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5th March 2024
The lockdowns imposed during the Covid-19 pandemic positively impacted the gut microbiome and subsequent allergy development of babies born during this time, a new study has revealed.
Researchers working in Ireland found significant differences in the gut microbiome development of babies born during lockdown periods compared to pre-pandemic babies, including lower than expected rates of allergenic conditions.
The findings, published in the journal Allergy, highlighted how environmental exposures and dietary components significantly impacted microbiota community assembly.
And they were the first to demonstrate gut health benefits arising from the unique lockdown environment, including lower rates of infection and consequent antibiotic use and increased duration of breastfeeding.
The researchers from the Royal College of Surgeons in Ireland (RCSI), Children’s Health Ireland and APC Microbiome Ireland at University College Cork collected faecal samples from 351 babies born during the first three months of the pandemic. The samples were collected at six months (n = 351) then at 12 (n = 343) using 16S sequencing.
Skin prick testing (SPT) was performed at 12 (n = 343) and 24 (n = 320) months of age, accompanied by atopic dermatitis and food allergy assessments.
In infants with atopic dermatitis, a Scoring Atopic Dermatitis (ScorAD) was calculated at 12 and 24 months and a total and objective ScorAD recorded. SPT was completed for the three most common food allergens (peanut, egg and milk) and aeroallergens (house dust mite, grass pollen and cat dander) in all infants.
Online questionnaires were used to gather epidemiological information about the babies’ diet, home environment, health and healthcare utilisation and allergic diseases, including suspected adverse food reactions and atopic dermatitis.
The pandemic-born babies were part of the CORAL (Impact of CoronaVirus Pandemic on Allergic and Autoimmune Dysregulation in Infants Born During Lockdown) project, and the results were compared with samples from pre-pandemic cohorts of babies.
Professor Liam O’Mahony, from the University of Cork and principal investigator at APC, said: ‘We took the opportunity to study gut microbiome development in infants raised during the early Covid-19 era when strict social distancing restrictions were in place, as the complexity of early life exposures was reduced and this facilitated a more accurate identification of the key early life exposures.
‘Prior to this study, it has been difficult to fully determine the relative contribution of these multiple environmental exposures and dietary factors on early life microbiome development.’
Significant differences existed in the gut microbiomes of the two cohorts. Pandemic-born babies showed a higher relative abundance of bifidobacteria at both six and 12 months, which was associated with a reduced likelihood of atopic dermatitis and positive SPT results.
Infants with elevated Bifidobacterium levels at six months of age typically exhibited fewer allergic symptoms or a lower risk of developing allergic diseases than those with lower levels of this bacteria.
The increase in bifidobacteria was linked to reduced external exposure, an increase in breastfeeding and a decrease in antibiotics during lockdown.
Social distancing was associated with delayed acquisition of horizontally transmitted spore-forming bacteria. Bacteria such as the environmentally transmitted Clostridia were found to have lower concentrations at both six and 12 months in the pandemic cohort compared with the pre-pandemic babies, correlating with the microbial exposure index.
Levels of atopic dermatitis observed in the study were not higher than expected levels. Specifically, at 12 months of age, atopic dermatitis was observed in 24.8% of participants (n=343), and at 24 months, it was observed in 19.5% (n=320).
Levels of food allergen and airborne sensitisation were also within the expected range for this age group, with SPT positivity at 7.4% at 12 months and 12.0% at 24 months.
The prevalence of allergen sensitisation, food allergy, and atopic dermatitis did not increase over pre-pandemic levels, suggesting the lockdown period did not lead to a higher incidence of allergic conditions.
Joint senior author of the study Professor Jonathan Hourihane and head of paediatrics at RCSI, added: ‘This study offers a new perspective on the impact of social isolation in early life on the gut microbiome.
‘Notably, the lower allergy rates among newborns during the lockdown could highlight the impact of lifestyle and environmental factors, such as frequent antibiotic use, on the rise of allergic diseases.’
The researchers hope to re-examine the children born during the pandemic when they are five years old to investigate whether there are longer-term health benefits arising from the early differences seen in the gut microbiome.
In August 2023, researchers found that delays in gut microbiome maturation in young children were uniformly associated with distinct allergic diagnoses at five years of age.
14th December 2022
HOPE Governors discuss their national Covid-19 programmes and delivery, and the consequences of the pandemic on somatic and mental healthcare provision to non-Covid patients.
Data were obtained from the OECD, Eurostat and WHO. When data were not available for one of the specific years, the closer year was used (denoted by *).
AUSTRIA
Different virus variants (and corresponding protection measures), especially seasonal ones, led to different stress situations and requirements in the hospitals. In 2020, the general measures included putting lockdown into effect, to prevent the spread of infection, and implementation of a test system. Protection measures were implemented in hospitals. Additional hospital capacities were created for these unknown and un-assessable hospitalisation needs.
The Ministry commissioned a study on the impact of the pandemic on inpatient care in Austria in 2020. The results showed that in the areas analysed there was – with the exception of stroke – a reduction in inpatient stays in the months of March to May 2020 and in November and December 2020 compared with previous years, although the reduction during the second lockdown was not as significant. Due to sufficient PPE, more testing possibilities and increased knowledge about Covid-19 gleaned during the first phase of the pandemic, the reduction was comparatively moderate considering the considerable number of hospitalised Covid-19 patients.
The vaccination programme commenced in 2021. The Delta variant brought with it an increased risk of infection with a similar severe course of disease and hospitalisation requirements as before. This was the first time for an increased capacity utilisation with intensive care capacities regionally exceeding the utilisation limit. In all federal states, elective surgeries had to be reduced to some extent to enable adequate capacity for Covid-19 patients in intensive care units.
By 2022, the Omicron variant changed some of the framework conditions. Compared with Delta, the Omicron variant is more infectious, but the course of the disease is milder (also due to vaccination) although the targeted level of vaccinations could not be achieved. Nevertheless, the high number of cases resulted in a high rate of hospitalisation. This again led to increased capacity utilisation, mainly regarding normal care capacities. At the same time, incapacity to work and segregation led to staff absence.
A seasonal additional demand for different resources has not yet been considered by structural planning in the health care system. In addition to the physical availability of beds, the utilisation of normal and/or intensive care units, as well as sick or separated health care staff, are limiting factors. In addition to regular monitoring activities, structural-, organisational- and personnel-related measures must be taken to ensure appropriate capacities in hospitals (e.g. beds, staff, equipment, protective gear). Flexible deployment of staff and flexible use of capacities are central to this. Framework conditions at federal and state levels are also important. The main objective is to cope with the (at least to some extent) seasonal increase in demand for Covid supplies care while largely maintaining standard care.
Also, mental health is a big focus, because depression, anxiety disorders and other mental health problems were aggravated or increased during the pandemic. An advisory group of experts in the Ministry of Health works on necessary measures, also addressing the mental health of children and juveniles and the subsequent issues arising in these populations. Various measures to improve the supply of specialists for psychiatry and psychotherapeutic medicine and for child and adolescent psychiatry are being examined, and thereby being able to offer patients easy and accessible comprehensive and multidisciplinary care.
To achieve the best possible coverage of demand, both specialties have already been classified as shortage subjects, and in the field of child and adolescent psychiatry, the training key was expanded by law at the beginning of 2022 to be able to train more physicians in this specialty. Additional quality assurances must be implemented to accompany such measures. Also, social paediatric facilities and child and adolescent psychiatric networks are included in comprehensive care considerations.
BELGIUM
In Belgium, 52% of the population have received the dose of the vaccine, producing a sharp decrease of infections during the past two months. There are only 1,000 people in hospital due to Covid-19 and 400 people in the ICU. The vaccination strategy is based on age and comorbidities and takes place mainly in vaccination centres. However, some hospitals are used for specialised vaccination, e.g. for oncology patients. The strategy challenges are mainly people not wanting to receive the vaccination and uncertainty. This varies among regions: vaccination willingness is high in Flanders and lower in Wallonia and Brussels.
During the two first waves of Covid, impact on care delivered to non-Covid patients was significant, notably given legal restrictions on hospitals. For 2020 and 2021, hospitals’ main activities decreased by 10-20%. Teleconsultation partially replaced in-person care. More than 30% of the Belgian adult population received care by phone and/or online, which is significantly lower than the OECD average.
Covid had a huge impact on mental health. Nearly 20% of the total population declare symptoms of depression – an increase of 100% compared with the pre-Covid period.
BULGARIA
Since the beginning of the pandemic, the total number of confirmed cases of coronavirus in Bulgaria is 1,253,934 (17.6% of the population), of which 1,207,195 (17% of the population) have been cured to date. Of these, the number of medics with proven coronavirus infection is 25,751 (38% of all). There are no data on the actual number of people who have become infected; it is assumed that the number is five-times more.
The number of deaths from Covid-19 as of 21 September 2022 was 37,694 (3% of confirmed cases and 0.53% of the population).
Currently, 1% of all available hospital beds, in a small number of hospitals, are engaged in the fight against the Covid pandemic.
The total number of doses of the Covid-19 vaccine administered was 4,540,537 (64% of the population). 2,071,300 people (29% of the population) were fully vaccinated.
As of 21 September 2022, 881,410 had received a booster dose, of which 72,704 had received a second booster.
Almost all hospitals have by now restored normal work practices and admission of patients.
However, the trend of increasing complicated medical cases in non-Covid patients due to untimely treatment or lack of treatment due to the pandemic continues. Cases of long-Covid are also increasing. Clinical pathways have been developed and are already being implemented for the rehabilitation of patients with long-Covid or with other complications due to a more severe Covid infection.
Research on the impact on the mental health of non-Covid patients has not been carried out in our country.
DENMARK
In Denmark, there has been a great willingness to get vaccinated. By August 2022, 84% of the population over the age of five years had received the first dose and 77% of the population over the age of 18 years had received second and third doses. Citizens over the age of five years were previously invited to receive the first, second and third dose – this former vaccination programme has now been phased out and replaced by a new programme. If citizens do not receive the first three doses, they are still recommended to have them.
Based on previous experience, it is expected that Covid-19 will be a seasonal disease – we also know that the risk of a severe Covid-19 infection is higher in older age. In Autumn 2022, the vaccine will first be offered to residents of nursing homes and citizens over 85 years of age. For this group, it was available from 15 September 2022. Following this, the vaccine was offered to citizens over 50 years of age from 1 October 2022. Employees from the healthcare sector who have close contact with patients and citizens who are in risk of severe Covid-19 will be offered a booster vaccine from 1 October 2022. The vaccines offered are variant-updated versions of Pfizer and Moderna vaccines.
Citizens will be offered the vaccine via digital post, whereafter it will be possible to book a timeslot for the vaccination. Citizens will be able to get vaccinated at public vaccination centres, private vaccination centres and some general practitioners.
The situation for other patients is, as in other EU countries, affected by delays. There is an agreement with the government to catch up on all the surgeries, but the work of reducing the delays is ongoing.
ESTONIA
The vaccination target in Estonia at the beginning of 2021 was for 70% of adults to be fully vaccinated by the start of autumn. We did not reach that goal by autumn 2021, but in autumn 2022, 75.8% of adults and 65.2 % of the whole population are vaccinated. The vaccination programme started with healthcare workers and older people in care homes, but since May 2021, vaccination has been available for everyone. Health care staff has been willing to being vaccinated, which has resulted in a positive outcome of decreasing numbers of infections in staff. The support of health care workers was confirmed with the signing of national collective agreement in 2021 where it was stated that vaccinated workers receive additional vacation bonuses while non-vaccinated workers do not. Our vaccination plans are currently being renewed by the government to consider new vaccines.
During different phases of the pandemic, there has been a need to postpone planned healthcare services for non-Covid patients. Medical departments and hospitals have been working overtime as much as possible to get these services back on track. But in doing so, the hospitals face difficulties not only with lack of staff but also with funding. There is a separate funding measure for Covid treatment in the Health Insurance Fund, and for 2023 there is also a separate budget planned to deal with the longer waiting times for planned care.
GERMANY
When immunisation of the public began, vaccination was organised primarily based on six priority groups in vaccination centres, and later also in medical practices and pharmacies. In addition to vulnerable patient groups, vaccination was offered as early as possible to hospital personnel as one of the priority groups. The demand from hospital employees was generally very high. Batches of the vaccine for the vaccination centres were delivered directly to hospitals to allow vaccination of personnel on site.
Institutionally-related mandatory vaccination has been in place Germany since 16 March 2022. This stipulates that those persons employed in hospitals that had not submitted proof of vaccination or recovery by 15 March 2022, and that are not subject to any medical contraindication for a Covid-19 vaccine, were to be reported by the hospitals to the competent public health authority. This measure was founded on the grounds of protection of patients from others in order to reduce transmission frequency by specialised staff and was to serve as the precursor for general mandatory vaccination of the public. The attempt to introduce mandatory vaccination for the public failed in April 2022. An important argument for rejecting general mandatory vaccination was that it would not necessarily prevent transmission. Against this backdrop, institutionally-related mandatory vaccination has also become the focus of attention of a politically controversial discussion.
A questionnaire undertaken by the German Hospital Institute in March 2022 shows that, on 23 March 2022, 94% of hospital employees were fully vaccinated or recovered. According to occupational groups, the average reporting rate in the nursing service (7%) was somewhat higher than for doctors (3%).
As of 2 September 2022, 77.9% of the public had received primary immunisation and 62% an additional booster vaccination; 8.7% have already received a second booster vaccination. There is no approved vaccine available for four million of the 18 million unvaccinated, partly due to age (predominantly children are affected) or intrapersonal factors, such as a disability or other pre-existing medical conditions and predispositions (e.g. rare coagulation disorders).
Beds in German hospitals were kept free to ensure sufficient capacity available for the care of coronavirus patients, and planned treatments were postponed. According to the Federal Statistical Office, it is to be assumed that, in addition to this, many people have also delayed essential hospitalisation, partly also in order not to overburden the healthcare system. The number of treatment cases and bed occupancy rate in 2021 remain under the pre-pandemic level. The number of treatment cases fell from 19.4 million in 2019 to 16.7 million in 2021. Bed occupancy decreased from 77.2% to 68.0%. As these changes have serious repercussions on the financing related to the German Radiological Society (DRG) of hospital services, the publicly led debate on financial relief measures from policy makers to secure patient care is ongoing.
LUXEMBOURG
The right to protection of one’s health is a right that every citizen can claim from the state as a subject of rights. The state is therefore obliged to manage its health system in such a way that situations leading to non-treatment or insufficient treatment are avoided.
Concerning the impact on the care of non-Covid patients, there have not been many issues so far, except for mental healthcare, but this is an established problem as there are not enough psychiatric centres. Covid-19 counselling centres have been closed and the general practitioners are the points of contact. There was also a two-way stream implemented in emergency services for Covid-19 patients and for non-Covid-19 patients.
Generally speaking, the number of hospitalisations remained stable and did not increase alarmingly, and the situation of the health system in the Grand Duchy of Luxembourg was not overloaded due to Covid-19 hospitalisations, both during the Delta and Omicron periods.
With uncertainties for the future, a group of experts convened by the government recommended the introduction of a partial vaccination obligation that applies to people over the age of 50 (residents). Partial vaccination is therefore intended to be risk-targeted and would concern only a fraction of the general population. The primary objectives are the maintenance of a fully functioning health system for Covid and non-Covid patients, the protection of the vulnerable and a normalisation of life for most citizens.
Some particular features of Luxembourg (a very open society, high mobility of the population, a very high number of cross-border workers) make it unfeasible to contain the circulation of the virus at the level of the whole society. Therefore, the main purpose of compulsory vaccination is to protect the health services, and in particular hospitals (intensive care and normal care), to ensure normal functioning.
Hospital beds and hospital staff workload are at the forefront of the debate on partial and sectoral vaccination. The acceptable burden on intensive care units, hospitals, society and the economy must be decided at the political level and ultimately by society as a whole. However, from the hospitals’ point of view, the critical level, which corresponds to 38 intensive care beds and 138 normal care beds occupied by Covid-19 patients, is declared when there is a need to cancel clinical interventions.
The age threshold proposed by the experts is 50 years because older age is associated with a risk of severe Covid complications and the risk factors and co-morbidities that predispose to severe Covid are also more frequent from the age of 50 onwards.
However, a sectoral vaccination requirement for the health and care sectors would only be recommended in the case of a highly virulent variant. Even then, vaccination should provide at least 50% protection against infection and transmission. All things considered; this is unlikely with current vaccines. Therefore, the majority of the expert group considers that a sectoral vaccination obligation cannot be recommended at this time.
It is therefore strongly recommended that the vaccination status – even independently of SARS-CoV-2 – should be subject to special regulations governing the responsibilities of persons working in the health and care sectors towards care recipients. This would include the obligation to disclose one’s vaccination status.
At present, only a draft law on compulsory vaccination has been timetabled with the proviso that it will only be finalised if the health situation worsens to such an extent that no other outcome is possible.
PORTUGAL
According to the Portuguese Central Administration of the Health System (ACSS) data, primary and hospital healthcare activity in the National Health Service (Serviço Nacional de Saúde – SNS) registered a significant recovery up to the end of February 2022.
In the first two months of 2022, 40.4% more surgeries were performed compared with 2021. The median waiting time on the surgical waiting list was 3.1 months at the end of February, which corresponds to a 24.8% reduction compared with 2021.
SNS hospitals carried out 15.6% more medical appointments compared to the same period in 2021, which is still in line with the values recorded in the same period of 2020 and 2019.
The data also indicate that emergency episodes recorded up to February, were above (55.2%) that of 2021 but still below (-19%) the pre-pandemic figures.
In primary healthcare there were around 5.3% fewer medical appointments than in 2021 but 10.4% more than in 2020. Of this total, 43.3% of medical appointments were face-to-face, which corresponds to a 38.4% increase over the same period in 2021.
SWEDEN
In Sweden, vaccination is always voluntary and the willingness to get vaccinated is generally high. By September 2022, 87% of all residents aged 12 and over had received at least one dose and 85% had received two doses of vaccine. A total of 67% of all residents aged 18 and over had even received a third dose. The rate of vaccination is higher among elderly people, as this age group has been given priority. In February 2022, elderly people were recommended to take a fourth dose, and by September 2022 approximately 76% of all residents aged 65 and over had received four doses. In August 2022, the Public Health Agency of Sweden recommended that everyone aged 65 and over, and persons aged 18 and over belonging to any of the risk groups, take a booster dose.
Statistics shows that the vaccination rate is much higher among healthcare staff compared with other persons of working age.
In Sweden, individual regions are responsible for vaccinations. Vaccination for Covid-19 has taken place in many different settings, often in temporary premises or drive-in centres, but also in primary care centres and hospitals.
The Covid-19 pandemic has had many different effects on the Swedish healthcare services. Before the pandemic, Sweden had a low number of ICU beds, but in the Spring of 2020, hospitals managed to quickly transform wards into ICUs, and transfer healthcare professionals from one part of the system to another. There was also a significant increase of digital services.
At the same time, there was initially less pressure on other parts of hospital services (cardiology, oncology) and less pressure on primary care. Planned treatment was postponed and waiting times were extended. Between March 2020 and January 2021, the total number of surgeries decreased by 22% compared to the same period in 2019/20. The number of planned surgeries decreased by 30%. The largest decreases in the total number of surgeries/interventions occurred in orthopaedics, general surgery and ophthalmology.
Although many people still fall ill with Covid, there are now (as of September 2022) significantly fewer people who need hospital care. Apart from a peak in the beginning of 2022 when the regions once again had to postpone planned treatments, the hospitals are trying to reduce the backlog for surgery from 2021. A problem then is the lack of qualified healthcare staff, such as specialist nurses.
UNITED KINGDOM
The UK has now vaccinated 45 million people (93.2% of the population aged 12+); 42 million had a second dose (87.2%), and 33 million had a booster dose (68.7%). A fourth dose was offered this Spring to people aged over 75, adult care home residents, and individuals aged 12 and over who are immunosuppressed.
In early 2022, it had been intended to mandate vaccination as a condition of deployment for healthcare workers. However, on 31 January 2022, amidst concerns about the impact on capacity, and views that the staff vaccination rate was high, the Government revoked this imminent requirement, and this policy remains. Local leaders continue to encourage vaccine uptake at a local level.
The UK has experienced three major Covid-19 waves in 2022 and anticipates a particularly significant one in autumn/winter 2022. This will likely occur alongside seasonal flu. As such, plans are underway for vaccination for both infections. The NHS recommends that Covid, flu, and pneumococcal vaccines should be promoted and given together wherever possible, especially where this might improve uptake. The autumn booster programme is expected to include all adults over age 65, care home residents and staff, clinically vulnerable adults aged 16-64, and frontline social care and health workers, to maintain their protection over the winter against severe Covid-19, reducing hospitalisation and death over this period.
In England, there are currently about 6.5 million people awaiting NHS care, as well as significant pressure on urgent and emergency care. Significant progress has been made, but the waiting list for physical and mental health care does continue to grow. Progress has focused on eliminating the 104+ week waiting list by July 2022 with good results. The aim to deliver around 30% more elective activity by 2024/25 than before the pandemic is intended to address backlogs, but there is a range of capacity challenges, including ongoing Covid-19 waves, staff sickness, staff vacancies, and patient flow issues.
Our summary of progress against recovery targets in England up to the end of June 2022 can be found via the NHS Confederation website.
29th June 2021
A research programme established to determine the extent of COVID-19 transmission with both indoor and outdoor events without social distancing has been published by the UK government. Many mass gathering events such as music festivals, theatres and both indoor and outdoor sporting events were cancelled because of the risk of COVID-19 transmission. As a result, a primary aim of the research, which was conducted on behalf of the UK government, was to obtain an evidence base of the risks associated with COVID-19 transmission at large public events and to hopefully reassure members of the public that it was safe to return to such large-scale events. The first phase of the research consisted of nine pilot events running across multiple days in April and May 2021 and in a variety of outdoor and indoor venues. Each of the pilot sites examined variations in the seating, standing and the structure of the audience and participant numbers. The data captured by researchers was not restricted to transmission of COVID-19 but included monitoring of ventilation, analysis of carbon dioxide and crowd density as a proxy for airborne transmission, observing and analysing crowd behaviour, interviews and surveys with participants. Events included the World Snooker Championship, with 10,147 individuals seated indoors at which social distancing was required for the first five days but dropped for the final although face coverings were mandated at all times. Several football matches were also included and whilst the crowds were outdoors, as with the indoor events, face coverings were required. However, for some events such as one held at a nightclub over two consecutive evenings, with over 3000 people, no social distancing or face coverings were required. Similarly, an outdoor music festival with just over 6000 people there was no requirement for either social distancing or face covering. In addition, all participants were required to have a negative lateral flow test result within 36 hours of the event to be permitted to enter the venue. In addition, PCR testing prior to the event was a voluntary rather than mandatory requirement though it could also be undertaken on the day of the event. Moreover, participants were posted a home PCR test to be used five days later were also used to identify subsequent cases.
Findings
The results showed that there was limited evidence of COVID-19 transmission across all events with only 28 PCR-positive test results recorded, with 11 considered potentially infected before the event. Nevertheless, there were some important caveats with the data. Firstly, the return rate of PCR tests was low, ranging from 8% to 74% before the event to 13% to 66% post-event, hence limiting the estimate of infectivity rates. A further limitation of the data was the during the period of the pilot study estimates of infection rates in the community were low and prior to the emergence of the Delta COVID-19 variant of concern. An operational learning from the pilot was that the current contact tracing infrastructure is not designed for testing at events with large numbers of people.
Although the early results from the pilot are encouraging and inline with other studies and suggest that during mass gathering events there appears to be limited COVID-19 transmission, it should be emphasised that the data are limited because it was based on only a small number who returned their PCR test results.
25th June 2021
In a 2010 report from the World Health Organization (WHO), it was suggested that information and communication technologies (ICT) have a great potential to address some of the challenges faced by both developed and developing countries in the provision of accessible, cost-effective and high-quality health care. The WHO reported recommended that countries capitalise on the potential of ICT so that ultimately telemedicine strengthens, rather than competes with, other health services. While a 2012 observational study found that the value of virtual consultations was broadly similar to traditional face-to-face methods, a 2015 systemic review concluded that electronic consultations (or e-consults), are feasible in a variety of settings, flexible and facilitate timely speciality advice. Fast forward 10 years and in the midst of the global COVID-19 pandemic, health service providers have been forced into augmenting their ICT to enable continuity of clinical care. But what are today’s clinician’s perception of telemedicine consultations was a question addressed by a team from the department of medicine, Yale university, US. The team focused on physicians working in the area of infectious diseases (ID) and recruited two groups of participants: referring providers, i.e., physician assistants, advanced nurse practitioners and the ID consultants themselves based at the hospital.
The team created a web-based survey and defined an electronic consult or “e-consult” as a telemedicine consultation. The level of satisfaction with e-consults was assessed via perceptions of the quality, timeliness and amount of verbal communication compared with traditional face-to-face consultations, based on three categories: worse, the same or better. In addition, using the same three categories, respondents were asked “compared to traditional consults, e-consults provided good clinical care”.
Findings
A total of 130 surveys were analysed, representing a 23.6% response rate and completed by 107 referring providers and 23 ID consultants. Considering e-consults to traditional methods, in terms of quality, overall, 66.9% of respondents stated that these were either the same or better; with respect to timeliness, 95% reported that e-consults were the same or better and finally, 80% of respondents felt that communication was the same or better. In total, 80% of respondents agreed that e-consults provided good clinical care. However, there were some differences between the two groups of respondents. For instance, the majority (73.9%) of consultants rated the quality of care as being worse than face-to-face versus 24.3% for providers and 91.3% of consultants (versus 44.9% of referring providers) reported that timeliness was better for e-consults. Furthermore, a higher proportion of consultants felt that there were specific situations where face-to-face consultations were necessary (87% vs 33.6%).
In a discussion of their findings, the authors reported that it was reassuring to see an overall high level of agreement that e-consults provided good clinical care. While it was not explored in the study, they suspected that the poor rating for the quality of e-consults among consultants was probably a reflection of the need to undertake a physical examination of a patient with an infective disease. They concluded that future studies should explore the reasons for consultant dissatisfaction with telemedicine and the effect of virtual consultations on infectious disease outcomes.
Citation
Canterino JE, Wang K, Golden M. Provider Satisfaction with Infectious Diseases Telemedicine Consults for Hospitalised Patients During the COVID-19 Pandemic. Clin Infect Dis 2021
18th January 2021
It has become recognised that increasing age and a higher number of co-morbidities such as hypertension, obesity and diabetes are associated with higher levels of mortality among those infected with COVID-19.
Given that the prevalence of diabetes is often very high among this ethnic group, a team from the Hugh Kaul Precision Medicine Institute, University of Alabama, US, sought to determine the effects of different anti-diabetic treatments on mortality among an ethnically diverse population infected with COVID-19. The team retrospectively reviewed all electronic health records of subjects consecutively tested for COVID-19 between February and June 2020 at a single tertiary hospital in their area. In an effort to make the results more generalisable, the researchers included all patients within the five month period with the only exclusion criterion being a lack of available outcome data. The team sought to focus their attention on the diabetic treatments and in particular, insulin and metformin because these were the most commonly prescribed and there were too few patients prescribed other medicines to provide a meaningful statistical analysis. The primary outcome for the study was overall mortality and the researchers used logistic regression to explore the association between mortality and known risk factors and diabetic treatments.
Findings
There were 604 patients who tested positive for COVID-19 during the study period. The majority of those testing positive (43%) were aged 50 to 70 years and just over half (51.5%) were Black Africans, giving a highly significant odds of testing positive compared to those of white ethnicity (odds ratio, OR = 2.6 95% CI 2.19–3.10, p < 0.001). Overall mortality among those testing positive for COVID-19 was 11% and the presence of diabetes dramatically increased the risk of mortality (OR = 3.62 95% CI 2.11–6.2, p < 0.001). In fact, 67% of all deaths occurred among those with diabetes. Focusing on diabetic treatments, the researchers observed that use of metformin reduced the odds of dying by 62% (OR = 0.38 95% CI 0.17–0.87, p = 0.0221) although no such effect was seen with insulin. Moreover, after adjusting for the covariates age, race, sex, obesity and hypertension status, the odds ratio remained significant (OR = 0.33 95% CI 0.13–0.84, p = 0.0210). The researchers also observed that neither BMI or HBA1C levels were lower in those taking metformin thus discounting these as explanatory factors.
The authors noted that while the presence of type 2 diabetes was associated with an increased mortality risk in those with COVID-19 (as reported in other studies) there appeared to be a protective effect among diabetic patients treated with metformin although they were unable to explain their findings and called for more research to understand how metformin conferred these effects.
Citation
Crouse AB et al. Metformin use is associated with reduced mortality in a diverse population with COVID-19 and diabetes. Front Endocrinol 2021.
30th November 2020
The precise reasons why obesity enhances the risk of a more severe outcome in COVID-19 remains unclear. Nevertheless, obesity is associated with several other additional risk factors such as cardiometabolic, thromboembolic and pulmonary disease and it is likely that it is this combination of factors that raises the overall risk. For example, obese patients have higher levels of pro-inflammatory cytokines and oxidative stress which can impact on both the innate and adaptive immune system, all of which may contribute to a worse prognosis. Metabolic surgery in obese patients leads to improvements in cardiovascular risk factors and the amelioration of the pro-inflammatory state linked with obesity.
In a retrospective study of patients testing positive for COVID-19, researchers from the Bariatric and Metabolic Institute, Department of General Surgery, Cleveland Clinic, Ohio, US, set out to examine the relationship between prior metabolic surgery and the severity of COVID-19 in severely obese patients. A total of 33 individuals who had prior metabolic surgery (the surgical group) were identified and were matched 1:10 to non-surgical patients to create a cohort with a body mass index (BMI) greater than or equal to 40kg/m2 at the time of testing. The pre-specified endpoints examined were: admission to intensive care, need for mechanical ventilation, dialysis during their hospital stay and mortality.
Findings
Data on a total of 363 patients, including the 33 who had prior metabolic surgery were available for analysis. The surgical group had a mean age of 46.1 years (78% female) with a mean BMI of 37.2±7.1 compared to 46.7± 6.4kg/m2 in the control group. A subsequent univariate analysis showed that 18.2% of those in the surgery group and 42.1% in the control group were admitted to hospital because of their infection with COVID-19. A prior history of metabolic surgery was associated with a statistically lower odds of being admitted to hospital (odds ratio = 0.31, 95% CI 0.11 – 0.88, p = 0.028). Furthermore, none of the surgical group patients experienced one of the four pre-specified endpoints. In contrast, 13% of those in the control group were admitted to intensive care, 6.7% required mechanical ventilation, 1.5% dialysis and 2.4% died. The authors suggested that prior metabolic surgery was associated with a lower severity of COVID-19 infection but recognised that these observations were based on a small sample size and they were also unable to account for their findings.
They concluded by calling for more research to understand the mechanistic role of both obesity and intentional weight loss on COVID-19 infection.
Reference
Aminian A et al. Association of prior metabolic and bariatric surgery with severity of coronavirus disease 2019 (COVID-19) in patients with obesity. Surg Obes Relat Dis 2020. https://doi.org/10.1016/j.soard.2020.10.026
Mutations in RNA viruses can arise through copying errors, genomic variability when two viral lineages infect the same host and finally because of host-induced RNA-editing systems. Any mutations that have a deleterious effect on the virus will be quickly removed from the population although those which provide an advantage are retained. Researchers have been closely monitoring mutations in COVID-19 because any such changes could affect the ability of the virus to replicate and may even increase transmissibility.
A study by a team from the Genetics Institute, University college, London, have been cataloguing mutations in the virus and assessing whether or not these mutations have the potential to increase the transmissibility of COVID-19. They assessed the difference in transmissibility by estimating the relative fractions of descendants produced by a particular genotype. The rational for this approach was based on the notion that the worldwide distribution of the virus is likely to introduce a high level of genetic diversity which might increase the potential for greater transmissibility.
Findings
The researchers analysed 46,723 SARS-CoV-2 genome assemblies although none of these were found to deviate by more than 32 single-nucleotide polymorphisms from the reference genome, Wuhan-Hi-1. The team estimated a mutation rate of 9.8 x 10-4 substitutions per site per year and this finding is in line with work on other coronaviruses. The team also explored viral homoplasies, i.e., nucleotide changes that have not arisen through simple inheritance and identified a total of 185 such cases. However, none of these were associated with an increased risk of viral transmission or, interestingly, a reduced risk of transmission and all were effectively neutral changes.
Commenting on these findings, the authors noted that COVID-19 has only acquired moderate generic diversity since its jump to humans and concluded that there is currently no a priori reason to suspect that any lineage might arise with an increased potential for transmissibility.
Reference
Van Dorp Let al. No evidence for increased transmissibility from recurrent mutations in SARS-CoV-2 Nat Commun 2020;11:5986.
On 19 November, 2020, the FDA gave emergency use authorisation for the baricitinib combination therapy to be used in patients hospitalised with either confirmed or suspected COVID-19, from 2 years of age and who require mechanical ventilation, supplemental oxygen or extracorporeal membrane oxygenation.
The approval is based on preliminary results from the ACCT-2 trial, which compared the recovery time in patients receiving either remdesivir alone or in combination with the JAK STAT inhibitor, baricitinib at a dose of 4mg. Remdesivir is already approved by the FDA as an antiviral drug for hospitalised COVID-19 patients, aged 12 years and over. Baricitinib is currently only licensed for use in rheumatoid arthritis but since the drug blocks the JAK-STAT intracellular messaging system, which is an important inflammatory pathway, there was a potential benefit from combining the two drugs. ACCT-2 was a Phase III trial that enrolled 1033 participants, who were randomised to either intravenous remdesivir alone plus matching placebo (518) or oral baricitinib (515). Remdesivir was given as a loading dose of 200mg, followed by 100 mg daily while in hospital, for up to 10 days. Baricitinib was given at a dose of 4mg per day and limited to a maximum of 14 days. All patients were assessed daily and if discharged, they were followed-up at home on days 15, 22 and at the study endpoint, day 29. Recovery from COVID-19 was defined as either being discharged from hospital, no longer requiring supplemental oxygen or needing ongoing medical care.
Preliminary data published from the trial showed that the median time to recovery with remdesivir and baricitinib was one day shorter (7 vs 8 days) than using remdesivir alone and this difference was statistically significant. In addition, the odds of a clinical improvement at day 15 using the combined therapy was also found to be significantly lower. Under the emergency use authorisation, the manufacturer of baricitinib, Eli Lilly, is required to provide both health professionals and patients, fact sheets which include information on dosing, side-effects and drug interactions. The full results of the ACCT-2 trial will be published in due course.
Furthermore, the presence of hypercoagulation and thrombotic complications appeared to correlate with a worse prognosis.
Although COVID-19 is principally a respiratory infection, studies have shown that the virus also leads to coagulatory dysfunction and which increases the risk of both arterial and venous thromboembolism (TE) and ultimately mortality. In fact, the presence of TE correlates with a more severe form of infection. However, studies to date have shown that the association between TE and mortality in patients with COVID-19 is poorly characterised. This prompted a team from the Department of Surgery, University of California, US, to undertake a systematic review and meta-analysis of available studies to provide a more precise estimate of TE rates in COVID-19 and to determine the association between TE and mortality. They searched all the major databases in June 2020 and included studies where the thromboembolic event could be calculated. The primary outcomes were venous and arterial TE (ATE), deep vein thrombosis (DVT) and pulmonary embolism (PE) as individual endpoints and mortality in those who develop TE.
Findings
The review identified 42 studies with 8271 patients which were included in the meta-analysis. The overall rate of venous TE was 21% but this increased to 31% among patients admitted to an intensive care unit (ICU). Similarly, the rate of DVT was 20% but this increased to 28% among patients admitted to ICU. The overall rate of PE was 19% among patients in ICU. The pooled rate of ATE was much lower at 2%. The researchers calculated that the pooled odds of mortality among patients who developed a TE was 74% higher than those without the condition (odds ratio = 1.74, 95% CI 1.01 – 2.98, p = 0.04). Commenting on these findings, the authors stated how their observed rate of venous TE was much higher than expected for hospitalised patients with acute infections, which were estimated from previous work as been only 15.5%.
They concluded by noting that studies on the value of thromboprophylaxis and the optimal dosing in COVID-19 patients are currently ongoing but eagerly awaited given the higher risk of mortality due to TE.
Citation Malas MB et al. Thromboembolism risk of COVID-19 is high and associated with a higher risk of mortality: A systematic review and meta-analysis. Clin Med 2020. https://doi.org/10.1016/j.eclinm.2020.100639
25th September 2020
This was the question posed in a new study by a team from the Department of Population Medicine, Harvard Medical School who sought to determine the incidence of COVID-19 in a large, 793-bed hospital in Boston. They identified all patients who were hospitalised from 7 March 2020 through to 17 June 2020, including those who were admitted because of COVID-19, which was defined as a positive test during hospitalisation or within 14 days prior to admission. When assessing the extent of nosocomial infection, the authors reviewed medical records and only included those who tested positive on day 3 of their hospital stay or within 14 days after hospital discharge.
Findings
A total of 9149 patients with a mean age of 46.1 years (57.3% female), were admitted to the hospital during the study period, for whom 7394 COVID-19 tests were performed and of which 697 tested positive. However, of the 697 patients, only 12 (1.7%) were diagnosed on day 3 (or later) and the median time from admission to the first positive test result in these patients was 4 days (range 3 to 15 days). Interestingly, none of the 12 patients had known exposure to either staff or other patients who had tested positive for COVID-19. Analysis of medical records suggested that infection was definitely acquired before hospitalisation in 4 of the 12 cases and very likely for 7. Only a single patient was definitely infected in hospital because symptoms began on day 15. Post-discharge, among 8370 patients hospitalised with non-COVID-19-related conditions, 11 (0.1%) tested positive within 14 days and again, only a single case was deemed to have acquired the virus during their hospital stay and developed symptoms 4 days after discharge.
The authors concluded that the hospital had robust and rigorous infection control practices and suggested that these results should reassure patient that nosocomial infection is a rare event.
Reference
Rhee C et al. Incidence of nosocomial COVID-19 in patients hospitalised at a large US academic medical center. JAMA Netw Open 2020; 3(9):e2020498. doi:10.1001/jamanetworkopen.2020.20498
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