Ann Robinson’s research reviews—27 March 2020

Ann Robinson reviews the latest research from the top medical journals

International preparedness for covid-19

The rapid spread of covid-19 has exposed strengths and weaknesses in operational readiness against health emergencies in different countries and the extent to which they implement International Health Regulations 2005 (the World Health Organization’s blueprint for an appropriate global public health response to infectious disease). Alarmingly, there’s only patchy information about national and regional preparedness, so this study used indirect International Health Regulation data to review the state of play and develop an operational readiness index. The index will help the WHO, governments, and international agencies to prioritise the 28% of countries that have a low capacity to prevent a public health event. On the plus side, according to this study, 50% of countries (mostly high and middle income countries) have adequate resources for emergencies.

Lancet doi:10.1016/S0140-6736(20)30553-5

News from Singapore

Singapore has been quick to act to try to contain local clusters of covid-19 through active case-finding among close contacts of affected people and surveillance of people with pneumonia, flu-like symptoms, or contact with unwell travellers who have returned from China. This study analysed three clusters and found that covid-19 is transmissible in community settings beyond household clusters and could have occurred before the lockdown in Wuhan and the stringent Chinese travel restrictions. Temperature screenings at airports would not have been effective in identifying the primary cases because most patients weren’t febrile on arrival. Most of the cases in the three clusters were attributable to close physical contact (shaking hands, sharing meals, or serving customers in shops). The value of personal and hand hygiene is stressed by the authors.

Lancet doi:10.1016/S0140-6736(20)30528-6

No cure yet for covid-19

There’s no specific, proven treatment yet for the severe form of illness caused by the SARS-CoV-2 virus. A randomised, controlled, open-label trial of 199 patients with severe symptoms of covid-19 (oxygen saturation 94% while they were breathing ambient air, or a ratio of the partial pressure of oxygen to the fraction of inspired oxygen of <300 mm Hg) compared the response to lopinavir-ritonavir plus standard care for 14 days with standard care alone. There was no significant difference in the time taken for clinical improvement, discharge from hospital, or mortality at 28 days (19.2% vs 25.0%). Lopinavir is an antiretroviral drug used in the treatment of HIV infections, and it inhibits covid-19 in vitro; and ritonavir augments it by increasing its plasma half-life. So the combination may have worked, but it didn’t. And in these febrile days of fake and unsubstantiated claims, this negative finding is important too.

N Engl J Med doi:10.1056/NEJMoa2001282

Predicting who will get worse

How can we predict which of our patients with covid-19 are most likely to develop acute respiratory distress syndrome (ARDS) and die? This cohort study of 201 patients in Wuhan with pneumonia as a result of confirmed covid-19 identified older age, neutrophilia, and organ and coagulation dysfunction as being risk factors for progression. Older people have impaired immune responses, and the other factors are the result of immune activation. So in that sense these findings are tautological and don’t help us much. But the finding that methylprednisolone may be beneficial for patients who develop ARDS may be useful for clinicians.

JAMA Intern Med doi:10.1001/jamainternmed.2020.0994

Vulnerability of frail, elderly people in residential care homes

This study, published as a research letter, is the first description of critically ill patients infected with SARS-CoV-2 in the US. The 21 patients had a mean age of 70 years, many came from a single nursing home, 86% had comorbidities (such as chronic kidney disease and heart failure), and most presented with breathlessness (76%), fever (52%), and cough (48%). Twenty (95%) had an abnormal chest x ray, and 15 needed mechanical ventilation due to acute respiratory distress syndrome. Mortality was high at 67%, and only two of this cohort had made it home at the time of publication. Seven of the patients developed cardiomyopathy, which might be a direct result of the virus or a consequence of being so unwell. This cohort comes from a high risk, elderly group; these findings are not generalisable to the population at large, but do highlight the vulnerability of frail, elderly people, especially those in residential care homes. 

JAMA doi:10.1001/jama.2020.4326

Ann Robinson is an NHS GP and health writer and broadcaster