Tulane Outbreak Daily | April 28, 2020

Readers: A common theme I have noticed in the past few days has been reports of blood clots, strokes, gastro issues with positive COVID-19 patients. Please leave a comment on this post if you have any further information, or have seen similar cases in your part of the world. The Tulane Outbreak Daily email reaches about 3,000 researchers, doctors, and other health care professionals around the world. This is a great place to start a discussion or crowdsource a question.

Featured Headlines

Why Is COVID-19 Coronavirus Causing Strokes In Young And Middle-Aged People? – Forbes

We are also learning more and more about the devastating effects of this virus as it attacks other organs including the kidney, heart and the brain. However, the virus’s ultimate target that may inflict the most damage—via either a direct effect of the virus, hypoxia, (low oxygen), secondary inflammation or disseminated intravascular coagulation (DIC)—are blood vessels, leading to formation of blood clots, or excessive bleeding (DIC) in some cases, a consequence of consumption of clotting factors.

Bacterial superinfection and mortality in viral pneumonia such as influenza and COVID-19 – FLARE

The FLARE team investigates secondary bacterial infections in viral respiratory infections prior to COVID-19. Available data on secondary infections in COVID-19 are limited but do indicate that nosocomial infections are associated with increased COVID-19 severity and death. Risk factors for secondary bacterial and fungal infections include invasive devices (central venous catheters), diabetes, combination antibiotic therapy, and glucocorticoid treatment. Given long ICU stays associated with COVID-19, it is likely that rates of secondary bacterial infection will reflect, in part, nosocomial infections that are common in critical illness.

India coronavirus: The ‘mystery’ of low Covid-19 death rates

Most affected countries have inadvertently under-reported deaths. Studying mortality data in 12 countries, The New York Times found that in March at least 40,000 more people died during the coronavirus pandemic than the official death counts. These include deaths from the contagion as well as those from other likely causes. [Related Study]

Could genetics explain the confusing array of SARS-CoV-2 symptoms? – ARS Technica

A dry cough. Loss of smell. Diarrhea. Fever. All of these have been considered possible symptoms associated with SARS-CoV-2 infection, along with the complete absence of symptoms at all. In the absence of a sufficient testing capacity, many areas in the United States are being compelled to allocate their limited tests to only those who seem to have COVID-19 symptoms. But, given the difficulty of determining which symptoms actually indicate a likely infection, those are difficult decisions to make. [Related pre-pub study]

What policy makers need to know about COVID-19 protective immunity – The Lancet

About a third of the world is under lockdown as a public health measure to curb the spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes coronavirus disease 2019 (COVID-19). Policy makers are increasingly pressed to articulate their rationales and strategies for moving out of lockdown; the process of re-emergence is already cautiously starting in Austria, Switzerland, Denmark, Wuhan, and some US states. As the counterpoise between further disease spread and socioeconomic costs is debated, it is essential that policy makers in all affected countries have the best possible data and understanding to inform any course of action.

What if immunity to covid-19 doesn’t last? – MIT Technology Review

Starting in the fall of 2016 and continuing into 2018, researchers at Columbia University in Manhattan began collecting nasal swabs from 191 children, teachers, and emergency workers, asking them to record when they sneezed or had sore throats. The point was to create a map of common respiratory viruses and their symptoms, and how long people who recovered stayed immune to each one. [Related pre-pub study]

Many asymptomatic COVID-19 cases undetected – CIDRAP

More than half of residents of a Seattle-area nursing home had no symptoms when they tested positive for COVID-19 and had probably already spread the disease. [Related NEJM Study]

Heightened levels of SARS-CoV-2 RNA found in the air in some patient areas – Medical Express

Analyzing the samples for evidence of SARS-CoV-2 RNA, the researchers found dramatically different concentrations. As expected, they found much higher concentrations of the virus in the air where there were high concentrations of infected patients. They noted that concentrations were generally low in areas that were well ventilated. However, other areas, such as unventilated public toilets used by patients, were found to have much higher concentrations. [Related Study]

Myocardial Injury Common in COVID-19 – Med Page Today

Troponin elevations largely mild, but still linked to death in NYC hospitals [Related pre-print study]

Effect of Latitude on COVID-19 – CEBM

To look at this further and try and explain why some countries are disproportionately affected (see Six Countries: Three-Quarters of the COVID-19 Deaths) we analysed the effect of latitude on global deaths and cases per million in the Northern Hemisphere and globally. [Related Research]

Virus Likely to Keep Coming Back Each Year, Say Top Chinese Scientists – Bloomberg

It’s unlikely the new virus will disappear the way its close cousin SARS did 17 years ago, as it infects some people without causing obvious symptoms like fever. This group of so-called asymptomatic carriers makes it hard to fully contain transmission as they can spread the virus undetected. [Related Study]

U.K. Issues Warning Over Possible Coronavirus-Linked Illness in Kids – Bloomberg

The U.K. Paediatric Intensive Care Society posted an alert on Twitter reporting an increase in the number of children presenting the symptoms over the last three weeks, with some needing intensive care treatment. Abdominal pain, gastrointestinal problems and cardiac inflammation — consistent with toxic shock syndrome and atypical Kawasaki disease — are among the symptoms appearing, according to the NHS alert.

‘Spider-Man’ Immune Response May Promote Severe COVID-19 – Scientific American

Clinical trials have begun to test drugs that counter toxic molecular webs linked to lung distress. The menagerie of immune cells and proteins that defend the human body have received mounting scrutiny in struggles to ward off COVID-19. A lot of the debate has centered around whether, after recovery, a person carrying antibodies can safely return to the workplace. But attention has also turned to runaway immune reactions provoked by the infection that can lead to respiratory failure. [Related Study]


Editor’s note: Regarding the case counts below, please consider due to limited testing capabilities in some locations, the real number of cases could be considerably higher.

Official Reporting for April 28, 2020

WHO SITREP #98 ECDC | Country Data Johns Hopkins
Confirmed Cases 2,878,196 2,982,688 3,083,467
Deaths 198,668 210,193 213,824


Total cases: 957,875
Total deaths: 53,922
(Numbers close out at 4 p.m. the day before reporting.)

Surveillance Headlines


Michigan: State reports 2,637 current COVID-19 cases in Michigan nursing homes – WXYZ News


Germany: New Virus Cases Drop Below 1,000, Deaths Accelerate – Bloomberg

Germany: Reopening puts Germany’s much-praised coronavirus response at risk – Science

Russia: Putin Extends Russia’s Coronavirus Lockdown as New Infections Continue to Rise – Moscow Times


Nigeria: President Eases COVID-19 Restrictions, Citing Economic Hardship – NPR

Science and Tech

Max Planck Researchers Solve Structure of SARS-CoV-2 Viral Copy Machine – Technology Networks

When someone becomes infected with the novel coronavirus SARS-CoV-2, the pathogen proliferates rapidly in the cells of the infected person. To do so, the virus has to multiply its genetic material, which consists of a single long RNA strand. This task is performed by the viral ‘copy machine’, the so-called polymerase. Scientists led by Patrick Cramer at the Max Planck Institute for Biophysical Chemistry in Göttingen, Germany, have now determined the 3D structure of the corona polymerase. This makes it now possible to investigate how antiviral drugs such as remdesivir – which blocks the polymerase – work, and to search for new inhibitory substances.


Anti-viral drug has ‘positive results’ in lab tests – BBC

The University of St Andrews team used the anti-viral drug Neumifil and Carbohydrate Binding Modules (mCBMs) to block the Sars-CoV-2 virus from getting into lung cells.


Infectious Disease Society of America (IDSA) Antibody Testing Primer

As serological testing for SARS-CoV-2 advances, there are multiple issues that need to be addressed, from test quality to interpretation. Unlike molecular tests for COVID-19 (e.g., PCR), antibody tests may be better suited for public health surveillance and vaccine development than for diagnosis. The current antibody testing landscape is
varied and clinically unverified, and these tests should not be used as the sole test for diagnostic decisions. Further, until more evidence about protective immunity is available, serology results should not be used to make staffing decisions or decisions regarding the need for personal protective equipment.

Published Research

Clinical phenotypes of SARS-CoV-2: Implications for clinicians and researchers – European Respiratory Journal

Early risk factors for the duration of SARS-CoV-2 viral positivity in COVID-19 patients – Clinical Infectious Disease

Presymptomatic SARS-CoV-2 Infections and Transmission in a Skilled Nursing Facility

Improving the efficacy of Chloroquine and Hydroxychloroquine against SARS-CoV-2 may require Zinc additives – A better synergy for future COVID-19 clinical trials – Le Infezioni in Medicina Salerno, Italy

Aerodynamic analysis of SARS-CoV-2 in two Wuhan hospitals – Nature

Epidemiology and transmission of COVID-19 in 391 cases and 1286 of their close contacts in Shenzhen, China: a retrospective cohort study – The Lancet

Acute pulmonary embolism in conjunction with intramural right ventricular thrombus in a SARS-CoV-2-positive patient – European Heart Journal

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

Neutrophil extracellular traps in COVID-19 – American Society for Clinical Investigation/Insite

Persistence of intestinal SARS-CoV-2 infection in patients with COVID-19 leads to re-admission after pneumonia resolved – International Journal of Infectious Diseases

COVID-19: ICU delirium management during SARS-CoV-2 pandemic – BMC

Pre-Pub (not yet peer reviewed, should not be regarded as conclusive)

Direct observation of repeated infections with endemic – Columbia.edu

Supply Chain Impact

Americans on Cusp of Meat Shortage With Food Chain Breaking Down – Bloomberg

The coronavirus pandemic is pushing the food supply chain to its limits. Plant shutdowns are leaving Americans dangerously close to seeing meat shortages at grocery stores. Meanwhile, farmers are facing the likely culling of millions of animals and mass burial graves could soon be dug across the heartland.

Infection Prevention

When PPE’s in Short Supply, Disinfected N95 Best Bet – MedPageToday

However, IDSA backs surgical masks outside of aerosol-generating procedures. Adding a face shield or surgical mask to cover the N95 respirator to allow for extended use also gained a strong recommendation despite similarly “very low certainty evidence.” [CDC Recommendations Here] [IDSA Guidelines Here] [Related Study on Steam Sterilization Here]

Coping in Quarantine

When your FB friends post something like, “COVID-19 is no worse than the flu” here are a few data points from a recent study that may help.

  • From February 1 to April 18, the ratio of excess deaths in New York City was 21 times the number of deaths from seasonal influenza. [Related pre-print study]
  • CDC data indicates 619 flu deaths in New York City from Feb. 1 to April 18, 2020
  • The Johns Hopkins COVID-19 tracker reports the death toll for New York City as of April 27th at 5,870

When I see comments about COVID-19 is caused by 5G, I give up the fight and click over to Youtube to watch dogs wearing boots.