COVID-19 infection rates low in people with rheumatic diseases, most report mild illness

A new study shows that the COVID-19 infection incidence has been low in people with rheumatic diseases, and most of those infected experience a mild course of illness. Additionally, fatalities have been low among rheumatic disease patients infected with COVID-19. Details of this research was presented at ACR Convergence, the American College of Rheumatology's annual meeting (ABSTRACT #0008). 

COVID-19 is the infectious disease caused by the novel coronavirus SARS-CoV-2. As the COVID-19 pandemic surged worldwide in early 2020, the risk of serious infection, complications or fatality was unknown for people with rheumatic disease. Many patients with rheumatic disease are treated with immunosuppressant medications that leave them more susceptible to infection.

As the pandemic began, it was unclear how people with rheumatic diseases, on immunosuppressant therapy, were affected by a COVID-19 infection. Some early studies even suggested that these drugs could have a protective effect, but concerns remained about the vulnerability of this patient population. To learn more, researchers conducted a systematic review of studies that reported outcomes of COVID-19 infection among patients with rheumatic diseases who were taking biologic and targeted therapies.

"When the pandemic started, there was concern on whether to continue or hold immune therapies among patients with rheumatic diseases because they are at increased risk for infection," says the study's co-author, Akhil Sood, MD, an internal medicine resident in rheumatology at the University of Texas Medical Branch in Galveston. "We were interested to see if these patients are at an increased risk for COVID-19 infection. If they were to become infected, we wanted to know the severity of their clinical course. This can help us to determine whether it is safe to continue or hold immune therapies in setting of COVID-19 infection."

The researchers systematically searched PubMed/Medline and Scopus to identify relevant studies from January to June 2020 that reported the outcomes of COVID-19 among patients with rheumatic disease. They extracted demographic information and patients' use of biologics or targeted therapy with Janus kinase (JAK) inhibitors. They measured the following COVID-19 outcomes: hospitalization, admission to an ICU and death. Based on their clinical symptoms, patients were split into two groups: severe, or having increased risk of respiratory failure or life-threatening complications or non-severe.

The final review included 6,095 patients with rheumatic diseases from eight observational cohort studies, with 28% having rheumatoid arthritis (RA) and 7% having psoriatic arthritis (PsA). Of the 6,095 patients, only 123 or 2% were positive or highly suspicious for COVID-19. Across all the studies used for the review, 68% of COVID-19 patients were taking biologics, with 31% taking anti-TNF drugs and 6% taking JAK inhibitors. Among those patients who were infected with the coronavirus, 91 or 73% were never hospitalized. Thirteen patients who were hospitalized required admission to an ICU and four patients died.

"In our analysis, there was a small number of patients on biologic and targeted therapies to make definite conclusions on whether to continue or hold therapies," says Dr. Sood. "We are waiting for additional extensive studies that include more patients with rheumatic disease on biologic and targeted therapies. Another area of interest for us is examining risk factors for severe COVID-19 infection in patients with rheumatic disease. We hope this can help us identify which patients to closely monitor and possibly develop precautions to mitigate their risk."

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Different outcomes by race/ethnicity among patients with COVID-19 and rheumatic disease

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More information: acrabstracts.org/abstract/covi … a-systematic-review/

https://medicalxpress.com/news/2020-11-covid-infection-people-rheumatic-diseases.html

Physical distancing polices 'not enough to protect lower-income people'

A new Boston University School of Public Health study of the first four months of America's coronavirus epidemic, published in the journal Nature Human Behaviour, shows that physical distancing (also called "social distancing") policies had little effect on lower income people still needing to leave their homes to go to work—but does show them staying home when they could. 

"If lower-income people were simply ignoring the trend towards physical distancing, we would have expected them to continue going to places like supermarkets, liquor stores, and parks at the same rates as before. Instead, their visits dropped at almost the same rates as the very highest-income group," says study lead author Dr. Jonathan Jay, assistant professor of community health sciences at BUSPH.

"This indicates that lower income people were just as aware and motivated as higher-income people to protect themselves from COVID-19, but simply couldn't stay home as much because they needed to go to work," he says.

Jay and colleagues used anonymized mobility data from smartphones in over 210,000 neighborhoods (census block groups) across the country, each neighborhood categorized by average income. They were able to see whether people from these neighborhoods stayed home, left home and appeared to be at work—staying at another location for at least three hours during typical working hours, or making multiple stops that looked like delivery work. The researchers also tracked movement to "points of interest": beer, wine and liquor stores; carryout restaurants; convenience stores; hospitals; parks and playgrounds; places of worship; and supermarkets.

"The difference in physical distancing between low- and high-income neighborhoods during the lockdown was just staggering," says study co-author Dr. Jacob Bor, assistant professor of global health and epidemiology at BUSPH.

"While people in high-income neighborhoods retreated to home offices, people in low-income neighborhoods had to continue to go to work—and their friends, family, and neighbors had to do the same," he says. "Living in a low-income neighborhood is likely a key risk factor for COVID-19 infection."

To analyze the role that policies played in these mobility patterns, the researcher used the COVID-19 U.S. State Policy Database (CUSP), a project led by study co-author Dr. Julia Raifman, assistant professor of health law, policy & management at BUSPH.

They found that the huge drop in mobility early in March had little to do with state policy, following similar patterns in different states regardless of when their orders went into effect. When state policies did go into effect, they modestly decreased mobility further—but did nothing to close the gap between low- and high-income neighborhoods.

"The orders did not have the effect of making it easier for lower-income people to stay home," Jay says. But they did stay home to the degree possible, visiting non-work non-home locations less—which counters a major narrative about how different groups of people have responded to COVID, Jay says. "Early in the pandemic, there was a lot of talk about 'non-compliance,' and it was rarely directed at the people with the most power and privilege," he says.

"We found strong evidence of compliance among the people who are most economically marginalized, which because of structural racism disproportionately includes people of color. As the pandemic has played out, the evidence of poor safety practices at the very highest levels of power has become more clear.

"Still, it's deeply troubling that throughout the pandemic, staying home has been a choice for some people and not for others."

The researchers say that closures are an important tool for states and cities to prevent the spread of the coronavirus, but that they need to be accompanied by other policies that make it easier for frontline workers to protect themselves.

"That people living in low-income households are more likely to face exposure to COVID-19 at work increases the importance of complementary policies, such as mask requirements in indoor spaces, that protect essential workers from COVID-19," Raifman says.

"One of the most important arguments for mask mandates is that they protect the folks who are in public spaces not because they want to be, but because showing up is how they make ends meet," Jay says. He also points to "policies that make it easier to work from home, stay home sick, and not to take a risky new job just to put food on the table."

However, Jay says, policies that make it easier to stay home only help if people have homes. As a wave of evictions and foreclosures sweeps the country, he says extending moratoriums and enacting other housing policies continue to be an important part of the picture. 

More information: Jonathan Jay et al. Neighbourhood income and physical distancing during the COVID-19 pandemic in the United States, Nature Human Behaviour (2020). DOI: 10.1038/s41562-020-00998-2

https://medicalxpress.com/news/2020-11-physical-distancing-polices-lower-income-people.html

Covid-Proofing Air Is a $10 Billion Opportunity

When's the last time you actually thought about your office's air conditioner? Pre-pandemic, assuming it worked, probably never. Today? Probably a lot. And even once the coronavirus outbreaks have subsided and a vaccine is finally in hand, you’re probably still going to feel differently about the air you breathe, especially indoors.

Increased interest in filtration, disinfection and other tools for improving the quality of indoor air will likely create a new revenue opportunity of multiple billions of dollars across the industry, Johnson Controls International Plc CEO George Oliver said on a call Tuesday to discuss the building-products company’s most recent quarterly results. Johnson Controls alone is looking at potential projects in this vein worth “a couple of hundred million” for just next year, he said. That echoes commentary from rivals including Carrier Global Corp., which estimates the ultimate market for indoor air-quality improvements will reach about $10 billion, including $150 million of potential business opportunities the company has already identified for itself. Honeywell International Inc. cited a more than $600 million sales pipeline for its “healthy buildings” offerings.

It’s in these companies’ interest to tout this opportunity. Heating, vent

ilation and air conditioner (HVAC) systems have been a rare bright spot in an industrial sector that’s struggled to inspire investors with third-quarter results that signaled a sure but slow recovery. Consumers have been snapping up new air conditioners amid a lockdown-inspired home-improvement wave, but even commercial landlords are investing at a greater rate than expected as they try to lure people back to offices, restaurants and retail space. There were fears that air conditioners were to blame for spikes in coronavirus cases as hot summer weather pushed people indoors. The reality is that these systems can be an effective tool in fighting off contagions — with some upgrades. These range from adding higher levels of filtration and allowing for more outside air flow to installing ultraviolet light disinfectant systems and digital-monitoring technology that lets building managers know if everything is working as it should. All of these cost money.

“It's something that everybody needs,” Honeywell CEO Darius Adamczyk said on a call to discuss third-quarter results last week. “At least in the U.S. and some other parts of the world, people are not working in their workplace yet. But when they do come back, they do want to come back to a healthier environment. I think we're kind of hitting the spot there and the time to implement those solutions is now, not after people come back.”

Carrier CEO Dave Gitlin pointed out that people spend a whopping 90% of their lives indoors on average, meaning that if you are 50 years old, you’ve spent 45 years sitting inside. That is both depressing and instructive. We may be more aware of our time inside after having endured lockdowns, but even in a pandemic-free future we’re still going to be breathing in an awful lot of indoor air. And it seems likely that after everything the world has been through, the average person is at least going to think twice about the quality of that air.

This theme fits hand in hand with a broader pivot toward sustainability in both the HVAC industry in particular and the manufacturing economy more broadly. A building that’s helping the environment by releasing fewer greenhouse gases doesn’t have the same appeal if the air within its four walls can be a (real or perceived) conduit for disease. What we’ve learned is that our previous standards of air purification didn’t hold up to the test of the pandemic and those need to evolve accordingly, Oliver of Johnson Controls said. After all, the coronavirus is unlikely to be the last novel pathogen the world encounters.

Trane Technologies Plc estimates there are 1.7 trillion square feet of building space around the world and that some 400 billion of that is non-residential, communal real estate. If all of that ultimately needs to be upgraded, well, you get the picture.

https://finance.yahoo.com/news/covid-proofing-air-10-billion-133002673.html

'Pay people to get COVID-19 jab to ensure widespread coverage'

Governments should consider incentivising people to get a COVID-19 jab, when the vaccine becomes available, to achieve the required level of herd immunity -- which could be up to 80%+ of the population -- and stamp out the infection, argues a leading ethicist in an opinion piece accepted for publication in the Journal of Medical Ethics.

The incentive could be either financial or 'payment in kind', such as being allowed to forego the need to wear a facemask in public, he suggests.

Given the rising global death toll and the far reaching health and economic consequences of the pandemic, there have been calls, including in the UK, to mandate COVID-19 vaccination, if and when a jab is approved, points out the author, Professor Julian Savulescu, Oxford Uehiro Centre for Practical Ethics, University of Oxford.

In general, vaccination should be voluntary, he says. But there is a strong case for making any vaccination mandatory (or compulsory) if four conditions are met: a grave threat to public health; the vaccine is safe and effective; the pros outweigh the cons of any suitable alternative; and the level of coercion is proportionate.

Put simply, if voluntary schemes fail, we need to move to Vaccination Plan B, he suggests.

There are examples of coercion for the public good: conscription during wartime; taxes; the wearing of seat belts. And mandatory vaccination policies are already in place in different parts of the world, he says.

But there are ethical issues if a mandatory approach were to be adopted, he contends. So, if voluntary vaccination proves insufficient, incentivisation should be considered to address these issues while boosting vaccination uptake.

A certain level of uptake will be required to make any vaccination programme really effective and quell the relentless surge of the pandemic.

"To be maximally effective, particularly in protecting the most vulnerable in the population, vaccination would need to achieve herd immunity (the exact percentage of the population that would need to be immune for herd immunity to be reached depends on various factors, but current estimates range up to 82%)," he writes.

While there are obvious logistical issues to producing and administering a COVID-19 vaccine to the world's population, universal coverage also faces rising vaccine hesitancy -- reluctance or refusal to be vaccinated because of safety concerns.

"Vaccines are some of the safest and most effective interventions we have, and have achieved incredible successes. We no longer face diseases that killed our ancestors," he says, "but vaccine hesitancy is on the rise even for well-established vaccinations.

"The problem is likely to be bigger for a new vaccine. For established vaccines, some countries have turned to mandatory vaccination schemes. In an ideal world, the vaccine would be proven to be 100% safe. But there will likely be some risk remaining, and there are risks that have not yet been identified.

"Any mandatory vaccination programme would therefore need to make a value judgement about what level of safety and what level of certainty are safe and certain enough. Of course, it would need to be very high, but a 0% risk option is very unlikely," he suggests.

"So we cannot say whether a mandatory policy of COVID-19 vaccination is ethically justified until we can assess the nature of the vaccine, the gravity of the problem and the likely costs/benefit of alternatives," he explains.

"However, another way of looking at this is that those at low risk are being asked to do a job which entails some risk, albeit a very low one. So they should be paid for the risk they are taking for the sake of providing a public good," Professor Savulescu suggests.

'Anti-vaxxers' may never be convinced to change their stance, but incentivising vaccination may persuade others who might not have done so to get the jab, he says.

"The advantage of payment for risk is that people are choosing voluntarily to take it on. As long as we are accurate in conveying the limitations in our confidence about the risks and benefits of a vaccine, then it is up to individuals to judge whether they are worth payment," he says.

Payment isn't about coercion, he insists. "If a person chooses that option, it is because they believe that, overall, their life will go better with it, in this case, with the vaccination and the payment.

"It is true that the value of the option might exercise force over our rational capacities, but that is no different from offering a lot of money to attract a favoured job applicant," he argues.

This is not about encouraging people to take unreasonable risks. Vaccine development and trials are in place to ensure that we are confident that there is very low risk, he emphasises.

"If a vaccine were deemed to be safe enough to offer on a voluntary basis without payment, it must be safe enough to incentivize with payment, because the risks are reasonable. It may be that those who are poorer may be more inclined to take the money and the risk, but this applies to all risky or unpleasant jobs in a market economy. It is not necessarily exploitation if there are protections in place such as a minimum wage or a fair price is paid to take on risk," he suggests.

"A payment model could also be very cheap, compared to the alternatives," he argues. "The cost of the UK's furlough scheme is estimated to reach £60 billion by its [original] planned end in October, and the economic shut down is likely to cost many billions more, as well as the estimated 200, 000 lives expected to be lost as a result.

"It would make economic sense to pay people quite a lot to incentivize them to vaccinate sooner rather than later -- which, for example, would speed up their full return to work."

There are precedents for paying people to perform their civic duty: for example, blood donations are paid for in several countries, and while the UK doesn't pay donors directly, it does import blood from countries that do, he points out.

Incentives could also take the form of 'payment in kind,' he suggests. "One attractive benefit would be the freedom to travel, to not wear a mask in public places if you carried a vaccination certificate, and not to socially distance," he suggests. "Moreover, it would help ameliorate the risks the unvaccinated would pose to others."

https://www.sciencedaily.com/releases/2020/11/201105183844.htm

Many Nursing Homes Shun Free Covid-19 Testing Equipment

housands of Covid-19 rapid-testing devices are sitting idle in nursing homes around the country, even as some of the facilities face delays in getting results from outside labs, according to federal data.

The federal government spent more than $100 million to send rapid-testing equipment to the vast majority of the nation's nursing homes, but some industry executives say they are concerned about the accuracy of the point-of-care tests, the staff time involved in using them, and guidelines in some states that discourage use of the tests.

Nearly 30% of 13,150 facilities that had rapid-testing equipment for at least two weeks hadn't used it to test a single resident or staff member, according to a federal survey of nursing homes. During weeks when regulations from the Centers for Medicare and Medicaid Services required them to do testing due to local outbreaks, hundreds of facilities didn't use the rapid-testing equipment at all, the survey shows.

The equipment, which allows nursing homes to perform tests on the premises and get fast results, is supposed to help ensure that facilities can catch coronavirus infections early, before they spread. Long-term care facilities have been tied to more than 88,000 Covid-19 deaths in the U.S. since the start of the pandemic, according to a Journal tally of recent state, local and federal data.

"They need accurate testing with rapid turnaround that isn't adding an additional burden on nursing-home staff," said Michael L. Barnett, an assistant professor at the Harvard T.H. Chan School of Public Health. The federally-supplied machines "are not providing what they need, and they're voting with their feet."

As Covid-19 cases surge around the country, more people are seeking tests. "There's absolutely waste" in providing nursing homes with testing machines that aren't being used, Dr. Barnett said.

"It's not what we need," said Barbara Klick, chief executive of Sholom Community Alliance, a nonprofit that uses a lab to test around 500 staffers a week at its two nursing homes in St. Paul and St. Louis Park, Minn. Using the rapid-testing equipment sent by the federal government requires too much staff time, largely for documentation and filing results with the government, she said.

Ms. Klick also worries about the risk of false negative and false positive results from the rapid tests: "It's too unreliable."

In addition to the nursing homes that haven't yet used the devices, another 16% reported using them on fewer than 20 residents and workers, according to the survey data, which is released weekly by CMS and currently updated through the week ending Oct. 25.

Almost half, or 48%, of the nursing homes reported they hadn't used their rapid testing equipment in the most recent week included in the data. Among nursing homes that were required under federal rules to test staff at least once a week due to local outbreaks, 41% said they hadn't used it in the most recent week.

Around 4,900 nursing homes that hadn't used the rapid-testing devices in the most recent week said in the survey that instead they were waiting a day or more for test results from labs.

The rapid tests the federal government provided to nursing homes, known as antigen tests, focus on virus proteins, while molecular tests, the type generally done by labs, look for the virus's genetic material. Lab-based molecular assays tend to be more precise than the fast antigen tests.

Because of concerns about possible false negative and false positive results with antigen tests, particularly when used to screen people without symptoms, public-health officials recommend follow-up confirmatory testing under some circumstances.

The Department of Health and Human Services in July announced plans to ship rapid antigen testing machines made by Becton Dickinson & Co. and Quidel Corp. to about 14,000 nursing homes around the country. An HHS spokeswoman said the cost of the effort has been around $116 million.

"This new testing initiative is critical for keeping vulnerable older adults safe," CMS administrator Seema Verma said in a statement at the time. The department later announced it also would send nursing homes a rapid antigen test made by Abbott Laboratories, known as the BinaxNOW COVID-19 Ag Card, a device roughly the size of a credit card.

Brett Giroir, the assistant secretary at the Department of Health and Human Services who oversaw the program, said 99.3% of nursing homes had recently reported being able to test their entire staffs, a key to keeping the virus out of their facilities. He said it was "fine" for facilities to use the point-of-care devices from the government or other methods.

"We are providing options to meet CMS requirements," Dr. Giroir said, referring to the rules from the Medicare agency that require testing.

An HHS spokeswoman said nursing homes had ordered an additional 4.2 million tests from Becton Dickinson, showing they are using the equipment.

Dr. Giroir has previously defended the performance of the rapid antigen tests. The Food and Drug Administration this week warned about the potential for false positive results, noting that they sometimes occur when users don't follow the manufacturers' instructions. 

Quidel, Becton Dickinson and Abbott all said their devices perform very well when used correctly. A spokeswoman for Quidel said it offers customers "a multifaceted approach to training," including a lot of support.

Becton Dickinson said in a statement that testing, including rapid antigen tests, plays "an essential role in detecting Covid-19 and helping to disrupt community spread." Most nursing homes that have its machines are getting regular reorders of tests, the company said.

Abbott said it has worked with nursing homes "proactively to ensure they have the resources needed to best deploy BinaxNOW, including conducting webinars and reaching out to facilities individually."

The HHS spokeswoman said it wasn't clear whether nursing homes were including the Abbott tests in their answers to the federal survey, and that some facilities may be using rapid tests to check visitors.

Some states have discouraged use of the rapid antigen tests. Massachusetts, for instance, has said they can't be used to satisfy state testing mandates for nursing homes.

In North Dakota, where Covid-19 cases are rising, an October state guidance urged cautious procedures in using the antigen tests, suggesting that negative results don't rule out Covid-19 and some positives need to be re-tested.

"The state's not accepting them yet as valid tests," said Sandy Gerving, the administrator of Marian Manor Healthcare Center, an independent nonprofit nursing home in Glen Ullin, N.D. Using the device HHS distributed "seemed like a waste of effort," she said.

Marian Manor had an outbreak in September, Ms. Gerving said, as the virus spread widely in the surrounding community. Thirteen patients died of the virus, federal survey data show. Ms. Gerving said the outbreak at the facility was over. She said the facility had had to test the entire staff 23 times as of Tuesday under state and federal guidelines, sending samples to an outside lab.

Meantime, Marian Manor's point-of-care testing device and its supplies are still in their boxes, Ms. Gerving said. "We're waiting to see, do we send it back or whatever," she said.

https://www.marketscreener.com/quote/stock/BECTON-DICKINSON-AND-COM-11801/news/Many-Nursing-Homes-Shun-Free-Covid-19-Testing-Equipment-31712554/