TTHealthWatch is a weekly podcast from Texas Tech. In it, Elizabeth Tracey, director of electronic media for Johns Hopkins Medicine, and Rick Lange, MD, president of the Texas Tech University Health Sciences Center in El Paso, look at the top medical stories of the week. A transcript of the podcast is below the summary.
This week's topics include analysis of patients with COVID-19 in New York, contact tracing, COVID-19 in a long-term care facility, and loss of smell as an early symptom of COVID-19 infection.
Program notes:
0:47 Contact tracing in Chinese cohort
1:45 Household contacts or traveling with cases
2:46 When they identified cases 20% had no symptoms
3:45 Identify individuals who never have symptoms
4:21 New York report of 5,700 patients
5:20 12% ventilated
6:18 COVID in skilled nursing facility in Washington
7:18 Shedding virus but unknown
8:20 Over half with positive results asymptomatic
9:20 It's important to do testing of all
9:38 Expanded number of symptoms
10:35 Sinonasal outcome test
11:40 Tested a provider
12:52 End
Transcript:
Elizabeth Tracey: Taking a look at presymptomatic SARS-CoV-2 infections and transmission in a skilled nursing facility.
Rick Lange: 5,700 patients who were hospitalized in New York City with COVID.
Elizabeth: What do epidemiology and transmission of COVID-19 from China tell us about contact tracing?
Rick: And COVID-19 infection altering your sense of smell and taste.
Elizabeth: That's what we're talking about this week on TTHealthWatch, your weekly look at the medical headlines from Texas Tech University Health Sciences Center in El Paso. I'm Elizabeth Tracey, a Baltimore-based medical journalist.
Rick: And I'm Rick Lange, President of Texas Tech University Health Sciences Center in El Paso, where I'm also Dean of the Paul L. Foster School of Medicine.
Elizabeth: Rick, how about if we start with The Lancet, this one that I talked about, the epidemiology and transmission of COVID-19 from Shenzhen, China? This is a retrospective cohort study. Their Center for Disease Control and Prevention identified 391 SARS-CoV-2 cases and 1,286 close contacts of those folks.
This population had a mean age of 45 years. 91% of the 391 cases had mild or moderate clinical disease severity at their initial assessment, and, as they followed these folks over time, their median time to recovery was 21 days. They contact traced all of their household contacts and those who were traveling with them. That's how this 1,286 close contacts were accreted. What they found was that those people who were either household contacts or traveling with these folks had a very high rate of actually becoming infected themselves. The household secondary attack rate was 11.2% and children were as likely to be infected as adults. And the close contacts' risk of infection was 7.06% for those who travelled with a case.
The interesting things to me about this, of course, is that we're not contact tracing with great energy here in the United States, but I think what this study shows is that when they did contact trace, they were able to reduce the duration that an infected individual transmits in the community in Shenzhen by 2 days. And that's significant, since we know that so many people are asymptomatic at the time of the initial infection and are also likely to be shedding the largest amount of virus during that time.
Rick: In fact, in this particular cohort, when they were trying to identify cases among their contacts, 20% of the individuals had no symptoms and 30% did not have a fever. I actually was surprised that the infection rate wasn't higher in the household contacts. Individuals that were either household contacts or travelers with the identified individual with COVID infection were six to seven times more likely to develop infection than casual contacts. But the fact that it was only 11% -- that is 1 in 8 or 1 in 9 individuals -- was a little bit surprising to me. Because there was active surveillance going on, they tried to do social isolating very quickly. That's why the reproduction rate was 0.4 and we know it's usually about 2.2 to 2.6 individuals infected.
Elizabeth: To me, this study clearly argues toward the efficacy of contact tracing and we're not doing that with anything like the kind of rigor that they did it here.
Rick: Elizabeth, I think two things about contact tracing. One is you identify individuals who never have symptoms. You also identify individuals that are presymptomatic. You can detect virus shedding about 2 to 2.5 days before they develop symptoms, and during that time period -- when someone is asymptomatic or presymptomatic -- they could be infecting other individuals. I agree if there was a way to rapidly detect them, we'd like to send a test back and hopefully get same-day results, and isolate them and avoid contacts with others. But I agree with you. We need to increase contact identification through increased surveillance and through increased testing.
Elizabeth: Let's turn to one of yours, both in the Journal of the American Medical Association. Which of them would you like to choose?
Rick: Let's talk about New York City. This is a report on 5,700 consecutively hospitalized patients in the Northwell health system, and that's 12 hospitals in the New York City, Long Island, and Westchester County in New York. It's the largest hospitalized cohort in the United States that's been reported. These were individuals that were hospitalized over about a 1-month period between March 1st and April 4th and they just looked at their characteristics and how they did.
Among those 5,700 patients, they determined that the vast majority of them that were hospitalized, about 94%, had comorbidities, and in fact, 88% of them had more than one comorbidity, with the most common ones being hypertension in about 57%, obesity in 42%, and diabetes in 34%. Interestingly enough, when the patients presented to the hospital and were triaged, about a third of them did not have a fever at the time. They provided outcomes on over 2,600 patients. 14% were treated in the ICU, 12% received invasive mechanical ventilation, 3% needed to be on dialysis because of kidney disease, and importantly 21% died. Very sobering.
This is only half the patients reported because the other half were still in the hospital at the time this was reported. Importantly, of those that were on the ventilator, only about 3% were discharged alive. 25% had died and 72% were still in the hospital on the ventilator at the time this publication was released.
Elizabeth: Well, among all the other data that, of course, we're being barraged with is the data that I just recently saw suggesting that the time between presentation and death is actually often right around 3 days, so we still don't really know what the mortality rates are.
Rick: Right. In fact, unfortunately some of the studies have suggested that mortality rates for people on mechanical ventilation are as high as 80%.
Elizabeth: Let's turn now to the New England Journal of Medicine. This is a population, of course, that's been getting a lot of attention, that's the population who resides in either skilled nursing facilities -- which is, of course, where the outbreak began in Washington state here in the U.S. -- or in other kinds of long-term care facilities.
In this case, they took a look at the second place in Washington State where they had a cohort who were infected. They surveyed in this skilled nursing facility these residents and they found that 23 days after their first positive test result in a single resident, they had 64% of all residents test positive for SARS-CoV-2. Among those who participated in subsequent point prevalence surveys, 63% tested positive; 56% were asymptomatic at the time of testing. Again, that really important piece of data that says, "Yeah, they're out there shedding a lot of virus, but we don't know that they're having a problem."
Of this number, 24 of them did develop symptoms after this testing and their median time to onset was 4 days. As they followed these folks out, ultimately 11% were hospitalized, 3 in the intensive care unit, and 15 had died, with a mortality of 26%. When they took a look at the virus, they found that 80% had sequences that were two different clusters of viruses very closely related to each other.
What we find out is that, not surprisingly, it spreads really rapidly. It probably is spreading while people are asymptomatic. The other part of this study that was really interesting was among the healthcare workers in this skilled nursing facility. They reported that 40% of the healthcare workers had reported symptoms, 37% were tested, and 19% had a positive result.
Rick: The thing I find most amazing about this is over half of the residents with positive results were asymptomatic at the time they turned positive. In skilled nursing facilities, we have people that have suppressed immune systems because they're older. We have people that have chronic conditions. Sometimes their coughs are chronic coughs. They don't recognize they have a symptom. Thirdly, we have individuals that are cognitively impaired, some mildly, some severely. All those things contribute to the fact that these individuals may have infection, and may be asymptomatic or mildly symptomatic and not realize it, and hence be infectious to not only other residents in the skilled nursing facility, but importantly, to healthcare providers as well.
Elizabeth: And I thought it was also concerning that this large number of their nursing staff and other folks who worked in this facility were positive and these are people who have roles where they go from one person to another, so I'm really interested in sort of who's the vector of infection.
Rick: In facilities like this -- or psychiatric centers as well -- where people may not be able to identify symptoms, it's important to do testing of all the residents and the providers in that setting as well and to isolate them as quickly as possible.
Elizabeth: Pointing to, of course, our continuing problem with testing. Let's turn to your last one, and that's also, as I said, in the Journal of the American Medical Association.
Rick: Many of the listeners may be aware that the CDC has expanded the number of symptoms that a person with COVID infection may have. Usually we talked about fever, cough, respiratory symptoms, but they've also included muscle aches, chills, and also the loss of taste and smell. Previous coronaviruses are known to attach to the nasal epithelium and to make their way up the nerves, the olfactory bulb, into the CNS and they've been associated with a decreased sense of taste and smell. So these investigators ask, "I wonder how often this occurs in COVID-19-infected patients because we've had anecdotal reports?"
Over about a 3-day period, they contacted individuals that had tested positive for COVID infection. They contacted about 5 to 6 days after the swab had been obtained and they asked them whether they had any change in the decrease in smell or taste.
Interestingly enough, you can quantitate the decrease in smell with what's called the SNOT-22 test. The SNOT-22 test, it's the Sino-Nasal Outcome Test. Was there any loss, or none? Was it very mild, mild, moderate, severe, or as bad as it could be, on a scale of 0 to 5? They identified 202 patients who completed the survey. Two-thirds of individuals -- these are all mildly symptomatic individuals, not hospitalized -- said they had a change or loss of smell or taste. In about 6% of individuals, it occurred as the only symptom and then in about 12% of individuals it was the very first symptom they had before they developed other ones at all. The remaining individuals had it concomitantly with the other symptoms they had.
So what we on this campus and many people around the U.S., the healthcare providers, realize is that when somebody says, "I have had a loss of taste," or change in smell, that may be the harbinger that the person is COVID-infected.
Elizabeth: Tell me how you would find that information important clinically.
Rick: Interestingly enough, one of our healthcare providers who is taking care of individuals reported to the attending that, in fact, this person had experienced a loss of smell. We took that individual out of the hospital and COVID tested them, and in fact they were COVID-positive. Then subsequently, about 2 or 3 days later, they developed more typical symptoms.
Elizabeth: One more thing to add to the list.
Rick: This is now one of the symptoms that's included in that litany of things that would warrant testing.
Elizabeth: Okay. On that note, would you like to tell us how things are going in El Paso?
Rick: We've had very strict restrictions here in El Paso with regard to social isolation and distancing and wearing face masks. The city has done a terrific job of communicating this. In fact, all the businesses have, and we as a healthcare center and our hospital partners as well. It looks like we may have plateaued over the last 2 or 3 days, which is wonderful news. We've not overwhelmed the hospital system at this particular point. We've not exhausted our supply of PPE and there have been few healthcare providers infected. We're keeping our fingers crossed. The governor is relaxing some of the restrictions across the state, but we'll be monitoring this situation very closely.
Elizabeth: On that note, that's a look at this week's medical headlines from Texas Tech. I'm Elizabeth Tracey.
Rick: And I'm Rick Lange. Y'all listen up and make healthy choices.
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