How Long Should Docs and Nurses With COVID Stay Home?

Let's say you're exposed to the coronavirus. Maybe you test positive and have mild symptoms, or none at all. And let's say you're working in a short-staffed hospital. Do you stay home? It's actually complicated.

But when it comes to what others should do, it's not complicated. We tell people exactly what the guidelines are.

Think back to when members in the White House were exposed to coronavirus. Doctors blasted social media with CDC recommendations. Many public health experts and doctors called for President Trump to isolate after he tested positive. The Infectious Diseases Society of America recommended that Mike Pence quarantine for 14 days because of his exposure even though he tested negative. Now, they're not essential workers, per se; they are not on the front lines in a hospital or clinic, and this is a politically charged example.

But if we just push that tribal mentality aside, I still want to know if healthcare professionals stand by the same CDC guidelines when it comes to their own exposures or if they're around a close contact.

According to the CDC, a close contact is defined as being within 6 feet of someone who's tested positive for at least 15 minutes, starting 2 days prior to their illness onset. That has happened to so many of us, both in the hospital and out.

Let's say you have been exposed and you're scheduled to work shifts in the hospital. There don't seem to be clear guidelines on what you're supposed to do if you're exposed and you test negative. It kind of depends on who you ask. I've heard of people saying that in this exact situation, they were told to quarantine for 10 days. Others said 72 hours. Others were told that they could go right back to work as long as they didn't have any symptoms. But what if you test positive?

According to the CDC, if you test positive and you're asymptomatic, you can come back to work if it's been 10 days since your test.

If you test positive and you have symptoms, you can come back to work if it's been 10 days since your symptoms first appeared, 24 hours since your last fever, and if your symptoms have improved.

These recommendations kind of concern me because, based on how strained our healthcare system is, I don't know how closely they are adhered to.

I read one story about a nurse who tested positive, was coughing and had GI symptoms, but because she was fever free, she was told to come back to work within 2 days. This sends a terrible message and it adds to the reality of "presenteeism," where people go to work when they are sick, and they shouldn't be there because they can't fully, safely do their jobs.

Now, I don't think healthcare professionals are inherently irresponsible, but for many reasons, many of us do show up to work when we're sick, and there are surveys that demonstrate this. People in healthcare cite a lot of different reasons why they feel pressured to do this. They're afraid of letting down their patients or colleagues, they’re afraid of being criticized, or they're afraid they're going to lose continuity of care.

Also, not every hospital service has backup call or a jeopardy system. Some people have seen pay cuts or lost their PTO, or they feel pressured by administration or their colleagues to go back to work faster than they should. In the end, I really hope our colleagues feel supported enough to say, "Hey, you know what? I've been exposed. I may need to quarantine."

This is a loaded topic. I know. We're still in this pandemic and we're heading into cold and flu season. I want to hear from all of you. What do you think we healthcare professionals should actually be doing if we're exposed or if we test positive and still have mild or no symptoms? Also, what changes need to be made to ensure that our colleagues who are sick actually stay home? Comment below.

Alok S. Patel, MD, is a pediatric hospitalist, television producer, media contributor, and digital health enthusiast. He splits his time between New York City and San Francisco as he is on faculty at both Columbia University/Morgan Stanley Children's Hospital and the University of California San Francisco Benioff Children's Hospital. Alok hosts The Hospitalist Retort video blog on Medscape.

https://www.medscape.com/viewarticle/939579

Does timing of government COVID-19 policy interventions matter?

Melodena Stephens, Jose Berengueres, Sridhar Venkatapuram, Immanuel Azaad Moonesar

doi: https://doi.org/10.1101/2020.11.13.20194761

This article is a preprint and has not been certified by peer review [what does this mean?]. It reports new medical research that has yet to be evaluated and so should not be used to guide clinical practice.

PDF: https://www.medrxiv.org/content/10.1101/2020.11.13.20194761v1.full.pdf

Abstract

Recent scientific literature and public discussion have asserted that delays in implementing COVID-19 response policies resulted in thousands of preventable infections, and consequent deaths. These studies usually rely on dynamic mathematical models of infectious disease spread such as the well-known S-I-R model.There are few papers in this area. Despite the public interest in government speediness in responding to the COVID-19 pandemic, we have found only 22 studies that examine the timing of interventions. Most studies that do focus on time, compare disease cases or the mortality rates before and after the time a policy is implemented. There are only two comprehensive policy and country studies. As policies have a cascading effect in a pandemic, this is an important topic for research. In this study, we measure if implementing a policy earlier or later relative to three points in time (first Wuhan case, first national disease case, first national death) has any relation to the subsequent higher or lower mortality rates. Based on the analysis of an original dataset of 87 policies across 17 countries (or 1,479 government responses) with the COVID-19 mortality rates of 17 countries we find: (1) No Correlation found between Policy Timing and Mortality Rate; (2) Policies across countries are not implemented with the same urgency; (3) Countries implement policies faster from Wuhan first case; and (4) No correlation between country ranking and country policy timing implementation.The findings also have implications for trans-national coordination of pandemic response policymaking. There is no consensus among countries on the appropriate timing from when an outbreak in a country is announced and when any particular policy should be implemented by other countries. Further the policy responses need to be tailored to country-specific factors existing prior to the onset of the pandemic and perhaps need to consider reinforcing effects of policies (health, economic, social, innovation). There is a lack of data being shared and it is important to note that policy publishing or announcement dates does not mean policy implmentaion nor does it mean the policy had immediate impact.

Competing Interest Statement

All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi__disclosure.pdf and declare: IAM and MS would like to acknowledge the Alliance for Health Policy and Systems Research at the World Health Organization for financial support for publishing as part of the Knowledge to Policy (K2P) Center Mentorship Program (BIRD Project).

Funding Statement

We would like to acknowledge the Alliance for Health Policy and Systems Research at the World Health Organization for financial support as part of the Knowledge to Policy (K2P) Center Mentorship Program (BIRD Project).

https://www.medrxiv.org/content/10.1101/2020.11.13.20194761v1

Estimated Education Attainment, Years of Life Lost in Pandemic Primary School Closures

Dimitri A. Christakis, MD, MPH¹; Wil Van Cleve, MD, MPH²; Frederick J. Zimmerman, PhD³

JAMA Netw Open. 2020;3(11):e2028786. doi:10.1001/jamanetworkopen.2020.28786

Key Points

Question  Based on the current understanding of the associations between school disruption and decreased educational attainment and between decreased educational attainment and lower life expectancy, is it possible to estimate the association between school closure during the coronavirus disease 2019 pandemic and decreased life expectancy of publicly educated primary school–aged children in the United States?

Findings  This decision analytical model found that missed instruction during 2020 could be associated with an estimated 5.53 million years of life lost. This loss in life expectancy was likely to be greater than would have been observed if leaving primary schools open had led to an expansion of the first wave of the pandemic.

Meaning  These findings suggest that the decision to close US public primary schools in the early months of 2020 may be associated with a decrease in life expectancy for US children.

Abstract

Importance  United States primary school closures during the 2020 coronavirus disease 2019 (COVID-19) pandemic affected millions of children, with little understanding of the potential health outcomes associated with educational disruption.

Objective  To estimate the potential years of life lost (YLL) associated with the COVID-19 pandemic conditioned on primary schools being closed or remaining open.

Design, Setting, and Participants  This decision analytical model estimated the association between school closures and reduced educational attainment and the association between reduced educational attainment and life expectancy using publicly available data sources, including data for 2020 from the US Centers for Disease Control and Prevention, the US Social Security Administration, and the US Census Bureau. Direct COVID-19 mortality and potential increases in mortality that might have resulted if school opening led to increased transmission of COVID-19 were also estimated.

Main Outcomes and Measures  Years of life lost.

Results  A total of 24.2 million children aged 5 to 11 years attended public schools that were closed during the 2020 pandemic, losing a median of 54 (interquartile range, 48-62.5) days of instruction. Missed instruction was associated with a mean loss of 0.31 (95% credible interval [CI], 0.10-0.65) years of final educational attainment for boys and 0.21 (95% CI, 0.06-0.46) years for girls. Summed across the population, an estimated 5.53 million (95% CI, 1.88-10.80) YLL may be associated with school closures. The Centers for Disease Control and Prevention reported a total of 88 241 US deaths from COVID-19 through the end of May 2020, with an estimated 1.50 million (95% CI, 1.23-1.85 million) YLL as a result. Had schools remained open, 1.47 million (95% credible interval, 0.45-2.59) additional YLL could have been expected as a result, based on results of studies associating school closure with decreased pandemic spread. Comparing the full distributions of estimated YLL under both “schools open” and “schools closed” conditions, the analysis observed a 98.1% probability that school opening would have been associated with a lower total YLL than school closure.

Conclusions and Relevance  In this decision analytical model of years of life potentially lost under differing conditions of school closure, the analysis favored schools remaining open. Future decisions regarding school closures during the pandemic should consider the association between educational disruption and decreased expected lifespan and give greater weight to the potential outcomes of school closure on children’s health.

https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2772834

How Effective Will Lilly’s Bamlanivimab be in Battle Against COVID-19?

Eli Lilly’s antibody neutralizing antibody bamlanivimab (LY-CoV555) is the latest bright spot in the battle against COVID-19. Despite the greenlight from the U.S. Food and Drug Administration (FDA) as an emergency treatment, there are some questions about how effective the treatment will actually prove to be due to labeling limitations.

Earlier this week, the FDA granted Emergency Use Authorization to bamlanivimab for the treatment of adults over age 65 recently diagnosed with mild-to-moderate COVID-19 and pediatric patients 12 years and older with a positive COVID-19 test, who are at high risk for progressing to severe COVID-19 and/or hospitalization. However, the intravenous antibody treatment is not recommended for more severely-infected patients who have been hospitalized and are on supplemental oxygen. In its announcement, Eli Lilly notes that no benefit has been seen in patients who require hospitalization. And when it comes to those who require supplemental oxygen, Eli Lilly said the use of bamlanivimab may actually worsen the condition of patients. Also, there is no language in the label about a reduction in mortality, only in hospitalization up to 28 days after treatment.

Analysts at SVB Leerink noted these limitations in a recent note to investors and suggested that some physicians may balk at administering the medication due to concerns over how to define who may be at risk of hospitalization from COVID-19.

“On the other side of the indication, to be eligible you can’t be too sick, or in need of supplemental oxygen or hospital care, because then you are too advanced, and may not benefit or may suffer harm from the medicine. We expect this limited indication to be highly confusing,” the analysts wrote, according to FiercePharma. 

These concerns could spill over to Regeneron, which is developing its own monoclonal antibody treatment for COVID-19. New York-based Regeneron is also seeking EUA for its antibody cocktail, REGN-COV2. The company is seeking EUA for patients with mild-to-moderate COVID-19 who are at risk for poor outcomes. The Regeneron antibody treatment received some positive press after it was given to President Donald Trump following his diagnosis with COVID-19 last month.

Not only are some analysts raising concerns about the antibody treatment and its potential to impact the bottom line for Eli Lilly, the Infectious Disease Society of America is also reviewing clinical data associated with bamlanivimab. The association said it will issue a recommendation to its member physicians soon, Reuters reported this morning.

“It is important for clinicians and members of the public to be aware that the available data are limited, and that more information is needed to determine the effect of this therapy on clinically meaningful outcomes,” the IDSA said in a statement. “For new therapeutics to be used widely and routinely outside of clinical trials, we urge that there be sufficient safety and efficacy data to be confident regarding their use.”

Bamlanivimab is derived from the blood of a recovered patient and was first discovered by AbCellera from the blood of one of the first recovered COVID-19 patients in the United States. Bamlanivimab is a neutralizing IgG1 monoclonal antibody (mAb) directed against the spike protein of SARS-CoV-2. It is designed to block viral attachment and entry into human cells, which should neutralize the virus, and potentially prevent and treat COVID-19. 

The EUA for bamlanivimab is based on data from the Phase II BLAZE-1 study of patients with recently diagnosed mild to moderate COVID-19 in the outpatient setting. In the study, patients treated with bamlanivimab showed reduced viral load and rates of symptoms and hospitalization.

Before the EUA was granted for the antibody treatment, Eli Lilly began manufacturing of the medication to meet demand. Lilly anticipates having about 1 million doses available by the end of 2020. Of those, about 300,000 doses are allocated to the United States through an agreement with the federal government. Next year, Lilly said it anticipates increased manufacturing for the antibody treatment as additional manufacturing resources come online throughout the year.

https://www.biospace.com/article/how-effective-will-eli-lilly-s-bamlanivimab-be-in-the-battle-against-covid-19-/

NMC's Shetty says will return to UAE

NMC Health founder BR Shetty said on Saturday he planned to the return to the United Arab Emirates and denied reports he had fled the country after the hospital group’s implosion under a mountain of previously undisclosed debt.

NMC went into administration in April following months of turmoil over its finances and the discovery that it has $6.6 billion in debt, well above earlier estimates.

Earlier this month, administrators Alvarez & Marsal took preliminary steps towards legal action against NMC’s auditor, Ernst & Young, as it seeks to increase recoveries for creditors.

“I travelled to India in February to be with my ailing brother who sadly passed away at the end of March, just as the pandemic spread across the world disrupting international travel,” Shetty said in a statement, adding that reports he fled “could not be further from the truth.”

Shetty said investigations he commissioned had uncovered details of fraud at NMC Health, Finablr and other private businesses owned by his family, which he said caused “great hardship for employees, disruptions to suppliers, and losses to shareholders including myself and creditors.”

He said he intended to return to the UAE, without specifying when, having filed a criminal complaint in India seeking a probe into two former top executives of his companies and two Indian banks related to the multibillion dollar financial scandal engulfing his group.

He said he intended to support UAE authorities “to correct any injustice done” and “help find solutions to outstanding matters.”

https://www.reuters.com/article/nmc-health-shetty/nmcs-shetty-says-will-return-to-uae-idUSL4N2I004C