#NPM 2020 : Creating A Culture Of Preparedness

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Tomorrow, September 1st, marks the start of National Preparedness Month (#NPM), which has been promoted by FEMA, Ready.gov, and others (including AFD) since 2004.  Each year, during the month of September, I double down on preparedness blogs in support of this campaign. 

This year will be no different, although personally, the stakes have never felt higher. 

We are just now entering the height of hurricane season, in what has already been a record breaking year.  The earth, and the United States in particular, has been in a major earthquake drought for years, and as we all know - droughts - even good ones, end eventually. 

• When Category 4 Hurricane Harvey battered and flooded east Texas in 2017, it ended an 11+ year drought in major (CAT 3+) land-falling hurricanes in the Continental United States. Since then, we've seen Irma, Michael, and Laura.
• When a novel swine-origin H1N1 virus emerged in 2009, it ended a 40 year drought in flu pandemics, and just ten years later we have our 2nd pandemic. 

Over the next couple of years, the sun will climb back towards solar maximum, putting the earth at risk of damaging solar storms (see USGS: Preparing The Nation For Severe Space Weather). 

In 2014 a study was published suggesting the odds of earth being struck by one of these solar super storms is actually a lot higher than we’ve previously thought.  From a NASA article:

In February 2014, physicist Pete Riley of Predictive Science Inc. published a paper in Space Weather entitled "On the probability of occurrence of extreme space weather events."  In it, he analyzed records of solar storms going back 50+ years.  By extrapolating the frequency of ordinary storms to the extreme, he calculated the odds that a Carrington-class storm would hit Earth in the next ten years.

The answer: 12%.

In 2018's NIAC: Surviving A Catastrophic Power Outage, we looked at the President's National Infrastructure Advisory Council (NIAC) report on the potential for a prolonged grid-down scenario, along with a dismal report card on America's infrastructure from the ASCE (American Society of Civil Engineers).

And of course, to these catastrophic disasters we can always add floods, droughts, heatwaves, blizzards, and other weather related events both in the United States, and around the world, which could affect food harvests, supply chains, and global stability. 

While we can't predict what the next big disaster will be, or where it will strike, we do know that whatever comes over the next year or two will be greatly complicated by our ongoing pandemic, and global recession. 

Governments will almost certainly be slower to respond, and recoveries will take longer than usual.

 

As the (above) graphic illustrates (see #NatlPrep: FEMA National Household Preparedness Survey), while we've seen some improvement over past few years, Americans still have a long way to go if we are to cultivate a culture of preparedness.

The goal is to have every American household prepared to handle at least a week without essential services (electricity, running water, open grocery stores, etc.) in the event of a local or regional disaster. And frankly, 2 weeks would be better. 

In recent years preparedness has gotten a bit of a bad name.  The popular image of a prepper - promulgated by the media and cable TV - is that of a nut out gathering squirrels, as they wait anxiously for doomsday.

While that archetype undoubtedly exists, most `preppers' are regular folks who gear up to deal with more reasonable, and more survivable, scenarios like hurricanes, floods, blizzards, and yes, even pandemics. 

While I don't consider myself a survivalist (I don't own a stitch of camo), my years as a paramedic, and decades living on sailboats and in the backwoods of Missouri, have instilled in me a strong desire to be prepared for emergencies.

I know first hand what it is like when things go pear-shaped, and there's no one to call for help.

Which is why I promote the idea of having, and being, a `disaster buddy',and why when I give presents to friends and family, they are almost always in the form of `preps' (see The Gift Of Preparedness - 2019 Holiday Edition).

I hope you'll join me during the month of September in improving your, and your family's, resilience against the unexpected.  Even little preps - like having a week's worth of food and water in the pantry - can pay big dividends in a disaster.

Because, no matter what the emergency, the advantage always goes to those who are best prepared.

JAMA PEDS: Clinical Characteristics and Viral RNA Detection in Children With COVID-19 - ROK

Credit CDC 

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Very early on in this coronavirus pandemic, there were hopes - based on initial reports of low hospitalization rates - that children were largely immune to infection by SARS-CoV-2. More recent studies suggest they are equally susceptible to infection, but in general, tend to experience milder illness.

While  serious illness has been reported in children and adolescents (see MMWR: COVID-19–Associated Multisystem Inflammatory Syndrome in Children — U.S., March–July 2020), younger cohorts are statistically far less likely to experience serious COVID-19 illness than older adults.

Questions remain, however, over the ability to detect (via overt symptoms) COVID-19 in children, the extent of carriage and shedding of the virus in children, and the role that mildly ill or asymptomatic children may play in the spread of the disease (to other children, and to other more vulnerable adults).

A month ago, in JAMA PEDS: Nasopharyngeal Viral RNA Higher In Young Children Than Adults, we looked at evidence that children may be highly effective vectors of SARS-COV-2.

A day later, in MMWR: SARS-CoV-2 Transmission At A Summer Day Camp - Georgia, June 2020, we looked at a study that found - even when following many (but not all) of the CDC Suggestions for Youth and Summer Camps - the pandemic virus spread efficiently among camp goers.

From the study's conclusion:

These findings demonstrate that SARS-CoV-2 spread efficiently in a youth-centric overnight setting, resulting in high attack rates among persons in all age groups, despite efforts by camp officials to implement most recommended strategies to prevent transmission. 

Two weeks ago, in J. Peds: Pediatric SARS-CoV-2: Clinical Presentation, Infectivity, and Immune Responses, we looked at a study by Researchers at Massachusetts General Hospital (MGH) and Mass General Hospital for Children (MGHfC) that measured the amount of viral RNA in the upper airway of SARS-CoV-2 positive children and found - even in asymptomatic or mildly symptomatic children - that it was significantly higher than in hospitalized adults with severe symptoms.

The authors made the case that children - even those who are asymptomatic - are likely to be efficient spreaders of the virus, and that a rushed reopening of schools - or an over reliance on temperature and/or symptom checking to screen for the disease -  could help exacerbate the pandemic. 

In a similar vein, we have a new report (and an accompanying Editorial) - published Friday in JAMA Pediatrics - that examines the clinical presentation and the detectable levels of viral RNA in 91 children diagnosed with COVID-19 during South Korea's first big outbreak last spring 

They report that a large percentage of SARS-CoV-2 infected children may be asymptomatic or presymptomatic, and those who do present with mild symptoms may not be easily recognizable as having COVID-19.  They also report that asymptomatic and symptomatic children may be capable of shedding the virus for 2 to 3 weeks. 

 

I've only posted the link and key points below, so follow the link to read the report (and editorial) in their entirety. 

Original Investigation

August 28, 2020

Clinical Characteristics and Viral RNA Detection in Children With Coronavirus Disease 2019 in the Republic of Korea

Mi Seon Han, MD, PhD1; Eun Hwa Choi, MD, PhD2; Sung Hee Chang, MD3; et alByoung-Lo Jin, MD4; Eun Joo Lee, MD5; Baek Nam Kim, MD6; Min Kyoung Kim, MD7; Kihyun Doo, MD8; Ju-Hee Seo, MD, PhD9; Yae-Jean Kim, MD, PhD10; Yeo Jin Kim, MD11; Ji Young Park, MD, PhD12; Sun Bok Suh, MD, PhD13; Hyunju Lee, MD, PhD14; Eun Young Cho, MD15; Dong Hyun Kim, MD16; Jong Min Kim, MD17; Hye Young Kim, MD, PhD18; Su Eun Park, MD, PhD19; Joon Kee Lee, MD, PhD20; Dae Sun Jo, MD, PhD21; Seung-Man Cho, MD22; Jae Hong Choi, MD23; Kyo Jin Jo, MD19; Young June Choe, MD, PhD24; Ki Hwan Kim, MD25; Jong-Hyun Kim, MD, PhD26

 

JAMA Pediatr. Published online August 28, 2020. doi:10.1001/jamapediatrics.2020.3988

 

Key Points

Question

How long is severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RNA detected in children, and are children with coronavirus disease 2019 (COVID-19) identifiable by symptoms?

Findings 

In this case series of 91 children with COVID-19 in Korea, 22.0% were asymptomatic. Only 8.5% of symptomatic cases were diagnosed at the time of symptom onset, while 66.2% had unrecognized symptoms before diagnosis and 25.4% developed symptoms after diagnosis; SARS-CoV-2 RNA was detected for a mean of 17.6 days overall and 14.1 days in asymptomatic cases.

Meaning 

Symptom screening fails to identify most COVID-19 cases in children, and SARS-CoV-2 RNA in children is detected for an unexpectedly long time.

(SNIP)

Conclusions and Relevance 

In this case series study, inapparent infections in children may have been associated with silent COVID-19 transmission in the community. Heightened surveillance using laboratory screening will allow detection in children with unrecognized SARS-CoV-2 infection. 

(Continue . . . .)

 

CDC HAN: Hurricane Laura - Carbon Monoxide Poisoning

 

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While the landfall of a major hurricane is always dramatic and newsworthy, most people take the warnings seriously and get out of the way of the storm, so the biggest danger to life and limb often comes in the days, weeks, and months that follow. 

In the days prior to Laura's landfall we looked at a number of these dangers (see Post-Disaster PTSD & Sequelae  and Flood Dangers Run Deep), and in both blogs Carbon Monoxide poisoning - usually due to improper generator operation - was mentioned. 

Eight years ago, in MMWR: Carbon Monoxide Exposures Related To Hurricane Sandy, we looked at a CDC Notes From The Field report on the the large number (260+) of CO exposures linked to the aftermath of hurricane Sandy in the Northeast, and two years ago we looked at a CDC HAN on CO poisoning following Hurricane Florence which affected the Carolinas. 

Tragically, but predictably, headlines coming out of Louisiana and Texas since Friday have been filled with similar reports of serious - and often fatal - carbon monoxide poisonings.  A couple include:

2 new carbon monoxide deaths reported, Hurricane Laura's death toll now 16
 
3 dead and 23 hospitalized in Port Arthur, all due to possible CO poisoning

With parts of Louisiana expected to be without power or water for weeks (see Entergy Press release:  Strongest Storm Since the 1800s Ravages Transmission Equipment in Louisiana and Texas), gasoline and diesel generators are the only way practical way to run wells, air conditioning, or power tools (for repairs).

Despite the standard safety advice (below) and warnings provided with every generator, the CDC reports `Every year, at least 430 people die in the U.S. from accidental CO poisoning. Approximately 50,000 people in the U.S. visit the emergency department each year due to accidental CO poisoning.'

 

Carbon monoxide is odorless and colorless, and most people who are exposed are only aware that they have a headache, and are tired and lethargic. Many simply lay down to take a nap, and never wake up again. 

On Thursday, the CDC released a HAN Advisory for clinicians reminding them to maintain a high index of suspicion of CO poisoning among patients in the days and weeks following Hurricane Laura's landfall. 

Hurricane Laura—Clinical Guidance for Carbon Monoxide (CO) Poisoning

Distributed via the CDC Health Alert Network
August 27, 2020, 3:30 PM ET
CDCHAN-00435

Summary

The Centers for Disease Control and Prevention (CDC) is reminding clinicians seeing patients from the areas affected by Hurricane Laura to maintain a high index of suspicion for CO poisoning. Other people who may be exposed to the same CO source may need to be identified and assessed.

The signs and symptoms of CO exposure are variable and nonspecific. A tension-type headache is the most common symptom of mild CO poisoning. Other symptoms may include dizziness, flu-like symptoms without a fever, drowsiness, chest pain, and altered mental status.

Clinical manifestations of severe CO poisoning include tachycardia, tachypnea, hypotension, metabolic acidosis, dysrhythmias, myocardial ischemia or infarction, noncardiogenic pulmonary edema, neurologic findings including irritability, impaired memory, cognitive and sensory disturbances, ataxia, altered or loss of consciousness, seizures, coma, and death, although any organ system might be involved.

Although CO poisoning can be fatal to anyone, children, pregnant women, the unborn, persons with sickle cell disease

Background

High winds and heavy rain from Hurricane Laura began affecting Louisiana, Texas, and Arkansas on August 27, 2020. Impact on the Gulf coast and inland led to thousands of people without power. Those without power may turn to alternate power sources such as gasoline generators and may use propane or charcoal grills for cooking. If used or placed improperly, these sources can lead to CO build up inside buildings, garages, or campers and poison the people and animals inside.

With a focused history of patient activities and health symptoms, exposure to a CO source may become apparent. Appropriate and prompt diagnostic testing and treatment are crucial to reduce morbidity and prevent mortality from CO poisoning. Identifying and mitigating the CO source is critical in preventing other poisoning cases.

Recommendations for Clinicians

1. Consider CO poisoning in patients affected by Hurricane Laura, particularly those in areas currently without power. Assess symptoms and recent patient activities that point to likely CO exposure. Evaluation should also include examination for other conditions, including smoke inhalation, trauma, medical illness, or intoxication.
2. Administer 100% oxygen until the patient is symptom-free or until a diagnosis of CO poisoning has been ruled out.
3. Perform COHgb testing when CO poisoning is suspected. Venous or arterial blood may be used for testing. A fingertip pulse multiple wavelength spectrophotometer, or CO-oximeter, can be used to measure heart rate, oxygen saturation, and COHgb levels in the field, but any suspicion of CO poisoning should be confirmed with a COHgb level by multiple wavelength spectrophotometer (CO-oximeter). A conventional two-wavelength pulse oximeter is not accurate when COHgb is present. For more information, see https://www.cdc.gov/disasters/co_guidance.html.
4. An elevated carboxyhemoglobin (COHgb) level of 2% or higher for non-smokers and 9% or higher COHgb level for smokers strongly supports a diagnosis of CO poisoning. The COHgb level must be interpreted in light of the patient’s exposure history and length of time away from CO exposure, as levels gradually fall once the patient is removed from the exposure. In addition, carbon monoxide can be produced endogenously as a by-product of heme metabolism. Patients with sickle cell disease can have an elevated COHgb level as a result of hemolytic anemia or hemolysis. For additional information about interpretation of COHgb levels, visit https://www.cdc.gov/disasters/co_guidance.html or call Poison Control at (800) 222-1222.
5. Hyperbaric oxygen therapy (HBO) should be considered in consultation with a toxicologist, hyperbaric oxygen facility, or Poison Control Center (800) 222-1222. For additional management considerations, consult a toxicologist, Poison Control at (800) 222-1222, or a hyperbaric oxygen facility.
6. Be aware that CO exposure may be ongoing for others spending time in or near the same environment as the patient. These individuals should be evaluated and tested as described in this advisory.
7. Clinicians treating people for CO poisoning should notify emergency medical services (EMS), the fire department, or law enforcement to investigate and mitigate the source and advise people when it is safe to return.
8. Advise patients about safe practices related to generators, grills, camp stoves, or other gasoline, propane, natural gas, or charcoal-burning devices. Stress that that these devices should never be used inside an enclosed space, home, basement, garage, or camper — or even outside near an open window or window air conditioner. Please see https://www.cdc.gov/co/pdfs/generators.pdfpdf icon.

For More Information
Clinical Guidance for Carbon Monoxide (CO) Poisoning After a Disaster

https://www.cdc.gov/disasters/co_guidance.html

While a generator can be a godsend following a disaster, if you have one and plan to use it, the time to decide how and were to operate it safely is before the storm arrives.  Decisions made under the stressful conditions of an emergency can often be faulty, or even fatal. 

EID Journal: Antibody Profiles According to Mild or Severe SARS-CoV-2 Infection

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The CDC's EID Journal has published a dispatch which finds distinct differences in the development of IgG antibodies between patients with mild and severe SARS-CoV-2 infection. While both cohorts quickly mounted IgM antibodies, patients with mild disease tended to mount a slower and less robust IgG antibody response.

For those who would like a 2-minute refresher in the differences between IgG and IgM antibodies, I can heartily recommend the following video.

 

But briefly, IgM antibodies are the first to arrive on the scene during the initial infection, and help clear the virus. IgG antibodies usually appear a week or 10 days later, and are generally responsible for long-term immunity.

Dispatch

Antibody Profiles According to Mild or Severe SARS-CoV-2 Infection, Atlanta, Georgia, USA, 2020 

William T. Hu , J. Christina Howell, Tugba Ozturk, Karima Benameur, Leda C. Bassit, Richard Ramonell, Kevin S. Cashman, Shama Pirmohammed, John D. Roback, Vincent C. Marconi, Irene Yang, Valerie V. Mac, Daniel Smith, Ignasio Sanz, Whitney Wharton, F. Eun-Hyung Lee, and Raymond F. Schinazi

Author affiliations: Emory University, Atlanta, Georgia, USA
 
Abstract

Among patients with coronavirus disease (COVID-19), IgM levels increased early after symptom onset for those with mild and severe disease, but IgG levels increased early only in those with severe disease. A similar pattern was observed in a separate serosurveillance cohort. Mild COVID-19 should be investigated separately from severe COVID-19.

(SNIP)

Conclusions

IgM reactive toward S1 and E proteins increased early regardless of disease severity, but IgG increased early only in hospitalized participants with severe COVID-19. This pattern was observed in a separate cohort of community participants who had recovered from self-limited ILI. Positive PRNT—a surrogate for antibody-mediated immune protection—may be better associated with elevated IgM and IgG than either antibody alone.

A diagnostic algorithm of IgG from hospitalized participants performed poorly for detection of mild COVID-19. Similarly, other studies found delayed or low-to-medium neutralizing antibody titers in persons who recovered from mild COVID-19 (E. Adams et al., unpub. data, https://www.medrxiv.org/content/10.1101/2020.04.15.20066407v1.full.pdf; F. Wu et al., unpub. data, https://www.medrxiv.org/content/10.1101/2020.03.30.20047365v2).

The delayed increase in IgG and neutralizing antibodies in persons with mild COVID-19 also suggests that mild cases do not necessarily represent an intermediate stage between severe and asymptomatic COVID-19. A corollary of slow IgG increases in persons with mild COVID-19 may be longer persistence of IgM, but more definitive characterization of IgM+ memory B cells (10) and long-term decay of antibody levels (11) is needed.

Our study has limitations. Our small cross-sectional cohort of patients with well-characterized and laboratory-confirmed COVID-19 limits generalization. The overrepresentation of African Americans in the more severely ill cohort may mediate some differences in antibody profiles (8), and we did not measure IgA levels or antibodies targeting other SARS-CoV-2 gene products (currently under development and validation). We also did not measure antibody levels in historic SARS or MERS case-patients, and cross-reactive antibody response against homologous regions cannot be ruled out.

We did confirm a complex relationship between antibody levels, disease severity, and time since symptom onset. Examining IgM and IgG against multiple SARS-CoV-2–related antigens may thus better inform natural history and vaccine studies than any one antibody.

Dr. Hu is a physician-scientist at Emory University in Atlanta, GA. His research interests involve reliable fluid biomarkers for human diseases related to inflammation.

While this report is (once again) suggestive that patients with mild (or asymptomatic) COVID-19 disease might have less immunity against reinfection than those who had severe disease, we will need larger and longer-term studies - and a better understanding of the body's complete immune response against SARS-COV-2 - before definitive conclusions can be drawn.

Another SARS-COV-2 Reinfection Report To Ponder (Nevada, United States)

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Although we've seen a number of reports of presumed `relapses' in `recovered' COVID-19 patients - six days ago, in HKU Med Announces 1st Documented Reinfection With SARS-CoV-2 - we saw the first real evidence of reinfection by the novel coronavirus by scientists in Hong Kong.

Less than twenty-four hours later, two more reports emerged from Europe (see Two More Reports of SARS-CoV-2 Reinfection (Netherlands & Belgium).

What removes these cases from the `likely relapsed' column to `likely reinfected' has been the ability to compare the genetic code of their first coronavirus infection to their second one. In each of these cases, virus samples were taken and genetically sequenced, and they showed genetically distinct variants of SARS-CoV-2. 

Yesterday, researchers at the University of Nevada, Reno School of Medicine (UNR Med), led by its Nevada State Public Health Laboratory (NSPHL), announced that they too had laboratory evidence of a likely reinfection in a presumably recovered COVID-19  patient (Male, 25).

Unlike the three previously mentioned cases - whose reinfections were described as either mild or asymptomatic - this patient's second bout was significantly worse than the first, and was serious enough to require hospitalization. 

The 16-page report (as yet, not peer reviewed) is available on SSRN pre-print server. I've only reproduced the abstract, so follow the link to download and read the full PDF file.  I'll have a postscript when you return.

Genomic Evidence for a Case of Reinfection with SARS-CoV-2

TILLETT, RICHARD and SEVINSKY, JOEL and HARTLEY, PAUL and KERWIN, HEATHER and CRAWFORD, NATALIE and GORZALSKI, ANDREW and LAVERDURE, CHRISTOPHER and VERMA, SUBHASH and ROSSETTO, CYPRIAN and FARRELL, MEGAN and JACKSON, DAVID and Pandori, Mark and VAN HOOSER, STEPHANIE

16 Pages Posted: 27 Aug 2020

Abstract

The degree of protective immunity conferred by infection with SARS-CoV-2 is currently unknown. As such, the possibility of reinfection with this virus is not well understood. Herein, we describe the data from an investigation of two instances of SARS-CoV-2 infection in the same individual. Through nucleic acid sequence analysis, the viruses associated with each instance of infection were found to possess a degree of genetic discordance that cannot be explained reasonably through short-term in vivo evolution. We conclude that it is possible for humans to become infected multiple times by SARS-CoV-2, but the generalizability of this finding is not known.

Funding Statement: Nevada IDEA Network of Biomedical Research (INBRE) supported this work and the publication was made possible by grants from the National Institute of General Medical Sciences (GM103440 and GM104944) from the National Institutes of Health.

Declaration of Interests: Missing.

Ethics Approval Statement: Missing.

Keywords: SARS-COV-2, CORONAVIRUS, SEQUENCE, REINFECTION

Suggested Citation:

TILLETT, RICHARD and SEVINSKY, JOEL and HARTLEY, PAUL and KERWIN, HEATHER and CRAWFORD, NATALIE and GORZALSKI, ANDREW and LAVERDURE, CHRISTOPHER and VERMA, SUBHASH and ROSSETTO, CYPRIAN and FARRELL, MEGAN and JACKSON, DAVID and Pandori, Mark and VAN HOOSER, STEPHANIE, Genomic Evidence for a Case of Reinfection with SARS-CoV-2. THELANCETID-D-20-05376, Available at SSRN: https://ssrn.com/abstract=3681489

The idea that acquired immunity following SARS-COV-2 infection (or vaccination) might be short-lived isn't new, and has been the topic of numerous blogs over the past few months (see COVID-19: From Here To Immunity). 

We'd seen evidence - as far back as 2016 (see EID Journal: Antibody Response & Disease Severity In HCW MERS Survivors) - that MERS-COV antibodies declined quickly HCWs with mild or moderate illness. 

Similarly, in July (see Kings College: Longitudinal Evaluation & Decline of Antibody Responses in SARS-CoV-2 infection),  researchers reported that `the magnitude of the nAb response is dependent upon the disease severity'. They also found a significant percentage of mild cases saw their nAb titers drop to near baseline within 60 days post-infection.

It should be noted that nAb titers aren't the only measure of potential post-infection immunity, as the role of T-Cells in fighting this virus is poorly understood

While it is becoming obvious that re-infection can occur with SARS-COV-2 - how often that happens remains unknown. Samples or sequencing data from first infections are rarely available for comparison, making discovery of these four cases somewhat serendipitous. 

For now, these cases are more cautionary signs than warning klaxons.  

That said, if over the next few months we start to see a significant number of (suspected or confirmed) reinfections with accompanying illness, it would not be a positive development. 

Stay tuned. 

J. Neurology: COVID-19 As A Potential Risk Factor For Chronic Neurological Disorders

https://twitter.com/KartikSehgal_MD/status/1281695760879202304


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Although initially viewed as a flu-like respiratory infection, over the past 6 months we've come to appreciate that SARS-COV-2  can cause a wide spectrum of disease (see Nature Med. Review: Extrapulmonary manifestations of COVID-19) across many other organ systems. 

While the case fatality rate of COVID-19 - with appropriate medical care - appears to hover somewhere around 1%, we continue to see reports of severe and protracted illness, slow recoveries (see Months after infection, many COVID-19 patients can't shake illness), and in many cases, significant sequelae. 

Two weeks ago, the Pan American Health Organization (PAHO) - in a 16-page Epidemiological Alert on Complications and sequelae of COVID-19 - acknowledged the growing evidence that many people who `recover' from a SARS-CoV-2 infection do so with lasting damage. 

Much of the concern has been focused on the impact of SARS-COV-2 infection on the heart, and in June  JAMA published an original investigation which found a 3-fold increase in out-of-hospital cardiac arrests in New York City during the peak of their COVID-19 epidemic, finding:

From March 1 to April 25, 2020, New York City, New York (NYC), reported 17 118 COVID-19–related deaths. On April 6, 2020, out-of-hospital cardiac arrests peaked at 305 cases, nearly a 10-fold increase from the prior year.

Other studies have linked cardiac arrhythmias and heart muscle inflammation to COVID-19, including:

JAMA: Two Studies Linking SARS-CoV-2 Infection To Cardiac Injury

EID Journal: Relative Bradycardia In Mild To Moderate COVID-19 Cases, Japan

The Cardiovascular Impact of COVID-19

Some cardiologists have even warned that the impact of COVID-19 on cardiovascular health may not be fully revealed for years to come (see  Coronavirus Disease 2019 (COVID-19) and the Heart—Is Heart Failure the Next Chapter? by Clyde W. Yancy, MD, MSc1,; Gregg C. Fonarow, MD).

In a similar vein, we've seen evidence of a wide range neurological manifestations and damage from SARS-CoV-2 infection. Four months ago, in JAMA: Neurologic Manifestations Of Patients With Severe Coronavirus Disease, we looked at reports that more than 1/3rd of a study group of 214 patients hospitalized with COVID-19 in Wuhan, China showed signs of neurological involvement.

Neurological manifestations ranged from relatively mild (headaches, dizziness, anosmia, mild confusion, etc.) to more profound (seizures, stupor, loss of consciousness, etc.) to potentially fatal (ischemic stroke, cerebral hemorrhage, muscle injury (rhabdomyolysis), etc.). 

Of note, in this study neurological symptoms were detected in 30.2% of non-severe cases, and nearly half (45.5%) of severe cases.  While some of these lingering effects may eventually resolve, for many survivors, long-term impairment is a real possibility.  

Some other blogs on the neurological impact of COVID-19 include:

The Lancet: Yet Another Study On Neurological Manifestations In Severe COVID-19 Patients

COVID-19: Another Neurological Study To Ponder

OVID-19: Another Neurological Study To Ponder

The Lancet: COVID-19: Can We Learn From Encephalitis Lethargica? 

Large-Vessel Stroke as a Presenting Feature of Covid-19 in the Young

In light of these reports, the question is increasingly being asked: Are we facing a crashing wave of neuropsychiatric sequelae of COVID-19? Neuropsychiatric symptoms and potential immunologic mechanisms  by  Emily A. Troyer,  Jordan N. Kohn, and Suzi Hong. 

All of which brings us to a new review, this time from the Journal of Neurology, which discusses the potential long-term impact of COVID-19 in causing chronic neurological disorders in some of its  survivors.  Disorders that may take months or even years to become apparent. 

While admittedly speculative, these concerns are not without some basis in fact (and history). 

Increasingly, we've seen Parkinson’s disease tentatively linked to viral infections (see Viral Parkinsonism  by Haeman Jang, David A. Boltz, Robert G. Webster, and Richard Jay Smeyne), and more recently, in 2017's  Nature Comms: Revisiting The Influenza-Parkinson's Link.

Whether due to a neurotropic pathogen, or the body's inflammatory immune response, viral and bacterial infection (i.e. West Nile Virus, EV-D68, Campylobacter jejuni, etc) have been strongly linked to CNS disorders like AFM (Acute Flaccid Paralysis) and Guillain-Barré syndrome (GBS).

All of which brings us to the following review.  Follow the link to read it in its entirety.

Review

Published: 27 August 2020

COVID-19: dealing with a potential risk factor for chronic neurological disorders

Tommaso Schirinzi,  Doriana Landi & Claudio Liguori 

Abstract

SARS-CoV2 infection is responsible for a complex clinical syndrome, named Coronavirus Disease 2019 (COVID-19), whose main consequences are severe pneumonia and acute respiratory distress syndrome. Occurrence of acute and subacute neurological manifestations (encephalitis, stroke, headache, seizures, Guillain–Barrè syndrome) is increasingly reported in patients with COVID-19.

Moreover, SARS-CoV2 immunopathology and tissue colonization in the gut and the central nervous system, and the systemic inflammatory response during COVID-19 may potentially trigger chronic autoimmune and neurodegenerative disorders.

 

Specifically, Parkinson’s disease, multiple sclerosis and narcolepsy present several pathogenic mechanisms that can be hypothetically initiated by SARS-CoV2 infection in susceptible individuals. In this short narrative review, we summarize the clinical evidence supporting the rationale for investigating SARS-CoV2 infection as risk factor for these neurological disorders, and suggest the opportunity to perform in the future SARS-CoV2 serology when diagnosing these disorders.

(Continue . . . . .)

 

Australia: Victoria Reports Outbreak From 3rd Avian Flu Subtype (H7N6) In A Month

 Victoria State - Credit Wikipedia 

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Not quite a month ago, Victoria agricultural officials announced the detection of a highly pathogenic (HPAI) H7N7 virus at an egg farm in Lethbridge, Victoria. A week later, a second outbreak was reported at a nearby farm(see Australia: 2nd Victoria Farm Hit By HPAI H7N7).

This was the first outbreak of H7N7 in reported Australia since 2014. 

While sporadic bird-to-human transmissions of H7N7 have been reported, it is not considered nearly as dangerous as either H5Nx or H7N9, as it usually produces only mild symptoms in humans.  

Two notable outbreaks include:

• 3 mild cases were reported in Italy in 2013 (see ECDC Update & Assessment: Human Infection By Avian H7N7 In Italy). 
• An in 2003 a large outbreak of H7N7 (89 confirmed, 1 fatality) was reported  in the Netherlands – with nearly all reported cases having very mild (often just conjunctivitis) symptoms. 

Less than a week later, a second avian flu subtype (LPAI H5N2) was reported at a Turkey farm (see OIE Report), in Bairnsdale, Victoria.  This particular ubtype had not been reported by Australia since 2013. 

As a general rule, LPAI (low path) viruses are of less concern than HPAI viruses. But LPAI H5 and H7 viruses both have the ability to mutate into highly pathogenic strains if allowed to circulate in poultry. Therefore all H5 and H7 viruses - regardless of pathogenicity - are reportable to the OIE. 

Today, Victoria Agricultural officials are reporting that a 3rd subtype - LPAI H7N6 - has been detected at an emu farm in Kerang, Victoria along with a 3rd outbreak of HPAI H7N7. Once again, H7N6 is a subtype that hasn't been reported in Australia since 2013.

Australia's recent reports are mirrored by recent reports out of Russia of HPAI H5N8 in Chelyabinsk Oblast, Russia and HPAI H5Nx in Omsk Oblast, HPAI H5N6 in the Philippines, HPAI H5N1 in Vietnam, HPAI H5N5 in Taiwan, and the following report today from South Korea on their first detection of environmental (wild bird feces) avian influenza since March.

Detection of H7 type low pathogenic avian influenza antigen in wild bird feces in Seocho 

(Yangjaecheon), Gyeonggi (Gyeongancheon), Seoul2020.08.26 13:33:31 Defense Policy Bureau

The Ministry of Agriculture, Food and Rural Affairs (Minister Kim Hyeon-su) said,'Avian influenza test results for wild bird feces collected from Yongin (Gyeongancheon), Gyeonggi-do on August 18th and Seocho-gu, Seoul (Yangjaecheon) on August 20th. Avian influenza (AI) was detected.

❍ This is the first time that an avian influenza antigen has been detected in this wild bird since March 18, Gangneung, Gangwon-do (Namdaecheon, H5N3 type low pathogenicity).
Accordingly, the Ministry of Agriculture and Food has implemented emergency quarantine measures* in accordance with the Avian Influenza Emergency Action Guidelines (AI SOP), and although it has been identified as a low pathogenic avian influenza, quarantine measures such as continuous disinfection measures are maintained for 7 days.

While none of these reports is particularly alarming, we do seem to be seeing a surge in avian flu activity after nearly 3 years of relative quiescence.  Globally, since China rolled out their experimental H5+H7 poultry vaccination campaign in the summer of 2017, we've seen a remarkable drop in outbreaks.

But the news hasn't been all good.  We've seen some subtle signs that avian flu may be staging a bit of a comeback, as reported previously in:

• EID Journal: Evolution and Antigenic Drift of Influenza A (H7N9) Viruses, China, 2017–2019

• Study: Genotyping & Reassortment Analysis of HPAI H5N8 and H5N2 viruses from Egypt

• China MOA: Two Outbreaks Of HPAI H5N6 (in Swans) in Western Xinjiang Province

• EID Journal: Antigenic Variant of Highly Pathogenic Avian Influenza A(H7N9) Virus, China, 2019

The twice annual (fall and spring) migration of birds is about to begin, and in the northern hemisphere that means that billions of birds will soon leave their high latitude roosting spots and begin to head south for the winter.

As described in a study published in 2016 (see Sci Repts.: Southward Autumn Migration Of Waterfowl Facilitates Transmission Of HPAI H5N1), the evidence suggests that waterfowl pick up new HPAI viruses in the spring (likely from poultry or terrestrial birds) on their way to their summer breeding spots - where they spread and potentially evolve - and then redistribute them on their southbound journey the following fall.

Which means that once again this fall, the risks of seeing new outbreak of avian flu - and potentially new subtypes - will increase (see WHO: Migratory Birds & The Potential Spread Of Avian Influenza), and poultry interests across the Northern Hemisphere will need to be extra vigilant with their bio-security if we are to avoid another avian epizootic like we saw in North America in 2015, and Europe in 2016-17. 

Post-Disaster PTSD & Sequelae

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Four years ago, during the peak of the 2017 Hurricane Season, the United States was hit by 3 devastating hurricanes in just over 30 days; Harvey, Irma, and Maria (see map above).

Tens of millions of people were impacted, thousands died (see Mortality in Puerto Rico after Hurricane Maria), and millions of people were left either homeless, or without basic services (power, water, communications) for weeks and even months. 

In 2018, a CAT 5 monster called Michael wiped out a wide swath of Florida's forgotten coast, while last year Dorian devastated the Bahamas. Along with past disasters, like Donna in 1960, Camille in 1969, Andrew in 1993, and Katrina in 2005, they all share one commonality. 

The lives of the people who went through the worst of these storms were forever changed.  Homes and businesses were lost, lives were lost, and in many cases - hope was lost as well. 

While we think about the first 24 hours of a hurricane's impact as being the most dramatic and newsworthy, the real impact comes in the days, weeks, and months that follow. The loss in terms of mortality, morbidity and permanent disability, PTSD, homes and belongings, businesses, jobs and life savings, and continuity of a community are never fully tallied or appreciated.

We've looked at some of these after effects in the past.

There are always the usual post-disaster accidents; drownings, carbon monoxide poisoning from using charcoal or generators indoors. Falls from roofs or ladders from clearing debris, or chain saw accidents. And even skin infections and food poisoning from contaminated waters (see After The Storm Passes).

Heat (or cold) related deaths may occur when the power is out for extended periods (see MMWR: Heat-Related Deaths During an Extreme Heat Event), and people who rely on oxygen concentrators at home could find themselves in a life threatening situation.

And this year, burdened as we are by the COVID-19 pandemic, restoration of power and water, emergency relief efforts, insurance settlements, and repairs and reconstruction may all take longer than following previous disasters. 

There is currently a nationwide lumber shortage, and supply chains are still stressed globally. Mutual aid, in the form of utility crews and medical teams from other states, may be limited due to the pandemic.  

But there are some other post-disaster impacts that have only recently become well acknowledged. 

In March of 2009, in a study led by Dr. Anand Irimpen (Associate Professor of clinical medicine at Tulane), it was disclosed that residents of New Orleans saw a 300% increase in heart attacks in the first 2 years after hurricane Katrina.

A follow up, published in 2014 (see Tulane University: Post-Katrina Heart Attack Rates - Revisited), once again found the impact of Katrina on cardiac health remained pronounced.

In the wake of Hurricane Katrina, a study funded by the National Institute of Mental Health, which surveyed 1,043 survivors,  found:

• More than 11% were diagnosed with a serious mental illness following the storm. This compares to just over 6% before the hurricane.
• 9.9% had mild-moderate mental illness, compared to 9.7% before Katrina.
• They estimated  200,000 people facing serious mental problems, such as PTSS (Post Traumatic Stress Syndrome) and depression, in the three states most affected.

In 2014, in Post-Disaster Stress Cardiomyopathy: A Broken-Hearted Malady, we looked at a rare condition known as Takotsubo cardiomyopathy – or stress induced cardiomyopathy which is often linked to extreme grief or stress, as might be experienced following a disaster.

Also known as broken heart syndrome, this acute ballooning of the heart ventricles is a well-recognized cause of acute heart failure and dangerous cardiac arrhythmia's. 

While often hidden from view, the psychological impact of a disaster can be enormous and ongoing. In 2011, in Post Disaster Stress & Suicide Rates, we looked at the impacts of disaster-related PTSD (Post Traumatic Stress Disorder). 

This has been recognized as such a pressing problem that the  World Health Organization released a comprehensive Guidelines For Post-Trauma Mental Health Care book on the treatment of PTSD, acute stress, and bereavement in 2013. 

Living as I do in hurricane country, I've made it a point to have a disaster plan, a disaster buddy, a bug-out destination, and the things I would need to survive without electricity, running water, open grocery stores or pharmacies for a week or longer. 

As long-time readers of this blog already know, I was forced to put all of that into action last year with Hurricane Irma (see A Post Irma Update).

I do this not only for my physical health, but for my mental health as well. I sleep well at night knowing I'm prepared for the worst, and if it happens, I'll be less stressed and less challenged than had I not prepared.  A few of my preparedness articles include:

The Gift Of Preparedness - 2019 Holiday Edition

When 72 Hours Isn’t Enough

My New (And Improved) Solar Battery Project (for CPAP)

My New Solar Power System (Updated For 2020)

For more, the CDC has a website geared to post-disaster stress.

Coping with a Disaster or Traumatic Event

The outbreak of coronavirus disease 2019 (COVID-19), may be stressful for people and communities.

Learn more about coping during COVID-19.

During and after a disaster, it is natural to experience different and strong emotions. Coping with these feelings and getting help when you need it will help you, your family, and your community recover from a disaster. Connect with family, friends, and others in your community. Take care of yourself and each other, and know when and how to seek help.

People with preexisting mental health conditions should continue with their treatment plans during an emergency and monitor for any new symptoms. Additional information can be found at the Substance Abuse and Mental Health Services Administration (SAMHSA) website.

Explore the resources below to learn how to cope and take care of yourself and each other during an emergency. 

Taking Care of Your Emotional Health

Helping Children Cope

Planning Resources for State and Local Governments

Response Resources for Leaders

Responders: Tips for Taking Care of Yourself

A small reminder that in the wake of a disaster not all wounds bleed, not all fractures show up on an X-ray, and that the best treatment doesn't always come from inside your first aid kit. 

Hurricane Laura Forecast To Become CAT 4 Before Landfall

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Even when it was still a tropical storm south of Cuba, the signs were all there indicating that Laura would become an intense hurricane once it entered the Gulf of Mexico. Now, with less than 24 hours until expected landfall (1 am Thurs CST), Laura is rapidly meeting those expectations. 

The headlines from the National Hurricane Center's 5 am advisory are:

...LAURA EXPECTED TO RAPIDLY STRENGTHEN TO A CATEGORY 4 HURRICANE... ...FORECAST TO PRODUCE A LIFE-THREATENING STORM SURGE, EXTREME WINDS, AND FLASH FLOODING OVER EASTERN TEXAS AND LOUISIANA LATER TODAY...

While the greatest impacts are expected along the Texas and Louisiana coast, this storm will have `legs', and those living and working many hundreds of miles inland will likely experience flooding, storms, and possibly even tornadoes. 

Some of the impacts may extend as far as to the mid-Atlantic states, as the remnants or Laura are expected to emerge over water and gain strength early next week as an extra-tropical storm. 

For now heavily populated Houston is forecast to remain on the weaker (left) side of the storm, but it is solidly inside the Hurricane warning area, and even the weak side of a CAT 4 hurricane can be formidable.  No one in the warned areas should take this storm lightly. 

Key Messages this morning from the NHC:

Storm surges, particularly to the right of where Laura makes landfall, are expected to be significant and life-threatening, with heights reaching 10 to 15 feet in some regions. 

The National Weather Service at Sabine Pass has issued the following grim assessment of potential impacts from the storm:

POTENTIAL IMPACTS: Devastating to Catastrophic 

• Structural damage to sturdy buildings, some with complete roof and wall failures. Complete destruction of mobile homes. Damage greatly accentuated by large airborne projectiles. Locations may be uninhabitable for weeks or months. 
• Numerous large trees snapped or uprooted along with fences and roadway signs blown over. 
• Many roads impassable from large debris, and more within urban or heavily wooded places. Many bridges and access routes impassable.
• Widespread power and communications outages.

In other words, for tens (or potentially, even hundreds) of thousands of people the next 36 hours could be a life-changing event. And should the storm track even a few dozen miles further west towards Houston, the impact would be even greater. 

Laura is unlikely to be the last major hurricane to threaten a U.S. landfall in this record setting 2020 hurricane season, and no one - from Texas to Maine - should feel immune. 

While for the residents of the upper Gulf Coast, the the time to prepare is just about over, for everyone else there remains a window of opportunity.  The two busiest months of the hurricane season (Sept & Oct) still lie ahead, and this year we may see storms well into November.  

Being prepared doesn't guarantee you'll come out of any disaster unscathed, but it can help reduce the risks to you and your family, and make the post-disaster recovery period easier to handle.