COVID-19 Transmission by Children

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Babies and toddlers may be more likely to transmit the virus that causes COVID-19 to others in their households compared to teenagers, a new study has found (Paul et al., 2021). Since early 2020, the coronavirus pandemic has overwhelmed countries all around the world. In the United States, the number of deaths from coronavirus is nearing 642,000, with an increase in cases, hospitalizations, and deaths in recent weeks (CDC). This study, which was published last month in JAMA Pediatrics, does not resolve the ongoing debate over whether infected children are as contagious as infected adults, nor does it suggest children are drivers of the pandemic. The study does, however, demonstrate that very young children can play a role in the transmission of COVID-19.

Researchers at Public Health Ontario, a Canadian public health agency, analyzed Ontarian health records from June 1 to December 31, 2020, and identified 6,280 households in which a child (0-18 years old) was the “index case” – the first person to develop COVID-19 symptoms or test positive for the virus. Then they looked for “secondary cases,” others in the household who got sick in the two weeks after the first child became ill (Paul et al., 2021). In most cases, the chain of transmission stopped with the infected child, but in 27.3% of households, children transmitted the virus to at least one other household member (Anthes, 2021). Another takeaway was that adolescents were most likely to bring the virus into the home, with 14–17-year-olds making up 38% of index cases (Paul et al., 2021). The study’s key finding, however, was that the odds of household transmission of COVID-19 were roughly 40% higher for infections in children 3 or younger compared to children between 14 and 17 (Paul et al., 2021). Behavioral differences might explain this finding, as babies and toddlers often require close contact and hands-on care. “The 0-to-3-year-old child is held differently, is cuddled,” offered Dr. Paul Offit, professor of pediatrics in the Division of Infectious Diseases at Children’s Hospital of Philadelphia (Salzman et al., 2021). And when young children are sick, for example, they cannot be isolated.

This study updates experts’ understanding of COVID-19 transmission risk. Earlier in the pandemic, some scientists suggested the risk of COVID-19 transmission declined with younger age, though this assumption was likely biased by the fact that lockdowns and social distancing limited  social encounters for young children (Choi, 2021). These new findings suggest the opposite, and Dr. Edith Bracho Sanchez, a primary care pediatrician and assistant professor of pediatrics at Columbia University Irving Medical Center, said that the study “just shows how humble we have to be when it comes to children and this virus. We always knew children could get it, could transmit it, and could get sick with COVID,” she continued (Salzman et al., 2021). “I think we’re learning more and more just how much.”

The study was conducted in 2020, before the delta variant emerged, so further research is necessary to understand transmission risk in the context of the variant and other potential variants. The study also took place before vaccines were available, so all household members were unvaccinated (Paul et al., 2021). Still, its findings reinforce the importance of implementing and maintaining mitigation strategies at schools and childcare facilities, especially as a new school year begins and more children are returning to school in-person. Strategies such as frequent cleaning, good ventilation, distancing, and masking when possible are essential. The study also reaffirms the importance of vaccination for all eligible people over 12, especially those that spend time with children (Salzman et al., 2021).

 

References

 

Anthes E. (2021, August 16). Babies and Toddlers Spread Virus in Homes More Easily Than Teens, Study Finds. New York Times. https://www.nytimes.com/2021/08/16/health/covid-kids-toddlers-transmission.html.

 

Centers for Disease Control (CDC). COVID Data Tracker, Updated Daily. U.S. Department of Health and Human Services. https://covid.cdc.gov/covid-data-tracker/#datatracker-home.

 

Choi J. (2021, August 19). Younger children more likely to spread COVID-19 to households than older kids. The Hill. https://thehill.com/policy/healthcare/568627-younger-children-more-likely-to-spread-covid-19-than-households-with-older.

 

Paul LA, Daneman N, Schwartz KL, et al. Association of Age and Pediatric Household Transmission of SARS-CoV-2 Infection. JAMA Pediatr. Published online August 16, 2021. doi:10.1001/jamapediatrics.2021.2770

Salzman S., Richter Lauren R. (2021, August 16). Younger children more likely to spread COVID-19, study finds. ABC News. https://abcnews.go.com/Health/younger-children-spread-covid-19-study-finds/story?id=79480836.

Returning to In-Person School

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On July 12, 2021, the United Nations Children’s Fund (UNICEF) and United Nations Educational, Scientific and Cultural Organization (UNESCO) jointly released a statement urging governments to reopen in-person school. Primary and secondary schools remain completely shuttered in 19 countries around the world due to COVID-19, increasing the likelihood of learning loss, reduced development of social skills, mental distress, exposure to violence and abuse, and missed school-based meals and vaccinations. Since March of 2020, schools in over 160 countries have been fully closed at one point. “The losses that children and young people will incur from not being in school may never be recouped,” the statement declares. [1] 

 

Over a year into the COVID-19 pandemic, with many schools around the world having cycled through periods of full closure and cautious or complete reopening, there is growing evidence that, in many scenarios, communities can resume in-person school in a safe manner with proper adherence to mitigation strategies. Research has consistently demonstrated that while children and young people are susceptible to COVID-19, they have had a lower incidence and a lower risk of severe COVID-19 outcomes than adults. [2] As of July 8, 2021, between only 0.1 to 1.9 percent of all child COVID-19 cases have resulted in hospitalization. [3] 

 

The Centers for Disease Control and Prevention (CDC) is promoting the reopening of in-person school in accordance with newly released guidelines. A July 9 report recommends indoor masking at all times, at least three feet of distancing, weekly testing, and maintaining small groups/pods. The report promotes, but does not mandate, vaccination for teachers, staff, families, and students. [4] Encouragingly, a July 2021 national polling update from the Morning Consult indicates that nearly three-quarters of teachers have been vaccinated. [5] The new CDC report removes speculation that schools will be required to separate vaccinated and unvaccinated individuals, which could foment division and create major logistical challenges.  

 

Evidence supports the principle that layering prevention strategies can reduce or eliminate the occurrence of COVID-19 outbreaks in school and make it safe for reopening in-person, according to a comprehensive literature review by Resolve to Save Lives, an organization led by former CDC Director Tom Frieden. The report cites an English study finding no differences in COVID-19 positivity rates between teachers and other professions involving in-person interactions. Studies of schools in Australia and Europe have indicated that school outbreaks are generally associated with 10 cases or fewer, with protective measures limiting outbreaks. [6] Even in tight spaces, transmission can be contained: a new article in the Journal of School Health reports that universal testing and contact tracing revealed no transmission linked to school bus transportation serving 462 students. Although the buses were operating at near capacity of two students in every seat, universal masking and simple ventilation techniques were in place and appear to have been effective. [7]  

 

Notably, the CDC guidance incorporates language emphasizing the importance of in-person learning even in the absence of the full implementation of these measures. [6] Such guidance testifies to the concern elicited by growing evidence of the detriments of keeping schools closed, with students suffering socially, emotionally, and academically. [8] It also acknowledges that fully implementing prevention strategies is a major challenge in the U.S., where divisive debates over public health guidance continue, with some parents saying they won’t send their children to schools without masks, and some saying they’ll only send their children without them.  

 

While in the United States, virtual learning remains an option, as well as a tool of untapped potential, in lower-resource settings, school closures have been more prolonged while virtual learning tools have remained less accessible, according to UNICEF data. Even though vaccine shortages have plagued many of these countries, the UNICEF-UNESCO statement asserts that “reopening schools for in-person learning cannot wait.” [1] In the absence of vaccines — or in the context of vaccine hesitancy and refusal in the United States — the layering of mitigation strategies outlined by the CDC remains all the more critical. 

 

References 

 

  1. Reopening schools cannot wait: joint statement by UNICEF and UNESCO. United Nations Educational, Scientific and Cultural Organization. Published July 12, 2021. https://en.unesco.org/news/reopening-schools-cannot-wait-joint-statement-unicef-and-unesco 
  2. Leidman E, Duca LM, Omura JD, Proia K, Stephens JW, Sauber-Schatz EK. COVID-19 trends among persons aged 0-24 years – United States, March 1-December 12, 2020. MMWR Morb Mortal Wkly Rep. 2021;70(3):88-94. 
  3. Children and COVID-19: State Data Report. American Academy of Pediatrics. Published July 8, 2021. https://downloads.aap.org/AAP/PDF/AAP%20and%20CHA%20-%20Children%20and%20COVID-19%20State%20Data%20Report%207.8%20FINAL.pdf  
  4. CDC. Guidance for COVID-19 Prevention in K-12 schools. Centers for Disease Control and Prevention. Published July 10, 2021. https://www.cdc.gov/coronavirus/2019-ncov/community/schools-childcare/k-12-guidance.html  
  5. Teachers and K-12 Education: A National Polling Report. Morning Consult. Published July 2021. https://edchoice.morningconsultintelligence.com/assets/123916.pdf  
  6. Cash-Goldwasser S, Jones SA, Wu AC, Subramaniam HL and Frieden TR. In-Depth COVID-19 Science Review. Resolve to Save Lives. Published July 16, 2021. https://preventepidemics.org/covid19/science/review/july-15-2021/  
  7. Ramirez DWE, Klinkhammer MD, Rowland LC. COVID-19 transmission during transportation of 1st to 12th grade students: Experience of an independent school in Virginia. J Sch Health. 2021;(josh.13058). doi:10.1111/josh.13058 
  8. Duckworth AL, Kautz T, Defnet A, et al. Students attending school remotely suffer socially, emotionally, and academically. Educ Res. Published online 2021:0013189X2110315. 

Atrial Fibrillation Ablation: Anesthesia Considerations

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Atrial fibrillation is a medical condition that affects roughly 33.5 million people worldwide [1]. Underlying cardiac conditions such as hypertension and coronary heart disease, which are common in developed countries, are risk factors for this condition. In lower income countries, rheumatic heart disease is associated with a higher incidence of atrial fibrillation, though rates are decreasing worldwide due to access to antibiotics. A later stage treatment approach for atrial fibrillation is ablation, with the assistance of anesthesia.

 

The pathophysiology of atrial fibrillation involves rapid firing from a single focus in the atria that triggers a change in heart rate and rhythm. The most common location is from the pulmonary veins, which can be targeted with catheter ablation. Treatment is focused on prevention of future episodes in addition to prevention of thromboembolism. First line treatment for atrial fibrillation is rate or rhythm control with oral medications such as beta-blockers or amiodarone. Thromboembolism risk is reduced with a direct oral anticoagulant.

 

If patients continue to remain symptomatic with recurrent episodes of atrial fibrillation despite medication, ablation is a highly effective procedural technique that can be considered. It is associated with 70-75% of patients being symptom-free after 1 year with 4% risk of major complications like stroke, cardiac perforation, or damage to the surrounding structures, such as the esophagus and phrenic nerve [2]. Electrophysiology evaluation is used to determine the location of myocardial tissue which is most responsible for the repetitive firing. An electroanatomical map is made, creating a 3-D representation of the patient’s heart to determine where the physician will use radiofrequency energy, cryothermal energy, or laser balloon to ablate myocardial tissue [2].

 

Cardiac ablation is a technique that is highly dependent on the practicing physician, with variability in duration of the procedure and the type of ablative energy used. The anesthesia used for atrial fibrillation ablation is highly important as this procedure is associated with significant risks. Conscious sedation with fentanyl and midazolam used to be the most common technique until studies comparing conscious sedation against general anesthesia found lower rates of recurrence and pulmonary vein reconnection with general anesthesia [3]. New retrospective cohort studies comparing monitored anesthetic care (MAC) vs. general anesthesia (GA) demonstrated MAC was independently associated with shorter total laboratory time due to reducing non-procedure time with no significant changes in freedom from documented atrial fibrillation, atrial flutter, atrial tachycardia and no significant difference in complication rates [4,6].

 

Despite this evidence, in a 2021 retrospective review, researchers demonstrated GA was still the most common mode of sedation for 54,231 patients who underwent cardiac ablation in the U.S., with 94% of patients receiving general anesthesia and only 6% receiving monitored anesthetic care (MAC) [5]. Patients who received MAC were more likely to be >80 years old, female, and have American Society of Anesthesiologist physical status > III. MAC cases were mostly done in Northeast urban hospital centers.

 

Current literature demonstrates that MAC is a safe anesthetic option for atrial fibrillation ablation that is not currently used widely in the United States. Due to its benefits, including shorter time in the laboratory with equitable outcomes to general anesthesia, more anesthesiologists may choose to use MAC over GA in the future.

 

References 

 

  1. Lip GYH, Brechin CM, Lane DA. The global burden of atrial fibrillation and stroke: a systematic review of the epidemiology of atrial fibrillation in regions outside North America and Europe. Chest. 2012 Dec;142(6):1489-1498. doi: 10.1378/chest.11-2888. PMID: 22459778. 
  2. Oral H, Knight BP, Ozaydin M, Tada H, Chugh A, Hassan S, Scharf C, Lai SW, Greenstein R, Pelosi F Jr, Strickberger SA, Morady F. Clinical significance of early recurrences of atrial fibrillation after pulmonary vein isolation. J Am Coll Cardiol. 2002 Jul 3;40(1):100-4. doi: 10.1016/s0735-1097(02)01939-3. PMID: 12103262.
  3. Price A, Santucci P. Electrophysiology procedures: weighing the factors affecting choice of anesthesia. Semin Cardiothorac Vasc Anesth. 2013 Sep;17(3):203-11. doi: 10.1177/1089253213494023. Epub 2013 Jul 3. PMID: 23827944. 
  4. Dada RS, Hayanga JWA, Woods K, Schwartzman D, Thibault D, Ellison M, Schmidt S, Siddoway D, Badhwar V, Hayanga HK. Anesthetic Choice for Atrial Fibrillation Ablation: A National Anesthesia Clinical Outcomes Registry Analysis. J Cardiothorac Vasc Anesth. 2021 Jan 5:S1053-0770(20)31393-8. doi: 10.1053/j.jvca.2020.12.046. Epub ahead of print. PMID: 33518460. 
  5. Wasserlauf J, Knight BP, Li Z, et al. Moderate Sedation Reduces Lab Time Compared to General Anesthesia during Cryoballoon Ablation for AF Without Compromising Safety or Long-Term Efficacy. Pacing Clin Electrophysiol 2016; 39:1359. doi: 10.1111/pace.12961. Epub 2016 Nov 10. PMID: 27747896. 
  6. Kuck KH, Brugada J, Fürnkranz A, et al. Cryoballoon or Radiofrequency Ablation for Paroxysmal Atrial Fibrillation. N Engl J Med 2016; 374:2235. doi: 10.1056/NEJMoa1602014. Epub 2016 Apr 4. PMID: 27042964. 

 

ASA Recommendations on No Surprises Act Implementation

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On January 1st, 2022, the Biden administration’s “No Surprises Act” will be implemented in medical practices throughout America. The bill intends to protect patients from additional unanticipated medical bills following treatment while also establishing an independent dispute resolution for physicians to demand fair payment from health insurers. While the legislation is a promising step towards greater clarity on the financial component of healthcare, there remain some uncertainties about how this change will alter the ever-complicated relationship between physicians and health insurers. To this end, the American Society of Anesthesiologists (ASA) generated a list of recommendations for the implementation of the No Surprises Act.

The recommendations are included in an 11-page document addressed to the U.S. Department of Health and Human services, the U.S. Department of Labor, and the U.S. Department of Treasury, and are organized into five key categories: independent dispute resolution, qualifying payment amount and initial payment, patient engagement, interaction with state laws, and auditing. The ASA requests in particular that the process for independent dispute resolution be transparent by weighing all factors equally in the determination of payment and explicitly stating an intention to do so. According to the document, these factors include:

 

“the QPA, any additional information requested, the provider or facility’s level of training and experience, and the parties’ market shares, among other factors…We believe it is necessary for the Departments to be specific as to these considerations so the IDR process is standardized and does not vary significantly from one entity to the next. Even in the best of circumstances, these factors are subjective and will be assessed differently by each arbiter.”[1]

 

The list of recommendations also includes a demand for active commitment towards the reduction of biases in the settlement of payment disputes.

Moreover, the ASA requests that calculations of insurer’s median in-network amounts are done both accurately and fairly. The letter mentions the number of variables that can affect the cost of healthcare dramatically, including zip code, specialty, physician’s level of training, the frequency of payments, and several other factors. According to the ASA, the No Surprises Act does not specify its plans to determine median in-network amounts, and to not consider these factors would result in inaccurate payments and provide ample opportunity for healthcare insurers to underpay physicians.

One of the final notable components of the ASA’s requests is the demand that physicians be able to access the federal independent dispute resolution process. The ASA argues that in states where similar legislation to the No Surprises Act is already being implemented, the interaction between state and federal law would place too much strain on physicians. The letter states:

 

“We are concerned that the interaction of these federal and state frameworks will result in a patchwork scheme that creates tremendous uncertainty about which laws apply, placing the burden on parties to analyze which regulatory scheme they fall under. We believe this is asking too much of providers and patients. Providers’ primary concern is patient care and patients’ primary concern is obtaining the care needed to promote good health. We urge the Department to never lose sight of these important objectives.”1

 

While the No Surprises Act has the potential to change the landscape of healthcare payment for both patient and physician alike, there remains the need for increased clarity. The ASA’s recommendations offer an actionable template for equitable implementation.

References

[1] ASA Makes Recommendations to Biden Admin: Implement ‘No Surprises Act’ Equitably Without Improper Advantage to Health Insurers. (2021). Retrieved from https://www.asahq.org/about-asa/newsroom/news-releases/2021/06/asa-makes-recommendations-to-implement-no-surprises-act-equitably

 

Mosquito Modification to Control Mosquito-Borne Disease

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Mosquitos are a common vector for deadly diseases in humans, including malaria and dengue fever. Their capacity for disease transmission makes them dangerous to human populations, resulting in mosquitoes being responsible for millions of deaths per year (Ito et al. 2002). There have been substantial efforts to reduce mosquitos’ populations, from insecticide to removing pools of still water (Ito et al 2002). However, mosquito populations have persisted, and they have continued to spread disease. Insecticide resistance in mosquitoes makes controlling mosquito populations difficult, causing a need for alternative methods to reduce mosquito-borne disease transmission. Recent advances have led scientists to research the effectiveness of a modification that limits the ability of mosquito populations to get infected themselves, rather than limiting the spread of mosquitoes themselves.

 

Viral disease spread was significantly reduced in mosquito populations that were infected with Wolbachia pipientis (wMel), an inherited intracellular bacterium which infects many insects (Utarini et al. 2021). The wMel bacteria causes the mosquito to be less susceptible to dengue virus than non-modified mosquitoes. A previous study in 2013 showed wMel infected mosquitos were less likely to transmit dengue, however, the impact on human disease transmission was still unknown. In an Indonesian study, areas with wMel mosquito populations had reduced 77% of viral dengue cases, compared to areas with control populations (Utarini et al. 2021).

 

This study showed that modified mosquitoes can compete in natural environments. Additionally, the reduced vector capacity had tangible impacts on communities. The wMel versus non-modified population disparity in dengue cases shows how effective targeted infection of mosquitoes can be in controlling mosquito-borne diseases in human populations.

 

Similarly, control of parasitic diseases spread by mosquitoes have been hindered by an inability to control mosquito populations. Malaria, a disease caused by infection by Plasmodium parasites, has evaded many tools designed to limit its spread. New understanding of the gut’s role in the immune system has provided a new method to limit the transmission of malaria (Pike et al. 2017).

 

Researchers genetically modified mosquitoes create a peptide to inhibit Plasmodium development, specifically in the midgut. This genetic modification reduced the vector capacity of mosquitoes; however, it did not affect the overall fitness (Pike et al. 2017). Another study of genetically modified mosquitoes revealed the genetic modification is inheritable in mosquitoes and the resistance to the malaria parasite persisted through at least ten generations (Ito et al. 2002).

 

Genetic modification of mosquitoes can reduce transmission for diseases caused by mosquito-borne pathogens. This is important because genetic transmission can be effective in addressing a wide array of mosquito-borne diseases. While each situation would require specific knowledge of what genetic modification to create in the mosquitoes to limit disease control, this research is providing a new standard in how to control vector disease spread.

 

Genetic modification is a new method to address the significant issue of mosquito-borne diseases. It directly targets the vector capacity of mosquitoes, allowing for disease control at the source. Additionally, existing genetic modifications have been proven to be inheritable. This would allow the mosquito populations to naturally maintain resistance to known diseases. If genetic modification of mosquitoes becomes common practice, this would significantly lower the efforts needed to maintain a genetically modified mosquito population.

 

References

 

Ito, J., Ghosh, A., Moreira, L., et al. Transgenic anopheline mosquitoes impaired in transmission of a malaria parasite. Nature 417, 452–455 (2002). https://doi.org/10.1038/417452a

Pike, A., et al. “Changes in the Microbiota Cause Genetically Modified Anopheles to Spread in a Population.” Science, vol. 357, no. 6358, Sept. 2017, p. 1396, doi:10.1126/science.aak9691.

Utarini, A., et al. “Efficacy of Wolbachia-Infected Mosquito Deployments for the Control of Dengue.” New England Journal of Medicine, vol. 384, no. 23, Massachusetts Medical Society, June 2021, pp. 2177–86. doi:10.1056/NEJMoa2030243.