COVID-19 Scan for Apr 26, 2021

News brief

Higher stroke risk linked to asymptomatic COVID-19 in younger men

Men under 50 recovering from asymptomatic COVID have double the likelihood of acute ischemic strokes (AIS) compared with men of the same age without COVID infection, according to a study last week in JAMA Network Open.

Eighteen South Asian men were treated in Singapore for AIS a median of 54.5 days after their initial COVID-19 diagnosis. Twelve (67.7%) had no known pre-existing risk factors. While AIS is a known neurologic complication from symptomatic COVID-19, none of these men experienced respiratory symptoms during their infection.

Median stroke severity was a 5 on the National Institutes of Health Stroke Scale (those with a score lower than 4 are highly likely to have good clinical outcomes, according to MDCalc). Ten patients had large-vessel occlusion, and six of those went on to receive either intravenous thrombolysis, endovascular therapy, or both. Three patients may have had a possible cardiac source.

The researchers also found increased levels of dimerized plasmin fragment D in three patients, and two had positive results for lupus anticoagulant antibodies but no other antiphospholipid antibodies.

The cohort came from 54,485 South Asian workers living in Singapore dormitories through Oct 14, 2020, and had an AIS incidence of 82.6 per 100,000 people, or a 2.16 rate ratio (95% confidence interval, 1.36 to 3.48) compared with a matched cohort of non-COVID men from 2018 (38.2 cases per 100,000). Overall, Singapore's dormitory workers accounted for 94.1% of the city-state's cases.

"This case series suggests that the risk for AIS is higher in adults 50 years or younger during the convalescent period of a COVID-19 infection without respiratory symptoms," write the researchers. "Acute ischemic stroke could be part of the next wave of complications of COVID-19, and stroke units should be on alert and use serological testing, especially in younger patients or in the absence of traditional risk factors."
Apr 22 JAMA Netw Open study

Studies detail likely COVID-19 aerosol spread in vans, car

Two new studies suggest infectious COVID-19 aerosols can travel in passenger cars and vans.

The first study, from Clinical Infectious Diseases, found that two Cleveland-area van drivers traveling to a hospital 2 hours away most likely spread COVID-19 to their passengers. SARS-CoV-2 strains between infected passengers and their respective drivers were closely related, and in a simulation using fluorescent microspheres, airflow transported both small and larger droplets greater than 3 meters from the front to the back of the van.

The same van was used in both trips, one on Dec 2, 2020, and one on Jan 23, 2021. Physical distancing was followed as closely as possible, but the van's windows were closed while the heaters were operating with a medium fan speed.

In December, the first driver transported four passengers one day prior to symptom onset, and three passengers tested positive for COVID-19 despite everyone using face masks. The second driver transported three passengers on the day of symptom onset and did not wear a face mask. One of his three passengers tested positive for COVID.
Apr 24 Clin Infect Dis study

The second study, published in the International Journal of Infectious Diseases, found that a woman in her 20s with mild COVID-19—no fever or cough—transmitted infectious viral aerosols 0.25 to 0.5 micrometers in size while driving a car for 15 minutes.

University of Florida researchers instructed her not to wear a mask, and she operated the car's air conditioning while the windows were closed. To measure SARS-CoV-2 particles, a personal cascade impactor sampler was clipped to the sun visor above the front passenger seat for the duration of the drive and 2 hours after.

"Our data highlight the potential risk of SARS-CoV-2 transmission by minimally symptomatic persons in the closed space inside of a car and suggest that a substantial component of that risk is via aerosolized virus," the researchers write. The scientists detected viral RNA in respiratory secretions of all sizes but were able to grow viable virus only from the smallest particles—those 0.25 to 0.5 micrometers in diameter.
Apr 23 Int J Infect Dis study

News Scan for Apr 26, 2021

News brief

Study finds high broad-spectrum antibiotic use in Indonesian hospitals

A point-prevalence study (PPS) conducted in six Indonesian hospitals found a high rate of empirical use of broad spectrum antibiotics, researchers reported today in JAC-Antimicrobial Resistance.

The hospital-wide PPS was conducted at six hospitals in Jakarta from March 2019 to August 2019. Eligible patients included everyone who received one or more antimicrobials on the day of the survey or surgical prophylaxis less than 24 hours prior to the survey. The analysis focused on antibiotics for systemic use, and researchers classified antibiotics according to the World Health Organization's AWaRe (Access, Watch, and Reserve) classification system.

Of 1,602 hospitalized patients on the day of the survey, 993 (62%) received one or more antimicrobial, and of the 1,666 antimicrobial prescriptions, 1,273 (76.4%) were antibiotics. Antimicrobial use was highest in patients in intensive care units (86.8%), followed by surgical wards (66%), mixed medical-surgical wards (65%), and medical wards (51.4%). The most common prescribing reasons were pneumonia (27.7%), skin and soft-tissue infections (8.3%), and gastrointestinal prophylaxis (7.9%).

The most prescribed antibiotic classes were third-generation cephalosporins (44.3%), fluoroquinolones (13.5%), carbapenems (7.4%), and penicillins with beta-lactamase inhibitor (6.8%). According to the AWaRe classification, Watch antibiotics—broad-spectrum agents with an increased risk of developing resistance—accounted for 67.4% of antibiotics prescribed, while Access antibiotics accounted for 28% and Reserve antibiotics accounted for 2.4%. This pattern was similar across indications and ward types.

The researchers also found that hospital antibiotic guidelines were not available for 28.1% of prescriptions, and, when they were available, compliance was only 52.2%. In addition, the reason for the antibiotic prescription, the stop/review date, and the planned duration were poorly documented.

The authors note that the proportion of inpatients receiving antimicrobials in the study was significantly higher than has been reported in global PPS datasets.

"In conclusion, we observed high levels of parenteral, empirical use of broad-spectrum antibiotics in Indonesian hospitals, and inadequate performance on key quality indicators of prescribing," the study authors wrote. "Despite important progress in AMS [antimicrobial stewardship], supported by national policies, the study findings highlighted the need to strengthen AMS to increase use of narrower-spectrum antibiotics through culture-guided, targeted treatment and hospital guideline compliance."
Apr 26 JAC-Antimicrob Resist study

Measles infects 2 children in Connecticut household

Connecticut's Department of Public Health (CDPH) recently reported two measles cases in a Fairfield County household, the first of which was linked to international travel.

State officials reported the first case on Apr 9, which involved a child who wasn't yet vaccinated against measles and contracted the infection during international travel. On Apr 23, it reported a second case in a child from the household. The CDPH said it is working with local partners to identify contacts and implement control measures and that the cases mark the state's first measles reports since 2019.

In most places in the world, measles cases have been much lower than usual, likely due to reduced travel and COVID-19 restrictions. In 2020, the US Centers for Disease Control and Prevention (CDC) reported 13 cases, down dramatically from 1,282 reported in 2010. As of Mar 5, the CDC hadn't received any reports of measles cases for 2021. Last month Doctors Without Borders (MSF) warned about widespread measles activity in the Democratic Republic of Congo, and global health officials have warned of a possible resurgence due to a pandemic-related lapses in routine childhood immunizations.
Apr 9 CDPH statement
Apr 23 CDPH statement
CDC measles page
Mar 31 MSF statement

H5 avian flu strikes poultry in Slovakia and Bulgaria

Two European countries recently reported new highly pathogenic H5 avian influenza outbreaks in poultry, including the first involving H5N1 in Slovakia, according to the latest notifications from the World Organization for Animal Health (OIE).

Slovakia's outbreak began Apr 21 at a small backyard holding in Bratislava region in the far west of the country. The virus killed all six of six susceptible hens. Investigators said wild birds probably introduced the virus into the flock.

Earlier H5N1 detections in European poultry have involved the Eurasian strain, not the strain that has caused human infections.

Elsewhere, Bulgaria reported an H5 outbreak that began on Apr 22 at a layer farm in Haskovo province in the south of the country near the borders with Greece and Turkey. The virus killed 660 of 39,950 susceptible poultry.
Apr 22 OIE report on H5N1 in Slovakia
Apr 26 OIE report on H5 in Bulgaria