COVID-19 Statistics: Connecticut

COVID-19 Update: As of May 7, 2020

:

Fairfield Statistics:

• Cases per 100,000 population: 1343
• Cases: 12679
• Hospitalization: 469
• Deaths: 977

Special Commentary

JAMA, May 4, 2020

Choices for the “New Normal”

Donald M. Berwick

Fate will not create the new normal; choices will. Will humankind meet its needs—not just pandemic needs—at the tempo the COVID-19–related morbidity and mortality demand? Will science and fact gain the high ground in guiding resources and behaviors? Will solidarity endure? Will compassion and respect be restored for the people—all the people—who make life agreeable and civilization feasible, including a guarantee of decent livelihoods and security for everyone? Will the frenzied world of commerce take a breath and let technology help simplify work without so much harm to the planet and without so much stress on everyone? And will society take a break from its obsessive focus on near-term gratification to prepare for threats ahead?

Most important of all: Is this the time for equity, when the evidence of global interconnectedness and the vulnerabilities of marginalized people will catalyze at last the fair and compassionate redistribution of wealth, security, and opportunity from the few and fortunate to the rest? This virus awaits an answer. So will the next one.

Editorials, Perspectives, Commentaries and Reflections

Lancet, May 7, 2020

Access to Lifesaving Medical Resources for African Countries: COVID-19

Testing and Response, Ethics, and Politics

Matthew M Kavanagh, et al

Every life has equal worth. Yet global allocation of testing and other resources currently means that some are forced to wait, while those ahead in the global procurement line take precedence. In 2020, we have the opportunity to learn from past mistakes by countering market forces, thus ensuring that lives on the African continent count equally. Doing so will take both moral clarity and political courage.

Having navigated Ebola, HIV, and tuberculosis epidemics, and a range of annual, sporadic, and concurrent outbreaks, several African countries have unparalleled disease response capacity. African governments are offering rare examples of effective international cooperation on COVID-19.

In many high population density, unplanned areas of Africa's megacities, distancing is not feasible. Where informal employment is common, the social and economic consequences of shutdowns will be severe. Many people face food insecurity and economic crises amidst lockdowns. Targeted interventions, informed by testing, are needed to allow day-wage workers to work and children who are at a higher risk of a number of factors (including violence and malnutrition) to return to school.

Malawi has as few as 25 critical care beds for 19 million people—or 0·1 beds per 100 000 people, and most counties in Kenya reportedly have no functioning ventilators. Although a lower median age might help, the number of people with malnutrition, HIV, and tuberculosis in the region could increase the need for critical care. In Veneto, Italy, home-based care was combined with widespread testing and early diagnosis, resulting in a mortality rate four-times lower than that reported in Lombardy. Such home-based care could be a model for African contexts, building on community-level response experiences from the west African Ebola outbreak.

Africa CDC is providing strong coordination and COVID-19 guidance; additionally, strengthened national public health institutes, referral laboratories, laboratory and epidemiology workforces, infection control, and community networks are ready to be harnessed. By March 7, 2020, laboratories in 43 African countries could already do COVID-19 testing. Africa leads much of the world in community health-care networks that could be mobilised for the hard work of communication, testing, and contact tracing.

On vaccines and therapies, the current situation of inequitable access will repeat without action, as leaders highlighted at the launch of a new international effort to accelerate COVID-19 tools. Rich countries monopolising vaccine markets would mirror past actions. Meanwhile, demand for masks, gloves, and other personal protective equipment face similar dynamics.

Governments have an obligation to protect their own citizens. However, principles of fairness must be applied. No single community, country, or continent should bear the full brunt of global shortages. Although difficult decisions in resource allocation are inevitable, it is unethical for African countries to have considerably less access and harder choices than others.

Political leadership is urgently required to secure ethical global allocation of scarce resources. It is entirely foreseeable that many countries will be locked out of the market. Governments have structured the global trading system and they have the power now to ameliorate its ill effects during a crisis. This is an ethical imperative but also a shared interest; the COVID-19 pandemic has taught us that unaddressed outbreaks in one part of the world put people throughout the world at risk.

NEJM, May 6, 2020

Once Upon a Time…the Hero Sheltered in Place

Lisa Rosenbaum, M.D.

I have lupus and am on immunosuppressive therapy. When it became clear that Covid-19 would hit the United States hard — including Boston’s Brigham and Women’s Hospital, where I practice — I decided to proceed with my scheduled 2 weeks of attending on our inpatient cardiology service in April. I thought about the decision, but I didn’t find it difficult. Despite limited data, it seemed reasonable to assume that my risk — of both getting infected and becoming critically ill — was higher than average. But I was weighing these unknown risks against one that was entirely predictable: the agony of sitting out the biggest public health crisis of our time.

“It’s not your hill to die on,” my sister-in-law texts me. I wonder: Whose hill is it, then? I have many colleagues whose age puts them at risk, some of whom are world-renowned for their scientific and clinical expertise. Should they be on the front lines? What about women who are pregnant or trying to conceive? What about physicians who haven’t cared for critically ill patients in decades, or who have a spouse or child at risk, or who are simply scared and don’t want to do it? What about other essential health care workers — those who clean rooms, transport patients, hand out masks — for whom the financial consequences of not working may be more stark? And what about trainees, many of whom, unlike me, don’t have a choice? We pay them the least, work them the hardest, and rely on them for the majority of direct patient interactions. The odds of survival are better if you’re young, but with so many people infected, some young ones will die. Given all the impossible conversations the pandemic has forced about how much we value any given life, why have there been so few about how much health care workers value our own?

But the pandemic has also revealed a quiet kind of heroism: that of the billions of people whom we’ve asked to stay home, abandon their livelihoods, and set aside their own identities for the sake of preventing deaths they cannot see. There will be no parades for these people. Most will not be able to connect their sacrifices to any one life saved. Yet there is heroism in their stories, too. Writing the postpandemic script will be tough. But if we remember that everyone has a role to play, the empty pages will, once again, be filled with stories.

NEJM, May 7, 2020

Fear and the Front Line

Susan L. Murray

I have been thinking a lot about fear lately, and how much it behaves like a virus. How it can spread insidiously, person to person, or airborne, through new media and old, faster than we can contain it. How it induces so many of the same symptoms as a virus does: sweating, palpitation, nausea, shivering, and sometimes an almost overwhelming desire to curl up under a blanket in a dark room and stay there. How once fear has infected you, it is hard to get rid of, but extremely easy to pass on to others.

Most health care workers I know are brave people who perform demanding jobs in difficult circumstances. But one of the terrifying things about an outbreak of transmissible disease is that it’s not just our own life and health that we are being asked to put at risk in caring for patients. We risk being the vector that brings the illness home to the people we love — to our children and partners and parents — and that can be truly terrifying. It is easier to risk our own safety than to threaten the people we care about. Without support, without proper education, training, and contingency plans in place to help protect health care workers and their families, fear can run riot through a hospital or through a community. If we are not prepared to fight fear and ignorance as actively and as thoughtfully as we fight any other virus, it is possible that fear can do terrible harm to vulnerable people, even in places that never see a single case of infection during an outbreak. And a fear epidemic can have far worse consequences when complicated by issues of race, privilege, and language.

NEJM, May 6, 2020

Pandemic and Persona

Michael W. Kahn

One patient held up to his computer’s camera each book he was reading so I could see the covers. Another patient’s cat suddenly appeared in the frame during a virtual visit and prompted her to reflect on how vital the animal is to her well-being. I got a video tour of another patient’s apartment and was relieved to see a living situation more organized than I had imagined. Sometimes I feel more like a country doctor on a house call than a psychiatrist on a Zoom call.

I also find myself yielding to an unexpected urge to give a small wave good-bye as I conclude video sessions; it just feels like the right thing to do, at least for me. Telemedicine’s lack of physical closeness makes such unaccustomed informalities seem less incongruous with the doctor–patient relationship. Doctor and patient are sharing a history-making experience, and just as there are allegedly no atheists in foxholes, there seem to be few strangers in catastrophes.

The current crisis therefore offers an opportunity — owing to our shared vulnerability to the virus — for doctors to recognize more readily facts that can otherwise take years to learn: that we’re no different from our patients and that interacting with them in a manner similar to the one we naturally use with nonpatients can be gratifying for them and freeing for us. Doctors often equate professionalism with a kind of formal role playing and worry that deviations from this attitude might lead to excessive casualness or boundary problems. These are real concerns that must be considered — but without sacrificing clinical connection. Traditional medical procedures and attitudes do need to be learned. But I’m reminded that jazz great Charlie Parker reportedly said that the secret of improvisation was to learn the chord changes and then forget them. I think one way to successfully harmonize with patients is to learn the standard teachings of medical professionalism and then not exactly forget them, but allow them to resonate and even merge with one’s own persona.

The story continues to unfold, but I think that among the many unknown — and potentially positive — outcomes of the pandemic, one may be the more widespread realization that “acting like a doctor” ideally involves less acting and more authenticity.

JAMA, May 4, 2020

Randomized Clinical Trials and COVID-19: Managing Expectations

Howard Bauchne, et al

The global urgency and intense pressure for effective treatments has led to many investigator-driven studies that use a range of primary outcome measures, many of which are underpowered for confirming efficacy. Variation in design and poor design characteristics will impede much of the research to be implemented as results might not be conclusive.

To date, more than 1000 studies addressing various aspects of COVID-19 are registered on ClinicalTrials.gov, including more than 600 interventional studies and randomized clinical trials (RCTs). During the next few weeks and months, the results of numerous RCTs involving therapies for COVID-19 will be reported. Indeed, preliminary results from some studies have already been reported in social media and the popular press. How will clinicians, the public, and politicians understand the results of these much-anticipated and critically needed clinical trials?

First (no control group), the interventions in some of these trials are being evaluated in various ways. For instance, some studies do not have a control group, whereas others lack true “controls” such as trials that compare different dosages of the same drugs.

Second (heterogeneity of treatment effects), many ongoing trials were designed prior to emerging information that is providing a better understanding of the disease process. It has become clear that some critically ill patients with COVID-19 have substantially different manifestations, including profound hypoxia, extensive inflammatory activation, or evidence of coagulopathy. Accordingly, there may be significant heterogeneity of treatment effects based on the timing or constellation of disease manifestations.

Third (no survival as primary outcome and unblinded interventions), the outcomes for many of these trials involve time to symptom resolution, improvement of laboratory or radiographic abnormalities, or reduction in the use of mechanical ventilation. Few of the studies will be sufficiently powered to detect a difference in mortality.

Fourth (small effect size), even a highly successful trial is likely to reduce the mortality outcome by only a 5% to 10% absolute difference; hence, the number needed to treat will be a minimum of 10 to 20. Smaller absolute differences would have greater numbers needed to treat.

Fifth (no prevention studies), most of these trials are directed at treatment, and even if some trials show clinically important results, most will not address prevention of COVID-19.

Sixth (redundant studies), it will be helpful if investigators share individual patient data from similar trials with one another.

JAMA, May 6, 2020

Privileges and Immunity Certification During the COVID-19 Pandemic

Mark A. Hall

Scientific understanding of SARS-CoV-2 immunity is still fairly rudimentary. How much immunity infection confers, and for how long, is unknown, as is the level and type of antibodies that indicate immunity. However, the ideal of a measured, evidence-based approach to policy making appears likely to be overrun by hopes and demands for antibody testing. Antibody tests are proliferating.

For now, these testing issues,with unproven scientific assumptions of immunity, cast serious doubt on the merits of immunity certification. But if these issues are resolved and policies are administered fairly, the ethical and legal concerns raised may be overstated. A population-wide program of selective advantage based on disease status sounds potentially odious. But may be the policy most individuals would choose in a state of genuine uncertainty about whether or not they had acquired immunity. Immunity certification programs may have the added advantage of spurring more people to seek reliable testing, results of which will inform research and surveillance. If so, immunity privileges, although selective, could foster broader liberties and economic improvement for all.

JAMA, May 6, 2020

The Ethics of COVID-19 Immunity-Based Licenses (“Immunity Passports”)

Govind Persad, et al

Indeed a major concern, is that immunity licensing might seem to stigmatize people, undermining the value of equal treatment. Are immunity-based licenses like the yellow stars Nazis forced Jews to wear? Will they “split communities in two” and stigmatize those without immunity? The yellow star and similar forms of invidious discrimination divided people based on race, religion, or heritage: all factors that should be irrelevant to social participation.

• Immunity-based licenses can only be introduced if serology testing is accurate.
• Immunity-based licensing requires evidence that a positive serology test result indicates immunity.

Certifications of immunity are sometimes called “immunity passports” but are better conceptualized as immunity-based licenses. Such policies raise important questions about fairness, stigma, and counterproductive incentives but could also further individual freedom and improve public health.

The term “immunity-based licenses” is better than “immunity passports.” Passports suggest an all-or-nothing permission and endorse categorical denial of access to an entire country. In contrast, licensing requirements are more stringent for drivers of school buses or airplane pilots than for drivers of cars, and are more restrictive for younger drivers or those with conditions that may impair driving.

The ethics of COVID-19 immunity licenses can be assessed with respect to 3 fundamental ethical values: the maximization of benefit; priority to the least advantaged; and treating people equally.

NEJM, May 6, 2020

Adaptations and Lessons in the Province of Bergamo

Stefano Fagiuoli, M.D.

Lombardy, and particularly the province of Bergamo, has been the area of Italy most affected by Covid-19. As of April 26, 2020, the province had 11,113 confirmed cases and 2932 deaths from Covid-19. Delays in recognizing SARS-CoV-2 in the few infected patients admitted to the small hospital in Alzano Lombardo — and delays in activating measures to protect other patients, hospital personnel, and visitors, as well as in implementing adequate containment measures in patients’ villages — allowed the virus to spread rapidly and into the city of Bergamo. The province was not locked down until March 8, which was 2 weeks after the first documented cases at the Alzano hospital on February 23. By then, the virus had sickened thousands of people, many of whom visited the emergency department (ED) at ASST–Papa Giovanni XXIII, a referral hospital for high-need patients throughout the province, and were admitted. These patients rapidly overwhelmed the hospital’s capacity, forcing a major reorganization led by a crisis team established on February 23.

Two major lessons can be learned from Bergamo’s experience. First, all health care workers in hospitals, nursing homes, and the community should have been tested for Covid-19, and those testing positive should have been isolated, even if they were asymptomatic. Clinicians were initially overlooked during attempts to identify and isolate infected people, which were focused on sick patients. For this reason, and because complete personal protective equipment was not made immediately available, especially to family physicians, 19 doctors in the Bergamo province (all between 62 and 74 years of age) have died. They were all involved in the care of patients with Covid-19, though none worked at ASST–Papa Giovanni XXIII. The second, even more important lesson is that an urgent and decisive regionwide lockdown should have been implemented to contain the epidemic. This step could have reduced the number of Covid-19 cases, prevented hospitals from being overwhelmed, and potentially limited the number of deaths in the province.

NEJM, May 6, 2020

Racial Health Disparities and Covid-19 — Caution and Context

Merlin Chowkwanyun, et al

To gain a maximally precise picture of how vulnerability is distributed, it is indeed crucial to collect more data along these lines. The experience of past epidemics — and recent natural disasters — suggests that the most socially marginalized populations will suffer disproportionately.

It is equally important, however, that in documenting Covid-19 racial disparities, we contextualize such data with adequate analysis. Disparity figures without explanatory context can perpetuate harmful myths and misunderstandings that actually undermine the goal of eliminating health inequities. Such clarifying perspective is required not just for Covid-19 but also for future epidemics. There are several key dangers of insufficient contextualization, but researchers, journalists, public health officials, and policymakers can take a few important steps to address them when discussing racial disparities, especially in the public sphere.

First, data in a vacuum can give rise to biologic explanations for racial health disparities. Such explanations posit that congenital qualities unique to specific racial minorities predispose them to higher rates of a particular disease.

Second, lone disparity figures can give rise to explanations grounded in racial stereotypes about behavioral patterns.

Third, geographic disaggregation of Covid-19 data is welcome but requires caution. Granularity of data allows more fine-grained analyses, including multilevel spatial modeling. But presented by themselves, such granular data can reinforce what the sociologist Loïc Wacquant has dubbed “territorial stigmatization,” whereby resource-deprived neighborhoods suffer from “blemish of place” and are thought to be “composed essentially of poor people, minorities and foreigners,” many of whom have already been marginalized by the broader society.

All three of these dangers may feed into a fourth one. In the recent past, the perception (however erroneous) that certain social problems are primarily “racial” — and therefore of concern only to supposed minority interest groups — has been used to rationalize neglect and funding cuts.

To mitigate myths of racial biology, behavioral explanations predicated on racial stereotypes, and territorial stigmatization, Covid-19 disparities should be situated in the context of material resource deprivation caused by low socioeconomic status, chronic stress brought on by racial discrimination, or place-based risk.

Reports

Lancet, May 9, 2020

New Zealand Eliminates COVID-19

Sophie Cousins

An aggressive approach has enabled New Zealand to end community transmission of SARS-CoV-2.

New Zealand recorded its first day of no new cases of coronavirus disease 2019 (COVID-19) early this week, more than a month after its strict lockdown began.

New Zealand's decision to pursue an elimination approach was a vastly different approach to usual pandemic planning, which has historically been based on a mitigation model and focuses on delaying the arrival of the virus, followed by a range of measures to flatten the curve of cases and deaths.

Ardern has regularly appeared on social media, smiling and sharing parts of her personal life under lockdown but without underplaying the seriousness of the situation, which has helped to build public trust.

As New Zealand now eases its restrictions and its economy slowly reopens, there are discussions about how it can open up its borders while ensuring that everyone is protected, particularly susceptible populations.

Lancet, May 9, 2020

Chile Plans Controversial COVID-19 Certificates

Barbara Fraser

Chile’s contentious scheme to provide certification of past COVID-19 infection is aimed at reassuring patients about the risk of reinfection or infecting others.

The certificate will not free the person from lockdowns in their neighbourhoods or of the obligation to wear a mask in public but is meant to provide some reassurance that they could help neighbours or elderly parents without much risk of infecting others or becoming infected.

In Chile, a person whose infection is diagnosed using RT-PCR, is considered recovered after 14 days in asymptomatic or mild cases or 28 days if the case is more severe or the person has a compromised immune system.

After 3 months, the certificate will expire and the person will be considered to have the same risk of infection as anyone else.

The potential contribution to the community or the economy by the relatively small number of people who would qualify for certificates—about 10 000 as of May 3 will be negligible.

Epidemiology

Lancet, May 2, 2020

First Experience of COVID-19 Screening of Health-Care Workers in England

Ewan Hunter, et al

Screening symptomatic health-care workers for severe acute respiratory syndrome (SARS) coronavirus 2 (SARS-CoV-2).

Given that non-clinical staff had similar positivity rates to frontline staff, authors conclude that current isolation protocols and personal protective equipment appear sufficient to prevent high levels of nosocomial transmission to frontline staff. Rather, the data appear to reflect wider patterns of community transmission.

Between March 10 and 31, 2020, we did 1666 SARS-CoV-2 tests in 1654 staff. Overall, SARS-CoV-2 was detected in 240 (14%) tests. The mean age of those testing positive (41·7 years [SD 12·1]) or negative (40·6 years [11·5]) was similar. 12 staff were retested due to recurrent symptoms (mean interval 8 days, range 2–18). In one of these cases, repeat testing at 14 days resulted in detection of SARS-CoV-2.

The authors were able to identify staff roles for 1029 staff tested, categorising them into three groups: (1) directly patient facing (eg, nurses, doctors, allied health professionals, porters, etc), (2) non-patient facing but potentially at higher risk of nosocomial exposure (eg, domestic and laboratory staff), and (3) non-clinical (eg, clerical, administrative, information technology, secretarial, etc).

As the screening criteria initially prioritised those in patient-facing roles, most staff were in group 1 (834 [81%] of 1029), with a minority in groups 2 (86 [8%]) or 3 (109 [11%]).

Analysis of data showed no evidence of a significant difference between these groups, suggesting that nosocomial transmission from patients to staff was not an important factor. This is consistent with observations in China, where staff testing was widespread.

The testing protocol has enabled 1414 health-care workers to return more rapidly to NHS service in the past 3 weeks, the vast majority returning to direct patient care. Beyond this obvious benefit, we speculate that testing might have additional positive effects on health behaviour, by providing health-care workers with the confidence that they can self-isolate with mild symptoms, knowing that a rapid negative result will enable them to return to work in a timely manner. This might lessen the desire of staff with mild symptoms to soldier on, in fear of abandoning colleagues for 7–14 days, thereby inadvertently contributing to nosocomial transmission.

Lancet, May 2, 2020

COVID-19: The Case for Health-Care Worker Screening to Prevent Hospital Transmission

James R M Black, et al

Here we outline the case for mass testing of both symptomatic and asymptomatic health-care workers (HCWs) to: (1) mitigate workforce depletion by unnecessary quarantine; (2) reduce spread in atypical, mild, or asymptomatic cases; and (3) protect the health-care workforce.

A lack of effective testing has meant that a large number of HCWs are self-isolating. In one small sample, only one in seven self-isolating HCWs were found to have the virus.

Increased testing capacity will enable all staff who are self-isolating unnecessarily to bolster a depleted workforce.

1. Asymptomatic HCWs are an underappreciated potential source of infection and worthy of testing. The number of asymptomatic cases of COVID-19 is significant. In a study of COVID-19 symptomatic and asymptomatic infection on the Diamond Princess cruise ship, 328 of the 634 positive cases (51·7%) were asymptomatic at the time of testing. Estimated asymptomatic carriage was 17·9%. Among 215 obstetric cases in New York City, 29 (87·9%) of 33 positive cases were asymptomatic, whereas China's National Health Commission recorded on April 1, 2020, that 130 (78%) of 166 positive cases were asymptomatic. Moreover, transmission before the onset of symptoms has been reported and might have contributed to spread among residents of a nursing facility in Washington, USA. Furthermore, evidence from modelled COVID-19 infectiousness profiles suggests that 44% of secondary cases were infected during the presymptomatic phase of illnesses from index cases, whereas a study of COVID-19 cases in a homeless shelter in Boston, MA, USA, implies that individual COVID-19 symptoms might be uncommon and proposed universal testing irrespective of symptomatic burden. Substantial asymptomatic transmission might also mean that current estimates of the basic reproduction number, R0, for COVID-19 are inaccurate.
2. HCW testing could reduce in-hospital transmission. In a retrospective, single-centre study in Wuhan, 41% of 138 patients were thought to have acquired infection in hospital. At the Royal Gwent Hospital in Newport, Wales, approximately half of the emergency room workforce have tested positive. Blanket testing near Venice, Italy, helped to identify asymptomatic cases and might have helped eliminate SARS-CoV-2 in a village. Moreover, asymptomatic and presymptomatic HCWs continue to commute to places of work where personal protective equipment (PPE) might be suboptimal. This disease spread could, in turn, propagate out of hospitals: during a period of lockdown asymptomatic COVID-19 carriage among hospital staff could conceivably act as a potent source of ongoing transmission.
3. Protecting the health of HCWs is paramount when staffing is limited. As well as by the provision of adequate PPE, the wellbeing of HCWs can be promoted by ensuring that infected colleagues are promptly tested and isolated. The scale of this problem is not yet fully understood, nor is the full potential for asymptomatic and presymptomatic HCWs to transmit infection to patients who do not have COVID-19, other HCWs, or the public. However, given that asymptomatic transmission has been documented, utmost caution is urged.

The NHS Trust at University College London Hospitals, London, UK, will soon be testing asymptomatic HCWs. In partnership with the Francis Crick Institute in London, UK, where COVID-19 testing will be performed, this initiative is an attempt to further limit nosocomial transmission. It could also alleviate a critical source of anxiety for HCWs. A healthy, COVID-19-free workforce that is not burned out will be an asset to the prolonged response to the COVID-19 crisis. As testing facilities increase in number and throughput in the coming weeks, testing should aim to accommodate weekly or fortnightly screening of HCWs working in high-risk areas.

Lancet, May 7, 2020

COVID-19: PCR Screening of Asymptomatic Healthcare Workers at London Hospital

Thomas A Treibel

Here authors present the SARS-CoV-2 PCR results from nasal swabs collected at the first five time-points from the first 400 participants (figure). They show the number and percentage of asymptomatic HCWs who tested positive for SARS-CoV-2 on consecutive weeks from March 23, 2020: 28 (7∙1%; 95% CI 4∙9–10∙0) of 396 HCWs in week 1, 14 (4∙9%; 3∙0–8∙1) of 284 HCWs in week 2, four (1∙5%; 0∙6–3∙8) of 263 HCWs in week 3, four (1∙5%; 0∙6–3∙8) of 267 HCWs in week 4, and three (1∙1%, 0∙4–3∙2) of 269 HCWs in week 5 (figure). Seven HCWs tested positive on two consecutive timepoints, and one HCW tested positive on three consecutive timepoints. During this time, 50 HCWs (not necessarily those who were SARS-CoV-2 positive) self-isolated for symptoms. Of the 44 HCWs who tested positive for SARS-CoV-2, 12 (27%) had no symptoms in the week before or after positivity. If authors results are generalisable to the wider HCW population, then asymptomatic infection rates among HCWs tracked the London general population infection curve, peaking at 7∙1% and falling six-fold over 4 weeks, despite the persistence of a high burden of COVID-19 patients through this time (representing most inpatients). Taken together, these data suggest that the rate of asymptomatic infection among HCWs more likely reflects general community transmission than in-hospital exposure. Prospective patients should be reassured that as the overall epidemic wave recedes, asymptomatic infection among HCWs is low and unlikely to be a major source of transmission.

These data reinforce the importance of epidemic multi-timepoint surveillance of HCWs. The data also suggest that a testing strategy should link population-representative epidemiological surveillance to predict prevalence, with adaptive testing for symptomatic individuals at times of low prevalence, and rapidly expanding to include the asymptomatic HCWs during possible new infection waves.

JAMA, May 5, 2020

CDC Urges COVID-19 Testing at Homeless Shelters after Finding Swift Spread of Infection

Joan Stephenson

In this investigation published in MMWR, public health teams responded to clusters of 2 or more cases of coronavirus disease 2019 (COVID-19) at 5 homeless shelters—1 in Boston, 1 in San Francisco, and 3 in Seattle.

When investigators tested a total of 730 residents and 148 staff members at the 5 shelters with COVID-19 clusters, they found overall infection rates of 37% among residents and 21% among staff members. Infection rates were as high as 95 of 143 residents (66%) tested at the San Francisco shelter and 15 of 50 staff members (30%) tested at the Boston shelter.

In addition, the investigators tested 213 residents and 106 staff members at 12 shelters in Seattle where only a single case had been previously identified. They found a much lower prevalence of infection, with 5% of residents and 1% of staff members testing positive for SARS-CoV-2. The researchers also found low rates of infection at 2 homeless shelters in Atlanta with no known COVID-19 cases in the preceding 2 weeks, finding that 10 of 249 residents (4%) and 1 of 59 staff members (2%) had the infection.

In a related article in the Morbidity and Mortality Weekly Report, CDC investigators and other public health researchers described a COVID-19 outbreak at 3 affiliated homeless shelters in King County, Washington. After 1 person was found to be infected on March 30, SARS-CoV-2 testing was immediately offered to all residents and staff members of that shelter and 2 other shelters that used the first location’s day services. A second round of testing was offered approximately a week later to those not tested initially or those who had negative test results. In all, 35 of 195 residents (18%) and 8 of 38 staff members (21%) who were tested had COVID-19.

JAMA Infectious Diseases, May 6, 2020

Estimated Demand for US Hospital Inpatient and Intensive Care Unit Beds for Patients With COVID-19 Based on Comparisons With Wuhan and Guangzhou, China

Ruoran Li, et al

Even after the lockdown of Wuhan on January 23, 2020, the number of patients with serious COVID-19 cases continued to rise, exceeding local hospitalization and ICU capacities for at least a month. Plans are urgently needed to mitigate the consequences of COVID-19 outbreaks on local health care systems in US cities.

In Wuhan, strict disease control measures were implemented 6 weeks after sustained local transmission of SARS-CoV-2. Between January 10 and February 29, 2020, patients with COVID-19 accounted for a median (interquartile range) of 429 (25-1143) patients in the ICU and 1521 (111-7202) inpatients with serious illness each day. During the epidemic peak, 19 425 patients (24.5 per 10 000 adults) were hospitalized, 9689 (12.2 per 10 000 adults) were considered in serious condition, and 2087 (2.6 per 10 000 adults) needed critical care per day. In Guangzhou, strict disease control measures were implemented within 1 week of case importation. Between January 24 and February 29, COVID-19 accounted for a median (interquartile range) of 9 (7-12) patients in the ICU and 17 (15-26) inpatients with serious illness each day. During the epidemic peak, 15 patients were in critical condition and 38 were classified as having serious illness. The projected number of prevalent critically ill patients at the peak of a Wuhan-like outbreak in US cities was estimated to range from 2.2 to 4.4 per 10 000 adults, depending on differences in age distribution and comorbidity (ie, hypertension) prevalence.

At the peak of the epidemic, authors estimated the critical care risk among adults younger than 65 years to be 1.2 patients per 10 000 adults; among adults aged 65 years or older, 8.0 patients per 10 000 adults; among adults without hypertension, 1.3 patients per 10 000 adults; and among adults with hypertension, 9.5 patients per 10 000 adults. In the 30 most populous cities in the US, 11.0% to 22.5% adults are aged 65 years or older and the crude hypertension prevalence ranges from 22.0% to 46.9%. The projected number of prevalent critically ill patients at the peak of a Wuhan-like outbreak in US cities ranged from 2.2 to 3.2 patients per 10 000 adults, when the difference in age distribution was taken into account (Figure 2A) and from 2.8 to 4.4 patients per 10 000 adults when the differences in hypertension prevalence was taken into account (Figure 2B).

Viral Dynamics

JAMA, May 7, 2020

Clinical Characteristics and Results of Semen Tests Among Men With Coronavirus Disease 2019

Diangeng Li, et al

The virus responsible for COVID-19, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been detected in stool, gastrointestinal tract, saliva, and urine samples. However, little is known about SARS-CoV-2 in semen.

Of these 38 participants who provided a semen specimen, 23 participants (60.5%) had achieved clinical recovery and 15 participants (39.5%) were at the acute stage of infection. Results of semen testing found that 6 patients (15.8%) had results positive for SARS-CoV-2, including 4 of 15 patients (26.7%) who were at the acute stage of infection and 2 of 23 patients (8.7%) who were recovering, which is particularly noteworthy. But there was no significant difference between negative and positive test results for patients by age, urogenital disease history, days since onset, days since hospitalization, or days since clinical recovery.

If it could be proved that SARS-CoV-2 can be transmitted sexually in future studies, sexual transmission might be a critical part of the prevention of transmission, especially considering the fact that SARS-CoV-2 was detected in the semen of recovering patients. Abstinence or condom use might be considered as preventive means for these patients. In addition, it is worth noting that there is a need for studies monitoring fetal development. Therefore, to avoid contact with the patient’s saliva and blood may not be enough, since the survival of SARS-CoV-2 in a recovering patient’s semen maintains the likelihood to infect others.

Clinical Manifestations

Lancet, May 5, 2020

Acute Limb Ischaemia in Two Young, Non-Atherosclerotic Patients with COVID-19

Paolo Perini, et al

Changes in blood coagulation during severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection (ie, increased values of D-dimer, fibrin or fibrinogen degradation products, and fibrinogen; decreased antithrombin values, prothrombin time activity, and thrombin time) have been described by Han and colleagues. Systemic proinflammatory cytokine response is a mediator of atherosclerosis by inducing the expression of procoagulant factors, local inflammation, and haemodynamic alterations. Finally, the receptor for SARS-CoV-2 (angiotensin-converting enzyme 2) is expressed on the membrane of vascular muscle and endothelial cells.

Here authors describe patients with COVID-19 who presented with acute limb ischaemia but did not have atherosclerosis, atrial fibrillation, or pre-existing blood clotting disorders.

One patient, a man aged 53 years who received invasive mechanical ventilation, presented with bilateral lower limb ischaemia secondary to acute aortoiliac thrombosis. He underwent emergent thromboembolectomy through femoral cutdowns, with bilateral pedal pulse recovery. Inspected arteries were free from macroscopic atherosclerotic disease. However, thrombosis reoccurred approximately 2 h after the thromboembolectomy, and the patient died on postoperative day. The other patient, a man aged 37 years, received oxygen support through a nasal cannula and presented with an acute ischaemia of the upper left limb. The clot was visible by duplex ultrasound at the level of the humeral artery bifurcation. After 2 days of unfractionated heparin administration, the acute limb ischaemia resolved.

Lancet, May 5, 2020

Is the HScore Useful in COVID-19?

David L Leverenz

Emerging clinical data in severe COVID-19 infection highlight HScore limitations. Leukopenia increases the likelihood of secondary haemophagocytic lymphohistiocytosis (sHLH) in the HScore, whereas severe COVID-19 has leukocytosis with leukocyte subset lymphopenia. The HScore misses this important distinction. Although hyperferritinaemia, a hallmark of sHLH, occurs in severe COVID-19, ferritin concentrations rarely reach the HScore threshold of 2000·0 ng/mL until late in disease, limiting early intervention.

In a review of 191 patients with COVID-19 admitted to hospital, the IQR of ferritin concentrations at time of admission in non-survivors was 728·9–2000·0 ng/mL, and the median ferritin did not exceed 2000·0 ng/mL until 16 days after symptom onset, when most patients had experienced acute respiratory distress syndrome requiring intubation. Other HScore criteria such as hypertriglyceridaemia, splenomegaly, hepatomegaly, and bone marrow haemophagocytosis are not reported in most cohort studies of COVID-19. Finally, high fevers are weighted heavily in the HScore; however, temperature above 39·0°C does not distinguish between patients with moderate versus severe COVID-19.

NEJM, May 5, 2020

Lupus Anticoagulant and Abnormal Coagulation Tests in Patients with Covid-19

Louise Bowles, et al

A prolonged aPTT may indicate a clotting-factor deficiency or the presence of an inhibitor of coagulation that is either specific (e.g., antibody to factor VIII) or nonspecific (e.g., lupus anticoagulant). Lupus anticoagulant can affect in vitro tests of blood coagulation but typically is not associated with bleeding. As part of the antiphospholipid syndrome, lupus anticoagulant is associated with a thrombotic risk. We investigated the cause of prolonged aPTT in patients with Covid-19.

Blood specimens obtained from 216 patients who were positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) were received for coagulation screening, and 44 (20%) were found to have a prolonged aPTT. The specimens from 9 patients were excluded, and those from 35 patients were investigated further.

Pulmonary embolism was confirmed in 1 patient, and clinically suspected thrombosis was present in 1 patient. No clinically significant bleeding or arterial thrombosis were reported.

Lupus anticoagulant assays were performed in 34 patients, and 31 (91%) were positive. All lupus anticoagulant–positive specimens had a prolonged aPTT with a 50:50 mix (i.e., in a sample made up of 50% patient plasma and 50% normal plasma). In a historical control cohort of 540 specimens received for lupus anticoagulant testing, 43 (8%) had an aPTT of 30 seconds or longer, and 11 of the 43 (26%) were positive for lupus anticoagulant. The percentage of specimens that were positive for lupus anticoagulant was significantly higher among the patients with Covid-19 than in the control cohort (P<0.001).

In this study, most patients with Covid-19 who were admitted to the hospital with a prolonged aPTT were positive for lupus anticoagulant (91%) and often had an associated factor XII deficiency. It is important to note that neither observation is associated with a bleeding tendency; factor XII is not required for hemostasis, and the presence of lupus anticoagulant, if persistent, can be associated with a thrombotic tendency within the antiphospholipid syndrome. Further study is required to determine the role, if any, of lupus anticoagulant in the pathogenesis of Covid-19 thrombosis.

NEJM, May 6, 2020

Acute Cor Pulmonale in Critically Ill Patients with Covid-19

Christina Creel-Bulos, et al

Over a 48-hour period, five patients who were admitted to ICUs within authors’ hospital system had profound hemodynamic instability due to the development of acute cor pulmonale. Cardiac arrest with pulseless electrical activity occurred in four patients, and three of these patients had died as of May 1. In one patient, acute cor pulmonale developed without cardiac arrest; this patient’s condition improved with thrombolytic therapy. At the time of hemodynamic instability, one patient was receiving therapeutic anticoagulation with intravenous heparin according to a non–citrate-based anticoagulation protocol, and the remaining patients were receiving prophylactic anticoagulation.

Although acute pulmonary thromboembolism was the most likely cause of right ventricular failure in these patients, this was not definitively confirmed in all cases. Acute cor pulmonale causing obstructive shock should be included in the differential diagnosis in critically ill patients with Covid-19.

Lancet, May 7, 2020

Hyperinflammatory Shock in Children During COVID-19 Pandemic

Shelley Riphagen,et al

During a period of 10 days in mid-April, 2020, in England, the authors noted an unprecedented cluster of eight children with hyperinflammatory shock, showing features similar to atypical Kawasaki disease, Kawasaki disease shock syndrome, or toxic shock syndrome (typical number is one or two children per week). This case cluster formed the basis of a national alert.

All children were previously fit and well. Six of the children were of Afro-Caribbean descent, and five of the children were boys. All children except one were well above the 75th centile for weight. Four children had known family exposure to coronavirus disease 2019 (COVID-19).

All children tested negative for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on broncho-alveolar lavage or nasopharyngeal aspirates. Despite being critically unwell, with laboratory evidence of infection or inflammation including elevated concentrations of C-reactive protein, procalcitonin, ferritin, triglycerides, and D-dimers, no pathological organism was identified in seven of the children. Adenovirus and enterovirus were isolated in one child.

Baseline electrocardiograms were non-specific; however, a common echocardiographic finding was echo-bright coronary vessels (appendix), which progressed to giant coronary aneurysm in one patient within a week of discharge from paediatric intensive care (appendix). One child developed arrhythmia with refractory shock, requiring extracorporeal life support, and died from a large cerebrovascular infarct. The myocardial involvement in this syndrome is evidenced by very elevated cardiac enzymes during the course of illness.

All children were given intravenous immunoglobulin (2 g/kg) in the first 24 h, and antibiotic cover including ceftriaxone and clindamycin. Subsequently, six children have been given 50 mg/kg aspirin. All of the children were discharged from PICU after 4–6 days. Since discharge, two of the children have tested positive for SARS-CoV-2 (including the child who died, in whom SARS-CoV-2 was detected post mortem). All children are receiving ongoing surveillance for coronary abnormalities.

We suggest that this clinical picture represents a new phenomenon affecting previously asymptomatic children with SARS-CoV-2 infection manifesting as a hyperinflammatory syndrome with multiorgan involvement similar to Kawasaki disease shock syndrome. The multifaceted nature of the disease course underlines the need for multispecialty input (intensive care, cardiology, infectious diseases, immunology, and rheumatology).

As this Correspondence goes to press, 1 week after the initial submission, the Evelina London Children's Hospital paediatric intensive care unit has managed more than 20 children with similar clinical presentation, the first ten of whom tested positive for antibody (including the original eight children in the cohort described above).

Lancet, May 6, 2020

COVID-19-Associated Nephritis: Early Warning for Disease Severity and Complications?

Oliver Gross, et al

COVID-19-associated nephritis, which can be easily screened for through a simple and inexpensive urine sample analysis, might help predict complications.

Some patients with COVID-19 were eventually admitted to the ICU in a medical center in Germany. Before their admission to ICU, we detected low antithrombin III concentrations (26–62% [reference >70%]), severe hypalbuminaemia (serum albumin concentration of 1·4–1·9 mg/dL [reference 3·4–5·0 mg/dL]), and urine samples positive for blood, albumin, and leukocytes.

Unlike patients in ICU, patients with COVID-19 receiving treatment for mild symptoms in the intermediate care unit had serum albumin concentrations above 2·0 mg/dL, and antithrombin concentrations were low but within normal limits. Patients with COVID-19 on the normal ward had the best serum albumin results (above 2·5 mg/dL) and normal urine.

On the basis of these findings, we generated an algorithm for early detection of COVID-19-associated nephritis and to assess the risk of respiratory decompensation by capillary leak syndrome (figure).

Diagnosis

JAMA, May 6, 2020

Interpreting Diagnostic Tests for SARS-CoV-2

Nandini Sethuraman,et al

Using available evidence, a clinically useful timeline of diagnostic markers for detection of COVID-19 has been devised (Figure). Most of the available data are for adult populations who are not immunocompromised. The time course of PCR positivity and seroconversion may vary in children and other groups, including the large population of asymptomatic individuals who go undiagnosed without active surveillance. Many questions remain, particularly how long potential immunity lasts in individuals, both asymptomatic and symptomatic, who are infected with SARS-CoV-2.

Detection of Viral RNA by RT-PCR

Most tests are targeting 1 or more of the envelope (env), nucleocapsid (N), spike (S), RNA-dependent RNA polymerase (RdRp), and ORF1 genes. The sensitivities of the tests to individual genes are comparable according to comparison studies except the RdRp-SARSr (Charité) primer probe, which has a slightly lower sensitivity likely due to a mismatch in the reverse primer.

Cycle threshold (Ct) is the number of replication cycles required to produce a fluorescent signal, with lower Ct values representing higher viral RNA loads. A Ct value less than 40 is clinically reported as PCR positive. This positivity starts to decline by week 3 and subsequently becomes undetectable. However, the Ct values obtained in severely ill hospitalized patients are lower than the Ct values of mild cases, and PCR positivity may persist beyond 3 weeks after illness onset when most mild cases will yield a negative result. However, a “positive” PCR result reflects only the detection of viral RNA and does not necessarily indicate presence of viable virus.

In a study of 9 patients, attempts to isolate the virus in culture were not successful beyond day 8 of illness onset, which correlates with the decline of infectivity beyond the first week.

Detection of Antibodies to SARS-CoV-2

The most sensitive and earliest serological marker is total antibodies, levels of which begin to increase from the second week of symptom onset.

In a study of 140 patients, combined sensitivity of PCR and IgM ELISA directed at nucleocapsid (NC) antigen was 98.6% vs 51.9% with a single PCR test. During the first 5.5 days, quantitative PCR had a higher positivity rate than IgM, whereas IgM ELISA had a higher positivity rate after day 5.5 of illness.

ELISA-based IgM and IgG antibody tests have greater than 95% specificity for diagnosis of COVID-19. Testing of paired serum samples with the initial PCR and the second 2 weeks later can further increase diagnostic accuracy. Typically, the majority of antibodies are produced against the most abundant protein of the virus, which is the NC. Therefore, tests that detect antibodies to NC would be the most sensitive. However, the receptor-binding domain of S (RBD-S) protein is the host attachment protein, and antibodies to RBD-S would be more specific and are expected to be neutralizing. Therefore, using one or both antigens for detecting IgG and IgM would result in high sensitivity. Antibodies may, however, have cross-reactivity with SARS-CoV and possibly other coronaviruses.

The presence of neutralizing antibodies can only be confirmed by a plaque reduction neutralization test. However, high titers of IgG antibodies detected by ELISA have been shown to positively correlate with neutralizing antibodies. The long-term persistence and duration of protection conferred by the neutralizing antibodies remains unknown.

Treatment

JAMA, May 5, 2020

Association of Use of Angiotensin-Converting Enzyme Inhibitors and Angiotensin II Receptor Blockers With Testing Positive for Coronavirus Disease 2019 (COVID-19)

Neil Mehta, et al

Question: What is the association of use of angiotensin-converting enzyme inhibitors (ACEI) and angiotensin II receptor blockers (ARB) with testing positive for coronavirus disease 2019 (COVID-19)?

In this study of the associations of ACEI and ARB use with COVID-19 test positivity, the frequency of positive test results was not significantly different in patients taking either ACEIs or ARBs at the time of testing. ACEIs and ARBs are important medications in the management of coronary artery disease, heart failure, diabetes, and hypertension. As there may be a risk to withdrawing these agents, our study, showing no significant greater susceptibility with regard to test positivity, supports the recommendations of several professional societies that have recommended continuation of these medications. Results of the secondary analyses of association of ACEI or ARB use and markers of clinical disease severity, including hospital admission, ICU admission, or mechanical ventilation requirement, require replication and reanalysis in larger numbers of patients later in the course of the current COVID-19 pandemic.

While the effect of ACEI/ARBs on SARS-CoV-2 infection at the molecular level is being debated, the limited amount of clinical evidence available has added to the controversy. In a retrospective study of 187 patients with COVID-19, prior use of ACEIs or ARBs (in 19 patients) was associated with elevated troponin levels, which was indirectly associated with worse clinical outcomes. However, in a study of elderly patients with hypertension with COVID-19, those taking ARBs (10 patients) had better outcomes compared with those who were taking other antihypertensive agents.

In animals, ACEIs and ARBs have different effects on cardiac membrane ACE2 activity. It would be of interest to analyze differences in clinical outcomes among patients taking ACEIs and ARBs in future studies with larger data sets.

In this retrospective cohort study of 18 472 patients tested for COVID-19 within the Cleveland Clinic Health System in Ohio and Florida, 1322 (7.2%) were taking ACEIs and 982 (5.3%) were taking ARBs. A positive COVID-19 test result was observed in 1735 (9.4%) tested patients, and among all patients with positive test results, 116 (6.7%) were taking ACEIs, and 98 (5.6%) were taking ARBs; there was no association between ACEI/ARB use and testing positive for COVID-19 (overlap propensity score–weighted odds ratio, 0.97; 95% CI, 0.81-1.15).

Although the primary outcome was a positive laboratory test result for COVID-19, the authors also performed a secondary analysis of the clinical outcomes of COVID-19 among patients with positive test results and included hospital admission, admission to the ICU, and mechanical ventilation during index hospitalization. Among patients with positive test results, 421 (24.3%) were admitted to the hospital, 161 (9.3%) were admitted to an ICU, and 111 (6.4%) required mechanical ventilation. The cohort had a substantial prevalence of comorbidities: hypertension (7312 [40%]), diabetes (3478 [19%]), coronary artery disease (2179 [12%]), chronic obstructive pulmonary disease (2186 [12%]), and heart failure (1879 [10%]).Patients taking either ACEIs or ARBs had more comorbidities than those not taking these medications.

Among 1705 patients with SARS-CoV-2 with death status available, 42 deaths (2.5%) occurred. Eight of 211 patients (3.8%) were in the ACEI or ARB cohort and 34 of 1494 (2.1%) were in the no-ACEI or no-ARB cohort.

There was a higher likelihood of ICU admission among patients with positive test results who were taking ACEIs, but no such difference was observed among those taking ARBs. There was no difference in either group with regard to the requirement of mechanical ventilation during index hospitalization. However, data with regard to clinical outcomes and measures of COVID-19 severity taking ACEIs and ARBs must be interpreted with caution and be considered only hypothesis generating, owing in part to the small sample size and the wide width of the confidence intervals in addition to the limitations of the study discussed below.

JACC, Unpublished

Association of Treatment Dose Anticoagulation with In-Hospital Survival Among Hospitalized Patients with COVID-19

Ishan Paranjpe, et al

Authors assessed association between administration of in-hospital AC and survival in a large cohort of hospitalized patients with COVID-19.

Although limited by its observational nature, unobserved confounding, unknown indication for AC, lack of metrics to further classify illness severity in the mechanically ventilated subgroup, and indication bias, authors findings suggest that systemic AC may be associated with improved outcomes among patients hospitalized with COVID-19. The potential benefits of systemic AC, however, need to be weighed against the risk of bleeding and therefore should be individualized. The association of in-hospital AC and mechanical ventilation likely reflects reservation of AC for more severe clinical presentations. Interestingly, there was an association with AC and improved survival after adjusting for mechanical ventilation.

Special Groups

Lancet; May 7, 2020

Surgery in a Time of Uncertainty: A Need for Universal Respiratory Precautions in the Operating Room

Edward H. Livingston

Facilities should consider adoption of a universal precaution protocol for respiratory infections in the OR because it offers a path to mitigate the risk of exposure to SARS-CoV-2 and protect the most important resource in health care: physicians, surgeons, nurses, and other health care personnel.

Implementing a policy of universal respiratory precautions reinforces and highlights the need to identify individuals with acute COVID-19 infection, as well as those who may have been previously infected, who will undergo surgery and requires an adequate supply of personal protective equipment (PPE). Preoperative testing for SARS-CoV-2 infections should be performed. If patients have evidence of COVID-19 infection, surgery should be deferred if possible because the risk of poor patient outcomes and the risk of spread to health care workers is substantial. Patients who are not tested or test negative for acute infection should be assumed to potentially be infected with SARS-CoV-2. Tests for acute infection are variable, with sensitivity as low as 60% when nasal or 31% when pharyngeal swabs are used. In addition, some asymptomatic patients can shed SARS-CoV-2 and can potentially transmit the disease to others. Given the uncertainties of testing, the high prevalence of the disease in some regions, and that asymptomatic patients may be shedding virus, it should be assumed that the virus is present in every patient entering the OR. Until more is known, to reduce the risk of exposure for health care personnel, universal OR respiratory precautions would provide a better, more effective approach than current standard practices.

In addition to detecting potential acute disease, there is now emphasis on antibody testing to determine if individuals have had COVID-19 and recovered. Although these tests may detect an antibody response to a possible virus infection, it is not known yet if the measured antibodies can effectively prevent infection. Thus, even if patients or health care personnel have serology tests suggestive that they have recovered from COVID-19, there is no assurance that they cannot become reinfected with SARS-CoV-2. Until the value of serology tests is established, all health care personnel should follow recommendations for the use of appropriate PPE to avoid COVID-19 infection irrespective of serology results.