H5N1

COVID-19 survivors: Here's what recovery may look like

Via The New York Times: Coronavirus Survivors: Here's What Recovery May Look Like. Excerpt:

Hundreds of thousands of seriously ill coronavirus patients who survive and leave the hospital are facing a new and difficult challenge: recovery. Many are struggling to overcome a range of troubling residual symptoms, and some problems may persist for months, years or even the rest of their lives.  

Patients who are returning home after being hospitalized for severe respiratory failure from the virus are confronting physical, neurological, cognitive and emotional issues.  

And they must navigate their recovery process as the pandemic continues, with all of the stresses and stretched resources that it has brought. 

“It’s not just, ‘Oh, I had a terrible time in hospital, but thank goodness I’m home and everything’s back to normal,’” said Dr. David Putrino, director of rehabilitation innovation at Mount Sinai Health System in New York City. “It’s, ‘I just had a terrible time in hospital and guess what? The world is still burning. I need to address that while also trying to sort of catch up to what my old life used to be.’”  

It is still too early to say how recovery will play out for these patients. But here is a look at what they are experiencing so far, what we can learn from former patients with similar medical experiences, and the challenges that most likely lie ahead. 

What problems do patients experience after leaving the hospital? 

There are many. Patients may leave the hospital with scarring, damage or inflammation that still needs to heal in the lungs, heart, kidneys, liver or other organs. This can cause a range of problems, including urinary and metabolism issues.  

Dr. Zijian Chen, the medical director of the new Center for Post-Covid Care at Mount Sinai Health System, said the biggest physical problem the center was seeing was shortness of breath, which can be the result of lung or heart impairments or a blood-clotting problem. 

“Some have an intermittent cough that doesn’t go away that makes it hard for them to breathe,” he said. Some are even on nasal oxygen at home, but it is not helping them enough. 

Some patients who were on ventilators report difficulty swallowing or speaking above a whisper, a usually temporary result of bruising or inflammation from a breathing tube that passes through the vocal cords.

Many patients experience muscle weakness after lying in a hospital bed for so long, said Dr. Dale Needham, a critical care physician at Johns Hopkins School of Medicine and a leader in the field of intensive care recovery. As a result, they can have trouble walking, climbing stairs or lifting objects. 

Nerve damage or weakness can also whittle away muscle strength, Dr. Needham said. Neurological problems can cause other symptoms, too. Dr. Chen said that Mount Sinai’s post-Covid center has referred nearly 40 percent of patients to neurologists for issues like fatigue, confusion and mental fogginess. 

“Some of it is very debilitating,” he said. “We have patients who come in and tell us: ‘I can’t concentrate on work. I’ve recovered, I don’t have any breathing problems, I don’t have chest pain, but I can’t get back to work because I can’t concentrate.’”

Guillain-Barré syndrome associated with COVID-19 infection: A case report

Via ScienceDirect, a report in the Journal of Clinical Neuroscience: Guillain Barre syndrome associated with COVID-19 infection: A case report. This brings back very unhappy memories of Zika virus. The highlights and abstract:

Highlights 

• A novel coronavirus (COVID-19) was detected in Wuhan City, Hubei Province of China.  

• The most symptoms of disease have reported fever, cough, dyspnea, myalgia, headache, and diarrhea.  

• We described GBS symptoms in one infected patient with COVID-19, for the first time. 

• The patient revealed quadriplegia and facial paresis bilaterally, two weeks after COVID-19 infection. 

• The electrodiagnostic findings of patient demonstrated acute motor sensory axonal polyneuropathy. 

Abstract 

Novel outbreak with coronavirus 2019 began since 31 December 2019. Coronaviruses can cause multiple systemic infections that respiratory complications are the most obvious symptoms. In this report, we describe the symptoms of Guillain-Barré syndrome (GBS) in one infected patient with COVID-19, for the first time. We reported a 65-year-old male patient with complaints of acute progressive symmetric ascending quadriparesis. 

Two weeks prior to hospitalization, the patient suffered from cough, fever, and RT-PCR was reported positive for COVID-19 infection. The electrodiagnostic test showed that the patient is an AMSAN variant of GBS. COVID-19 stimulates inflammatory cells and produces various inflammatory cytokines and as a result, it creates immune-mediated processes. GBS is an immune-mediated disorder and molecular mimicry as a mechanism of autoimmune disorder plays an important role in creating it. 

It is unclear whether COVID-19 induces the production of antibodies against specific gangliosides. Further investigations should be conducted about the mechanism of GBS in patients with COVID-19, in the future.

5-year-old dies in NYC of rare illness linked to COVID-19

Via The New York Times: 5-Year-Old Dies in N.Y.C. of Rare Illness Linked to Virus. Now we have a new term: pediatric multisystem inflammatory syndrome, or PMIS.

A 5-year-old died in New York City on Thursday from what appeared to be a rare syndrome linked to the coronavirus that causes life-threatening inflammation in children, Gov. Andrew M. Cuomo said.  

It is believed to be the first known death in New York related to the mysterious new syndrome, which officials said began appearing in recent weeks.  

Mr. Cuomo said Friday that 73 children in New York area had been reported afflicted with the illness, which doctors have labeled “pediatric multisystem inflammatory syndrome.” 

He said the state Health Department was investigating whether other deaths of children were caused by the syndrome. 

“This would be really painful news and would open up an entirely different chapter,” Mr. Cuomo said. “Because I can’t tell you how many people I spoke to who took peace and solace in the fact that children were not getting infected.” 

According to the most recent breakdown from the state, three children under age 10 had died of the virus, out of more than 21,000 fatalities.  

In an apparently separate case, officials in Westchester County, just north of New York City, said on Friday that a child being treated there for the illness had died last week. 

The child suffered neurological complications from the syndrome, said Dr. Michael Gewitz, the physician-in-chief at Maria Fareri Children’s Hospital in Valhalla, where the child was being treated.  

The county’s health commissioner, Dr. Sherlita Amler, said that officials were still assessing whether underlying conditions might have been a factor in the child’s death.  

Mr. Cuomo also announced the state’s daily death toll: 216 more people died, a drop from the previous four days when about 230 people per day were dying.

Young people with COVID-19 are dying from strokes

Thanks to Mary Marshall for sending the link to this alarming report in The Washington Post: Young people with coronavirus are dying from strokes. Excerpt:

Thomas Oxley wasn’t even on call the day he received the page to come to Mount Sinai Beth Israel Hospital in Manhattan. There weren’t enough doctors to treat all the emergency stroke patients, and he was needed in the operating room. 

The patient’s chart appeared unremarkable at first glance. He took no medications and had no history of chronic conditions. He had been feeling fine, hanging out at home during the lockdown like the rest of the country, when suddenly, he had trouble talking and moving the right side of his body. Imaging showed a large blockage on the left side of his head. 

Oxley gasped when he got to the patient’s age and covid-19 status: 44, positive.  

The man was among several recent stroke patients in their 30s to 40s who were all infected with the coronavirus. The median age for that type of severe stroke is 74.  

As Oxley, an interventional neurologist, began the procedure to remove the clot, he observed something he had never seen before. On the monitors, the brain typically shows up as a tangle of black squiggles — “like a can of spaghetti,” he said — that provide a map of blood vessels. A clot shows up as a blank spot. As he used a needlelike device to pull out the clot, he saw new clots forming in real-time around it.  

“This is crazy,” he remembers telling his boss.

Stroke surge 

Reports of strokes in the young and middle-aged — not just at Mount Sinai, but also in many other hospitals in communities hit hard by the novel coronavirus — are the latest twist in our evolving understanding of its connected disease, covid-19. Even as the virus has infected nearly 2.8 million people worldwide and killed about 195,000 as of Friday, its biological mechanisms continue to elude top scientific minds. Once thought to be a pathogen that primarily attacks the lungs, it has turned out to be a much more formidable foe — impacting nearly every major organ system in the body.  

Until recently, there was little hard data on strokes and covid-19. 

There was one report out of Wuhan, China, that showed that some hospitalized patients had experienced strokes, with many being seriously ill and elderly. But the linkage was considered more of “a clinical hunch by a lot of really smart people,” said Sherry H-Y Chou, a University of Pittsburgh Medical Center neurologist and critical care doctor.  

Now for the first time, three large U.S. medical centers are preparing to publish data on the stroke phenomenon. The numbers are small, only a few dozen per location, but they provide new insights into what the virus does to our bodies.  

A stroke, which is a sudden interruption the blood supply, is a complex problem with numerous causes and presentations. It can be caused by heart problems, clogged arteries due to cholesterol, even substance abuse. Mini-strokes often don’t cause permanent damage and can resolve on their own within 24 hours. But bigger ones can be catastrophic.  

The analyses suggest coronavirus patients are mostly experiencing the deadliest type of stroke. Known as large vessel occlusions, or LVOs, they can obliterate large parts of the brain responsible for movement, speech and decision-making in one blow because they are in the main blood-supplying arteries.  

Many researchers suspect strokes in covid-19 patients may be a direct consequence of blood problems that are producing clots all over some people’s bodies.  

Clots that form on vessel walls fly upward. One that started in the calves might migrate to the lungs, causing a blockage called a pulmonary embolism that arrests breathing — a known cause of death in covid-19 patients. Clots in or near the heart might lead to a heart attack, another common cause of death. Anything above that would probably go to the brain, leading to a stroke.

Smell and taste dysfunction in patients with COVID-19

Via The Lancet Infectious Diseases: Smell and taste dysfunction in patients with COVID-19.

The plural of an anecdote is not evidence, yet anecdotal international reports are accumulating from ear, nose, and throat (ENT) surgeons and other health-care workers on the front lines that anosmia, with or without dysgeusia, are symptoms frequently associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. The American Academy of Otolaryngology—Head and Neck Surgery and the British Association of Otorhinolaryngology are now recommending these symptoms be added to the list of primary screening symptoms for COVID-19. 

Our understanding of an absent or diminished ability to smell or taste, resulting from a neurotropic or neurovirulent viral infection targeting the olfactory system, remains fragmentary and is largely historically informed. The clinical evaluation of the first cranial nerve (olfactory nerve or CN I) has all but dropped from history taking and physical examination; hence, it is often referred to by ENT professionals as the forgotten cranial nerve. 

To further complicate matters, immediate self-recognition of olfactory dysfunction is typically only present in the most severe cases, or it is only self-identified after a prolonged latency period. A scarcity of acute-phase advanced neuroimaging studies, difficulties in obtaining histopathological tissue specimens, and an absence of viral cultures of infected olfactory neuroepithelium compound the difficulties in studying this phenomenon. 

Moreover, in the context of normal trans-nasal airflow of odorant molecules (ie, no oedema in the nasal vault or olfactory cleft), and in the absence of intranasal disease (eg, infectious rhinosinusitis, allergic or vasomotor rhinitis, or polyposis), until now patients with sensorineural viral anosmia have been seldom seen in general otolaryngology practice—on the order of approximately one to two new-onset patients each year. Hence, up until the coronavirus disease 2019 (COVID-19) pandemic, the low prevalence of sensorineural viral anosmia in society as a whole has made clinical research challenging.  

Given the urgency and lethality of the current pandemic, knowledge obtained from front-line otolaryngologists who are currently managing and monitoring patients with COVID-19, and those with clinical experience in olfaction and rhinology, would have great value when transferred forward to deployed caregivers. Our multinational group, including one otolaryngologist currently infected with COVID-19 and experiencing anosmia and dysgeusia, suggest that physicians evaluating patients with acute-onset loss of smell or taste, particularly in the context of a patent nasal airway (ie, non-conductive loss), should have a high index of suspicion for concomitant SARS-CoV-2 infection. 

We have observed that traditional nasal cavity manifestations, as seen in other upper respiratory infections (eg, rhinovirus, influenza, and adenovirus), are commonly absent in patients with COVID-19. We have also observed that SARS-CoV-2 does not appear to generate clinically significant nasal congestion or rhinorrhoea—ie, a red, runny, stuffy, itchy nose. This observation suggests a neurotropic virus that is site-specific for the olfactory system. Although labelled as a respiratory virus, coronaviruses are known to be neurotropic and neuroinvasive. 

Finally, we and others have observed that anosmia, with or without dysgeusia, manifests either early in the disease process or in patients with mild or no constitutional symptoms. 

Nevertheless, it is still too early in our understanding of COVID-19 to definitively establish the incidence, as well as the full-spectrum clinical utility, of these symptoms.

Havana syndrome: Exposure to neurotoxin may have been cause, study suggests

Via CBC News: Havana syndrome: Exposure to neurotoxin may have been cause, study suggests. Excerpt:

The mysterious ailments experienced by some 40 Canadian and U.S. diplomats and their families while stationed in Cuba may have had nothing to do with sonic "attacks" identified in earlier studies.  

According to a new Canadian study, obtained by Radio-Canada's investigative TV program Enquête, the cause could instead be neurotoxic agents used in pesticide fumigation.  

A number of Canadians and Americans living in Havana fell victim to an unexplained illness starting in late 2016, complaining of concussion-like symptoms, including headaches, dizziness, nausea and difficulty concentrating. Some described hearing a buzzing or high-pitched sounds before falling sick.  

In the wake of the health problems experienced over the past three years, Global Affairs Canada commissioned a clinical study by a team of multidisciplinary researchers in Halifax, affiliated with the Brain Repair Centre, Dalhousie University and the Nova Scotia Health Authority.  

"The working hypothesis actually came only after we had most of the results," Dr. Alon Friedman, the study's lead author, said in an interview. 

The researchers identified a damaged region of the brain that is responsible for memory, concentration and sleep-and-wake cycle, among other things, and then looked at how this region could come to be injured.  

"There are very specific types of toxins that affect these kinds of nervous systems ... and these are insecticides, pesticides, organophosphates — specific neurotoxins," said Friedman. "So that's why we generated the hypothesis that we then went to test in other ways." 

Twenty-six individuals participated in the study, including a control group of people who never lived in Havana. The researchers — comprised of 15 principal investigators and their teams — conducted a thorough assessment of the Canadians' symptoms, including blood tests and several brain imaging tests.

"[The results] all support the diagnosis of acquired brain injury in the Canadian diplomats and their families posted in Cuba," the study report says.  

The scientists were also able to test several of the subjects before and after they returned from Cuba, Friedman noted, and the team saw changes in the brain "that are definitely due to that time when they were in Havana."

Zika was soaring across Cuba. Few outside the country knew

Via The New York Times: Zika Was Soaring Across Cuba. Few Outside the Country Knew. Excerpt and then a comment:

A previously unknown outbreak of the Zika virus swept across Cuba in 2017, a year after the global health emergency was declared over, scientists reported on Thursday.  

Until now, the Pan American Health Organization had no record of any Zika infection in Cuba in 2017, much less an outbreak. Following inquiries by The New York Times about the new study, published in the journal Cell, officials acknowledged that they had failed to tally 1,384 cases reported by Cuban officials that year.

That figure is a sharp increase over the 187 cases confirmed in 2016 and is “in line with the estimates for 2017 from our own study,” said Kristian Andersen, an infectious disease researcher at Scripps Research Translational Institute in La Jolla, Calif., and a co-author of the new study. 

Because most cases of Zika go unconfirmed, Dr. Andersen added, the outbreak actually may have comprised tens of thousands of infections.

 Cuba saw record tourism in 2017, raising the possibility that many travelers were unknowingly exposed. Some 4.7 million foreign visitors arrived that year, an increase of 16 percent over 2016. More than one million were Canadians.  

“If we want to stay ahead of communicable diseases, we need to know where they are and how many cases are occurring,” said Jennifer Gardy of the Bill & Melinda Gates Foundation in Seattle. “For some diseases in some settings, this is pretty straightforward. For others, like Zika, it isn’t.” 

Officials at P.A.H.O., an arm of the World Health Organization, blamed the failure to publish timely data on the Cuba outbreak on a “technical glitch.” The information was held in a database, they said, but not visible on the website. By Thursday afternoon, the website had been updated.

"Technical glitch" indeed. I blogged about this outbreak last December, when the Cell study appeared on bioRxiv. It's a very quiet scandal, reminiscent of PAHO/WHO's refusal to identify the source of Haiti's disastrous cholera outbreak in 2010 and thereafter. (And the Cubans were also very quiet about the cholera imported from Haiti by their own returning healthcare workers.)

Preparing for emerging infections means expecting new syndemics

A letter in The Lancet: Preparing for emerging infections means expecting new syndemics.

When several sources of morbidity come together to produce interlinked and worse health outcomes, they are sometimes called a syndemic. Research on syndemics explores how two or more diseases cluster together; how social, political, economic, and ecological factors drive those clusters; and how clustered conditions interact via biological, psychological, or social pathways. Syndemic interventions target underlying patterns of multidirectional causality to achieve better overall health in susceptible and often dispossessed populations. 

So far, syndemic theory has found limited traction in fields such as ecoepidemiology that dominate emerging infectious disease research, despite a natural fit for three major challenges: proliferation of closely-related emerging viruses; co-occurence with endemic infections; and broader interactions with other aspects of health, including non-communicable diseases, mental health, and stigma. We show the relevance of syndemics for ecoepidemiology by showing how each of these complicates our understanding of the Zika virus epidemic in Latin America and the Caribbean. 

First, the idea of a syndemic formalises existing knowledge about co-occurrence of Aedes mosquito-borne viruses. Dengue and chikungunya viruses have had substantial comorbidity and co-infection with the Zika virus, including at least one case of triple coinfection. Many studies implicitly examine the three viruses as syndemic but do not refer to this linkage using the term. All three viruses are linked through Aedes mosquitoes to urbanisation, driving a broad spatial correlation between poverty, chikungunya, and Zika congenital syndrome (ZCS) in Brazil. Thinking syndemically could lead to mosquito control and public health education that targets several Aedes-borne viruses at once. 

Second, syndemic thinking has the potential to broaden conversations about co-occurring morbidities without adding confusion about causality. After scientific consensus resolved that ZCS was responsible for Brazil's microcephaly epidemic, conversations about other possible drivers were mostly sidelined. However, Brazil is a global hotspot of congenital toxoplasmosis, and microcephaly cases attributable to toxoplasmosis were observed during the Zika virus outbreak. 

Zika, toxoplasmosis, and microcephaly could create a syndemic, even without links between toxoplasmosis and the 2015–16 ZCS epidemic; poverty and environmental degradation connect them, as could fear and stigma. Syndromic surveillance for emerging pathogens like Zika the virus might be weakened by syndemic clustering between endemic and emerging infections of similar pathology or etiology, especially in poor and undersurveilled populations. 

Third, sexual transmission of the virus and fetal effects of ZCS introduced two new topics—safe sex and abortion access—that had never before been extensively discussed in an arboviral outbreak. Already, work focused on the syndemic of Zika virus, HIV, and unintended pregnancy, has identified marital and cultural risk factors that can help target interventions such as condom use and social policy, emphasising the promise of syndemic thinking, and the need for social scientists' involvement in outbreak prevention and management. 

The long-term effects of Zika virus might also be syndemic, as surviving babies become adults with a range of disabilities and sequelae. Although virologists work tirelessly to understand ZCS, this basic medical research remains disconnected from broader anthropological inquiries about the ongoing social effects of Zika. Bridging this gap is imperative to understand and improve quality of life in affected communities. 

The Zika virus outbreak in Latin America and the Caribbean will not be the last major outbreak; several new outbreaks have been reported across India. Other diseases will also raise complicated issues regarding safe sex or access to safe and legal abortions, and virologists have begun to anticipate sexual transmission and teratogenic effects of other emerging viruses. Increased knowledge of these select pathogens can help emerging disease researchers plan for syndemics of the future.

DRC: 12 Kwango province health zones affected by Konzo disease

As if the DR Congo didn't have enough to deal with, province26.drc.net reports: DRC: 12 health zones affected by Konzo disease (Kwango). The Google translation, with a link to a definition of the disease:

Kwango Provincial Health Division Chief Pierre Mwela says 12 of the 14 health zones in the province are affected by Konzo disease. 

He said it Saturday, July 20 at Okapi Radio. 

The patients show signs of malnutrition and weaknesses in the upper and lower limbs. This disease affects the nerves of the individual and mainly causes paralysis of the lower limbs. The affected subject has deformed limbs and especially has difficulty walking because he has no balance, notes Mr. Mwela.  

The cause of this disease is mainly related to the consumption of cassava which has not experienced retting, a technique that eliminates the toxic substances of certain food plants. 

Pierre Mwela adds that several households are attacked. But to date, there is only preventive treatment. 

The Italian rights NGO ISCO sensitizes the population of Kwango on this disease which mainly affects children.  

According to Rachel Muwawa, ISCO's Communications Officer, this awareness concerns six sites already identified with 4,800 households. Targeted households will receive information needed to prevent this disease, the source said. 

Rachel Muwawa calls on the country's authorities to increase awareness and care for children and women with the disease.  

Konzo is a disease that dates back decades. It is experiencing a recrudescence, to date, following chronic malnutrition in this province, say the health authorities.

Impact of age-specific immunity on the timing and burden of the next Zika virus outbreak

Via bioRxiv: Impact of age-specific immunity on the timing and burden of the next Zika virus outbreak. The abstract:

The 2015-2017 epidemics of Zika virus (ZIKV) in the Americas caused widespread protective immunity. The timing and burden of the next Zika virus outbreak remains unclear. 

We used an agent-based model to simulate the dynamics of age-specific immunity to ZIKV, and predict the future age-specific risk using data from Managua, Nicaragua. We also investigated the potential impact of a ZIKV vaccine. Assuming lifelong immunity, the risk of a ZIKV outbreak will remain low until 2035 and rise above 50% in 2047. 

The imbalance in age-specific immunity implies that people in the 15-29 age range will be at highest risk of infection during the next ZIKV outbreak, increasing the expected number of congenital abnormalities. 

ZIKV vaccine development and licensure are urgent to attain the maximum benefit in reducing the population-level risk of infection and the risk of adverse congenital outcomes. This urgency increases if immunity is not lifelong.