overburdened hospitals and other health facilities. By Friday, 74 had died since Italy recorded its first coronavirus death on Feb. 21. No other country – including China, where the pandemic began in December – has seen so many doctors succumb to the disease. 

Italians are treating them as heroes and know their names. The Italian National Federation of Orders of Surgeons and Dentists (FNOMCeO) publishes a list of the deceased doctors on its website under a black ribbon. The dates of their deaths and their medical specialties are all the information that is given. Profiles of the prominent ones fill the news and obituary pages of Italian newspapers. 

The doctor fatalities are sure to rise because of the sheer intensity of the COVID-19 outbreak in Italy – which recorded 14,681 deaths by Friday night – the recruitment of elderly, retired doctors and shortages of high-quality personal protective equipment (PPE). By the end of the week, about 10,000 Italian hospital workers of every description had tested positive for the novel coronavirus. That’s about 8 per cent of Italy’s 120,000 cases. Published medical reports suggest that infections among Chinese medical workers was half that rate.  

Serious questions are being asked in Italy and elsewhere in Europe about why so many Italian doctors died and what lessons can be learned from their sacrifices, even if it seems certain that medical workers’ daily exposure to COVID-19 hospital wards means that none of them can be fully shielded from the highly contagious disease.

I'm posting the Italian doctors' website on the COVID-19 Links list.

‘It is a very dire situation’: At least 600 nursing, retirement homes in Canada have COVID-19 cases

Via The Globe and Mail: ‘It is a very dire situation’: At least 600 nursing, retirement homes in Canada have coronavirus cases. Excerpt:

The new coronavirus has invaded at least 600 nursing and retirement homes across Canada, including hundreds in Quebec, a situation that has overwhelmed front-line caregivers and left frightened families scrambling for information about loved ones they can’t visit. 

Canada’s coronavirus epidemic has caused more devastation in seniors’ homes than anywhere else in the country, with at least 75 known COVID-19 deaths among residents of such facilities, according to a tally done by The Globe and Mail after contacting provincial and local health authorities. 

Among the hardest hit are the 65-bed Pinecrest Nursing Home in the Ontario cottage-country town of Bobcaygeon, where 14 residents have died; the Lynn Valley Care Centre in North Vancouver, where at least 11 have died, and the Notre-Dame-de-la-Merci personal care home in Montreal’s Ahuntsic-Cartierville borough, where seven seniors have died. 

Seven Oaks, a 259-bed long-term-care home owned by the City of Toronto, announced six new deaths on Wednesday, bringing the total to eight.  

Staying away from seniors’ homes is now “a question of life and death,” Quebec Premier François Legault said on Wednesday as his government revealed that 519 of the province’s 2,200 seniors’ homes have at least one case of COVID-19. 

That is 109 more assisted-living complexes and personal-care homes with cases than Quebec reported on Monday.  

The novel coronavirus has gained a foothold in so many nursing and retirement homes across the country that front-line caregivers – many of whom have fallen ill with COVID-19 symptoms – and public-health officials are struggling to protect residents who are not already infected.  

COVID-19 is deadliest in people over 80, and the virus that causes it has whipped through seniors’ facilities. 

“Long-term-care homes are literally begging us to redeploy [personal support workers] out to them," said Miranda Ferrier, president of the Ontario Personal Support Workers Association. “It is a very dire situation.”

US: Health care workers see wave of COVID-19 coming in their ranks

Via NBC News: Health care workers see wave of coronavirus coming in their ranks. Excerpt:

WASHINGTON — With U.S. public health experts warning of a cresting wave of coronavirus infections in the coming weeks, rates of transmission among the nation’s front-line fighters — doctors, nurses and other medical staff — are setting off alarm bells.  

Disparities in testing and tracking in many states — and the lack of national data — make the actual infection rates among medical personnel difficult to pin down. Still, state health departments in Ohio and Minnesota are reporting that up to 20 percent of those infected are health care professionals, a number in line with Italy and other hard-hit regions of the world. 

In Ohio, the percentage of health care workers infected recently ticked up to 18 percent from 16 percent of all coronavirus cases, health department spokesperson Melanie Amato told NBC News. In Minnesota, as of early this week, the Department of Health confirmed approximately 1 in 5 diagnosed cases were health workers, with the caveat that health workers probably have better access to testing. Italian hospital shows how medics can avoid COVID-19 infection APRIL 1, 202003:31 

In Italy, the country hardest hit by the virus so far, 20 percent of health care professionals have become infected, according to a recent update in the medical journal The Lancet. Most of those were in the country’s northern Lombardy region, where the virus has been especially lethal.  

Dr. Barak Mevorak, a U.S.-trained doctor and health technology expert advising governmental health departments worldwide, said the U.S. lags behind Asian countries in knowing how to protect front-line workers. Asia, and China in particular, were hit hard by outbreaks of avian flu in the early 2000s and swine flu in 2009.  

"What China learned a while ago is the supplies were not the bottleneck at the end. The bottleneck was the staff because everybody was sick,” Mevorak said. “That’s something the U.S. hasn’t learned yet." 

At issue is the availability of personal protective equipment (PPE) for health care workers in the U.S. 

In China and South Korea, doctors treating COVID-19 — the illness caused by the coronavirus — are typically clothed in full-body Tyvek jumpsuits and N95 masks. U.S. medical personnel, by contrast, are often left to treat highly infectious patients in standard cloth gowns and surgical masks. Some hospitals are even threatening to fire health-care workers who publicize their working conditions, Bloomberg News reported. 

Governors across the country are pleading for additional PPE for their states. The situation has grown so dire that many health care workers have taken to social media to plead for adequate protective gear. The Centers for Disease Control and Prevention also relaxed its standards, including encouraging professionals to reuse masks and even use bandanas if necessary. 

A physician at a New York City hospital who spoke on the condition of anonymity said that while it is difficult to determine precisely, more than 20 percent of the hospital’s staff could have COVID-19, including doctors, nurses and aides. “We are short of everything and everybody.”

Spain sees slight decline in number of new COVID-19 deaths

Via TheLocal.es: LATEST: Spain sees slight decline in number of new coronavirus deaths. The attrition among healthcare workers is grim. Excerpt:

Spain confirmed another 812 deaths in 24 hours from the coronavirus on Monday, a slight decline on the previous day's toll, bringing the total number of deaths to 7,340.  

The country, which has the world's second most deadly outbreak after Italy, recorded 838 deaths from the pandemic on Sunday, its third straight daily record for coronavirus deaths.  

The growth in the number of new confirmed cases also slowed, posting a one-day rise of 8.0 percent to 85,195, according to the health ministry, compared to a 20-percent rise on Wednesday. 

However, Spain has now joined the United States and Italy in having more cases than China, where the virus first appeared in December and which had confirmed 81,439 cases as of Sunday evening. 

The breakdown of the cases by region, including the number of hospitalised, dead and recovered was published on Monday morning.          

Spain's healthcare system is struggling to cope with the surge of seriously ill patients all at once, with hotels and conference centres being used as temporary clinics and Madrid's largest ice rink turned into a provisional morgue.    

"While the isolation measures have reduced the pressure on intensive care units, in the coming weeks it will be significant," said Maria Jose Sierra of the health ministry's emergencies centre in reference to the lockdown measures the country has imposed. 

The medical director of Barcelona's Hospital Clinic, Antoni Castells, said his staff would soon have to start to "rationalise the resources it uses based on the possibility that a patient will survive." 

"The situation gets more complicated each day," he added in an interview with Spanish public radio RNE.  

The outbreak is also taking its toll on healthcare personnel, who complain of a lack of masks and other protective material.      

As of Monday, over 12,200 medical staff were infected, up from around 9,500 on Friday, according to the health ministry. 

US: Nurses die, doctors fall sick and panic rises on COVID-19 front lines

Via The New York Times: Nurses Die, Doctors Fall Sick and Panic Rises on Virus Front Lines. Excerpt:

A supervisor urged surgeons at Columbia University Irving Medical Center in Manhattan to volunteer for the front lines because half the intensive-care staff had already been sickened by coronavirus. 

“ICU is EXPLODING,” she wrote in an email.  

A doctor at Weill Cornell Medical Center in Manhattan described the unnerving experience of walking daily past an intubated, critically ill colleague in her 30s, wondering who would be next. 

Another doctor at a major New York City hospital described it as “a petri dish,” where more than 200 workers had fallen sick. 

Two nurses in city hospitals have died. 

The coronavirus pandemic, which has infected more than 30,000 people in New York City, is beginning to take a toll on those who are most needed to combat it: the doctors, nurses and other workers at hospitals and clinics. In emergency rooms and intensive care units, typically dispassionate medical professionals are feeling panicked as increasing numbers of colleagues get sick.

“I feel like we’re all just being sent to slaughter,” said Thomas Riley, a nurse at Jacobi Medical Center in the Bronx, who has contracted the virus, along with his husband.

Medical workers are still showing up day after day to face overflowing emergency rooms, earning them praise as heroes. Thousands of volunteers have signed up to join their colleagues.  

But doctors and nurses said they can look overseas for a dark glimpse of the risk they are facing, especially when protective gear has been in short supply. 

In China, more than 3,000 doctors were infected, nearly half of them in Wuhan, where the pandemic began, according to Chinese government statistics. Li Wenliang, the Chinese doctor who first tried to raise the alarm about Covid-19, eventually died of it.  

In Italy, the number of infected heath care workers is now twice the Chinese total, and the National Federation of Orders of Surgeons and Dentists has compiled a list of 50 who have died. Nearly 14 percent of Spain’s confirmed coronavirus cases are medical professionals. 

New York City’s health care system is sprawling and disjointed, making precise infection rates among medical workers difficult to calculate. A spokesman for the Health and Hospitals Corporation, which runs New York City’s public hospitals, said the agency would not share data about sick medical workers “at this time.” 

William P. Jaquis, president of the American College of Emergency Physicians, said the situation across the country was too fluid to begin tracking such data, but he said he expected the danger to intensify. 

 “Doctors are getting sick everywhere,” he said. 

Last week, two nurses in New York, including Kious Kelly, a 48-year-old assistant nurse manager at Mount Sinai West, died from the disease; they are believed to be the first known victims among the city’s medical workers. Health care workers across the city said they feared many more would follow.

BREAKING: Italy records steep rise in COVID-19 deaths with almost 1,000 fatalities in 24 hours

Via TheLocal.it: BREAKING: Italy records steep rise in coronavirus deaths with almost 1,000 fatalities in 24 hours. The fatalities are reportedly 50 more than Worldometer's tally, just below:

Italy recorded a shocking spike in coronavirus deaths Friday with 969 new victims, the worst daily record for any country since the pandemic began. 

The infection rate however continued its downward trend, with the civil protection agency reporting nearly 86,500 confirmed cases in Italy -- a 7.4 percent increase, down from around 8.0 percent in previous days. 

Earlier, experts said Italy's coronavirus epidemic could peak in the next few days, but regional authorities warned the crisis was far from over, as four more frontline doctors died.  

The national health institute (ISS) cautiously suggested lockdown measures to curb the spread of the disease -- which has claimed over 8,100 lives and infected some 80,000 people -- may soon bear fruit.  

"I want to be clear on one point. We have not peaked yet," the institute's head Silvio Brusaferro said. "There are signs of a slowdown, which makes us believe that we are close, we could peak in the next few days."  

But virologist Fabrizio Pregliasco warned that would not translate into a go-ahead to ease lockdown measures.  

The slight slowing in case numbers "should strengthen our desire to continue. We must not drop our guard."

Spain hits new one-day record for COVID-19 fatalities with 769 more deaths in 24 hours

Via TheLocal.es: LATEST: Spain records new one-day record for coronavirus fatalities with 769 more deaths in 24 hours. Excerpt:

The death toll in Spain soared over 4,800 Friday after 769 people died in 24 hours, in what was a record one-day figure for fatalities. 

Health ministry figures showed the number of deaths reaching 4,858, while cases jumped to 64,059, although the rate of new infections appeared to be slowing, registering a 14 percent increase compared with 18 percent a day earlier.

Spain has the world's second-highest death toll after Italy, and has so far suffered 4,858 deaths, while the number of cases jumped to 64,059.    

Although the figures showed a daily increase of nearly 8,000 new infections, the uptick comes as Spain moves to dramatically increase its rate of testing, ordering millions of new kits from around the world. 

Despite the increase, the rate of new infections appears to be slowing, registering a 14 percent increase compared with 18 percent on Thursday.    

Fernando Simon, the health ministry's emergencies coordinator described the figure as "promising" saying it showed that the flattening trend of the curve"was ongoing".  

"There is a clear stabilisation," he said, with the figures indicating "that, little-by-little, we're reaching the peak". 

The surge in numbers has brought the medical system to the brink of collapse, with Spain inking a major supply deal with China to source equipment and material to increase its capacity for testing, treatment and the protection of frontline workers.    

It has also seen a growing number of cases among healthcare personnel with 9,444 infected, Simon said, giving a figure which has nearly doubled since Tuesday when it stood at 5,400.

COVID-19 at Lynn Valley Care Centre: 'It was mayhem'

Via CBC News: 'It was mayhem'. Excerpt from a long report:

It had been a harrowing Sunday.  

One day after British Columbia's provincial health officer announced an outbreak of COVID-19 at North Vancouver's Lynn Valley Care Centre, the children of the long-term care home's aging residents descended on the facility. 

Deanna Harlow recalls a chaotic scene. Her sister told her there were only two people working on her 96-year-old father's floor. Some aides were in isolation, at home with suspected cases of the novel coronavirus. And replacements were scared to come to the facility. 

Residents were isolated in their rooms. Harlow estimates there must be about 45 units on the floor, each housing a patient. Many had complex problems. Catheters. Colostomy bags. Nearly all were wearing adult diapers.  

A nurse arrived, meaning that three employees were now tending to a floor that would normally require at least twice that many workers, Harlow said. 

The families pitched in to deliver meals and tend to patient needs. 

"Several patients, they were bedridden with a wet, wet diaper and calling out incessantly for help," said Harlow. "It was just — it was mayhem."  

Another woman who was at the facility says a clutch of daughters gathered together at the end of a heart-rending day. 

"We were all in there together," she said. "And one of the women said, 'We need to let people know about this, because it's already too late for this care home.'"  

A little more than two weeks later, that dire prediction appears to be largely accurate.  

The death toll at the Lynn Valley Care Centre remains a moving target after it recorded Canada's first COVID-19 death on March 8. Ten more residents have since passed. And more than 40 additional patients have tested positive for the virus, along with 21 staff members.