The only person I swabbed in the last two weeks for Covid-19 was a patient who needed proof for his employer that he is now testing negative after having Covid. That is not recommended by the way. That is not supposed to be required because people may test positive for weeks after they have recovered and are no longer infectious.

It won’t last. Numbers will go up again. Labor Day is approaching and kids are going back to school. College kids have not suddenly gotten smarter. If you have a child going to college, they will be exposed to covid-19. The question is, how do you avoid it when they return home? There are new tests being developed which are rapid, cheaper and not as accurate. Abbott has released one,BinaxNOW. New testing strategies may be developed that involve serial testing. New tests may tell you not just whether or not you have the virus, but how infectious you are. We need to have a strategy before Thanksgiving. Stay tuned.

Steroids help seriously ill patients. This isn’t really new, but the World Health Organization has now recommended them. You don’t want to give them to patients who are not seriously ill as it might make them worse.

From Journal Watch:

WHO Recommends Corticosteroids for Severe COVID-19 After Positive Study Results

By Kelly Young

Edited by Susan Sadoughi, MD, and Richard Saitz, MD, MPH, FACP, DFASAM

The World Health Organization recommends systemic corticosteroids to treat patients with severe and critical COVID-19. The guidance coincides with the publication of three randomized trials and a meta-analysis on corticosteroids in JAMA.

The WHO recommends 6 mg of dexamethasone orally or intravenously daily or 50 mg of hydrocortisone intravenously every 8 hours for 7 to 10 days in the most seriously ill patients.

The organization also suggests that corticosteroids not be used to treat patients with milder COVID-19, as they may increase mortality risk in these patients.

In the WHO-sponsored meta-analysis, researchers examined the results of seven trials of corticosteroids versus usual care or placebo among some 1700 critically ill COVID-19 patients. The 28-day mortality rate, the primary outcome, was significantly lower among corticosteroid users (32% absolute mortality for corticosteroids vs. 40% assumed mortality for controls).

Editorialists conclude: “These studies provide evidence and some hope that an effective, inexpensive, and safe treatment has been identified.”

A new vaccine shows evidence that it does provide immunity based on blood tests, but we still have to wait and see whether it reduces the incidence or severity of infections. From today’s New England Journal of Medicine:

ORIGINAL ARTICLE

Phase 1–2 Trial of a SARS-CoV-2 Recombinant Spike Protein Nanoparticle Vaccine

List of authors.

Cheryl Keech, M.D., Ph.D.,
Gary Albert, M.S.,
Iksung Cho, M.S.,
Andreana Robertson, M.S.,
Patricia Reed, B.S.,
Susan Neal,
Joyce S. Plested, Ph.D.,
Mingzhu Zhu, Ph.D.,
Shane Cloney-Clark, B.S.,
Haixia Zhou, Ph.D.,
Gale Smith, Ph.D.,
Nita Patel, M.S.,

Abstract

BACKGROUND

NVX-CoV2373 is a recombinant severe acute respiratory syndrome coronavirus 2 (rSARS-CoV-2) nanoparticle vaccine composed of trimeric full-length SARS-CoV-2 spike glycoproteins and Matrix-M1 adjuvant.

METHODS

We initiated a randomized, placebo-controlled, phase 1–2 trial to evaluate the safety and immunogenicity of the rSARS-CoV-2 vaccine (in 5-μg and 25-μg doses, with or without Matrix-M1 adjuvant, and with observers unaware of trial-group assignments) in 131 healthy adults. In phase 1, vaccination comprised two intramuscular injections, 21 days apart. The primary outcomes were reactogenicity; laboratory values (serum chemistry and hematology), according to Food and Drug Administration toxicity scoring, to assess safety; and IgG anti–spike protein response (in enzyme-linked immunosorbent assay [ELISA] units). Secondary outcomes included unsolicited adverse events, wild-type virus neutralization (microneutralization assay), and T-cell responses (cytokine staining). IgG and microneutralization assay results were compared with 32 (IgG) and 29 (neutralization) convalescent serum samples from patients with Covid-19, most of whom were symptomatic. We performed a primary analysis at day 35.

RESULTS

After randomization, 83 participants were assigned to receive the vaccine with adjuvant and 25 without adjuvant, and 23 participants were assigned to receive placebo. No serious adverse events were noted. Reactogenicity was absent or mild in the majority of participants, more common with adjuvant, and of short duration (mean, ≤2 days). One participant had mild fever that lasted 1 day. Unsolicited adverse events were mild in most participants; there were no severe adverse events. The addition of adjuvant resulted in enhanced immune responses, was antigen dose–sparing, and induced a T helper 1 (Th1) response. The two-dose 5-μg adjuvanted regimen induced geometric mean anti-spike IgG (63,160 ELISA units) and neutralization (3906) responses that exceeded geometric mean responses in convalescent serum from mostly symptomatic Covid-19 patients (8344 and 983, respectively).

CONCLUSIONS

At 35 days, NVX-CoV2373 appeared to be safe, and it elicited immune responses that exceeded levels in Covid-19 convalescent serum. The Matrix-M1 adjuvant induced CD4+ T-cell responses that were biased toward a Th1 phenotype. (Funded by the Coalition for Epidemic Preparedness Innovations; ClinicalTrials.gov number, NCT04368988. opens in new tab).

Now I just have to figure out whose vaccine that is.

Asthma may be not a risk factor for severe Covid 19. From Journal Watch:

Physician’s First Watch

David G. Fairchild, MD, MPH, Editor-in-Chief

In This Issue: August 31, 2020

Asthma Might Not Be a Risk Factor for Severe COVID-19

By Kelly Young

Edited by David G. Fairchild, MD, MPH, and Jaye Elizabeth Hefner, MD

Asthma doesn’t seem to be a major risk factor for COVID-19 hospitalization or intubation, suggests a study in the Annals of the American Thoracic Society.

Researchers analyzed 15 studies of patients hospitalized for COVID-19. They found that the prevalence of asthma was similar between hospitalized COVID-19 patients and the general population at each study site.

Separately, among over 300 people admitted with COVID-19 at a Colorado hospital, intubation rates were similar between those with asthma and those without.

The authors speculate that users of corticosteroid inhalers may have lower levels of ACE2 expression, which could make it more difficult for SARS-CoV-2 to enter the airway.

Annals of the American Thoracic Society correspondence (Free PDF)

NEJM Journal Watch COVID-19 page (Free)

NEJM COVID-19 page (Free)

But obesity is a big risk factor for severe disease in those under 60 or 65.

September 1, 2020

Obesity’s Influence on Mortality in Patients with COVID-19

Daniel D. Dressler, MD, MSc, MHM, FACP reviewing Anderson MR et al. Ann Intern Med 2020 Jul 29 Tartof SY et al. Ann Intern Med 2020 Aug 12 Kass DA. Ann Intern Med 2020 Aug 12

Two retrospective studies showed higher risk for death in obese patients.

Nearly half of the adult U.S. population is classified as obese (body-mass index [BMI], ≥30 kg/m²) and almost 10% are classified as severely obese (BMI, ≥40 kg/m²); observational studies have suggested that obesity is associated with worse outcomes in patients with COVID-19. Two new studies address this association.

The first study included nearly 2500 patients (mean age, 67; 49% Hispanic) hospitalized with COVID-19 at two New York City hospitals. Analysis adjusted for demographic factors and medical comorbidities showed that obese patients, compared with overweight patients, had significantly higher risk for the composite outcome of intubation or death at 45 days (hazard ratio, 1.6). The association of obesity with adverse outcomes was seen in patients younger than 65 but not in older patients.

The second study included ≈7000 hospitalized patients (mean age, 49; 54% Hispanic) at nine California Kaiser Permanente hospitals. After adjustment for relevant demographic and comorbid factors, severely obese patients had significantly higher 21-day mortality than did normal-weight individuals (relative risk, >3). Risk was most pronounced in younger patients (age, <60) and in men.

COMMENT

These two studies, comprising nearly 10,000 patients, provide additional evidence of excess short-term mortality in obese younger patients who are hospitalized with COVID-19. A possible mechanism is that greater fat mass can lead to immune dysfunction, a proinflammatory state, and hypercoagulability.

EDITOR DISCLOSURES AT TIME OF PUBLICATION

Disclosures for Daniel D. Dressler, MD, MSc, MHM, FACP at time of publication

Royalties	McGraw-Hill
Editorial Boards	Principles and Practice of Hospital Medicine (McGraw-Hill)
Leadership Positions in Professional Societies	American College of Physicians (Member, 2021 Annual Meeting Committee)

CITATION(S):

Anderson MR et al. Body mass index and risk for intubation or death in SARS-CoV-2 infection. Ann Intern Med 2020 Jul 29; [e-pub]. (https://doi.org/10.7326/M20-3214)

Tartof SY et al. Obesity and mortality among patients diagnosed with COVID-19: Results from an integrated health care organization. Ann Intern Med 2020 Aug 12; [e-pub]. (https://doi.org/10.7326/M20-3742)

Kass DA. COVID-19 and severe obesity: A big problem? Ann Intern Med 2020 Aug 12; [e-pub]. (https://doi.org/10.7326/M20-5677)

What Do I Know New About Covid-19?