Ontario's protocol for deciding who gets critical care in ICUs, explained

Aerosol Scientists Try to Clear the Air About COVID-19 Transmission “We are basically doing what a public health agency should be doing.” Medical textbooks have descriptions of virus transmission that are not consistent with basic physics, said Jose-Luis Jimenez, an atmospheric chemist at the University of Colorado Boulder. The WHO says that big droplets of human exhalations are the primary mode of transmission for the virus. The agency calls them respiratory droplets and defines them as anything larger than 5 micrometers, about the size of a red blood cell. But WHO’s definition of respiratory droplets is wrong, said Jimenez. Cloud droplets are around 20 micrometers and they don’t fall to the ground, he said. That means that droplets of larger size could be airborne longer than the WHO acknowledges. https://eos.org/articles/aerosol-scientists-try-to-clear-the-air-about-covid-19-transmission https://www.sciencedirect.com/science/article/pii/S0160412020319942 https://www.scientificamerican.com/article/protecting-against-covids-aerosol-threat/ CFNU research summary on COVID-19 - Updated February 12, 2021.. The following document is an overview of the scientific evidence to-date as it relates to COVID-19 as well as an update on the international guidance on infection prevention and control of COVID-19. It does not purport to be a comprehensive list of all the research available. Our understanding of COVID-19 is changing daily in response to emerging science. https://nursesunions.ca/cfnu-research-summary-on-covid-19/ This research is provided for your information, but the CFNU cannot guarantee its accuracy or completeness, as the CFNU was not involved in reviewing or producing these resource materials. Guidance in Canada for health care professionals recommends wearing a surgical mask for routine care of suspected and confirmed COVID-19 patients. Airborne precautions – requiring the use of N-95 masks for respiratory protection – are only recommended for aerosol-generating medical procedures. What do we mean by droplet, contact and airborne transmission? According to the U.S. Centers for Disease Control and Prevention: Infections with respiratory viruses are principally transmitted through three modes: contact, droplet, and airborne. ________________________________________________ See also: 900+ COVID-19 patients in Ontario ICUs as more young people need critical care Ontario is coping with an rising number of COVID-19 patients in the province’s intensive care units, with more than 900 people requiring critical care. As Mike Le Couteur reports, more young people are needing critical care than ever before. https://globalnews.ca/video/7826931/900-covid-19-patients-in-ontario-icus-as-more-young-people-need-critical-care Ontario ‘very close’ to running out of ICU space, doctor says • Apr 16, 2021. https://youtu.be/vE4qImBTzMo Ontario's protocol for deciding who gets critical care in ICUs, explained • Apr 22, 2021 https://youtu.be/1hfc2iZE4d8 ---------------------------------------------- Contact transmission is infection spread through direct contact with an infectious person (e.g., touching during a handshake) or with an article or surface that has become contaminated. The latter is sometimes referred to as “fomite” transmission. Droplet transmission is infection spread through exposure to virus-containing respiratory droplets (i.e., larger and smaller droplets and particles [aerosols]) exhaled by an infectious person. Transmission is most likely to occur when someone is close to the infectious person, generally within about 6 feet. Airborne transmission is infection spread through exposure to those virus-containing respiratory droplets comprised of smaller droplets and particles that can remain suspended in the air over long distances (usually greater than 6 feet) and time (typically hours). Airborne transmission is an important way that infections like tuberculosis, measles, and chicken pox are spread. Aerosols are defined as “tiny particles or droplets suspended in air.” How COVID-19 Spreads? (updated by the CDC on October 5, 2020) Close-range transmission – COVID-19 can remain in the air in small droplets and particles (aerosols) and be ‘inhaled’: When people with COVID-19 cough, sneeze, sing, talk or breathe, they produce respiratory droplets. These droplets can range in size from larger droplets (some of which are visible) to smaller droplets. Small droplets can also form particles [aerosols] when they dry very quickly in the airstream. Infections occur mainly through exposure to respiratory droplets when a person is in close contact – within 6 feet or direct contact – with someone who has COVID-19. COVID-19 can spread when individuals are asymptomatic (never experience symptoms) or pre-symptomatic (prior to experiencing symptoms). According to Dr. Anthony Fauci, asymptomatic cases represent 40-45% of cases and are likely ‘key drivers of transmission’. Respiratory droplets cause infection when they are inhaled or deposited on mucous membranes, such as those that line the inside of the nose and mouth. As the respiratory droplets travel further from the person with COVID-19, the concentration of these droplets decreases. Larger droplets fall out of the air due to gravity. Smaller droplets and particles spread apart in the air. With passing time, the amount of infectious virus in respiratory droplets also decreases. How COVID-19 spreads (updated by the Public Health Agency of Canada on November 3, 2020): “SARS-CoV-2, the virus that causes COVID-19, spreads from an infected person to others through respiratory droplets and aerosols created when an infected person coughs, sneezes, sings, shouts, or talks. The droplets vary in size from large droplets that fall to the ground rapidly (within seconds or minutes) near the infected person, to smaller droplets, sometimes called aerosols, which linger in the air under some circumstances. The relative infectiousness of droplets of different sizes is not clear. Infectious droplets or aerosols may come into direct contact with the mucous membranes of another person’s nose, mouth or eyes, or they may be inhaled into their nose, mouth, airways and lungs.” Long-range transmission – COVID-19 in small droplets and particles can sometimes be ‘airborne’ (see definition above): Some infections can be spread by exposure to virus in small droplets and particles that can linger in the air for minutes to hours (>30 minutes to multiple hours). These viruses may be able to infect people who are further than 6 feet away from the infected person or after that person has left the space. Factors affecting the airborne spread of COVID-19 [further than 6-feet-away] according to the U.S. CDC include: a) enclosed spaces; b) Inadequate ventilation or air handling that allowed a build-up of suspended small respiratory droplets and particles; c) prolonged exposure to respiratory particles; d) infected person may have been breathing heavily; e) people who become infected in the same space at the same time with infected person or in the space shortly after the infected person departed. Under these circumstances, scientists believe that the amount of infectious smaller droplets and particles produced by the people with COVID-19 became concentrated enough to spread the virus to other people. Contact transmission – spread from touching surfaces is not thought to be a common way that COVID-19 spreads: Respiratory droplets can also land on surfaces and objects. It is possible that a person could get COVID-19 by touching a surface or object that has the virus on it and then touching their own mouth, nose, or eyes. From The Washington Post. Sun, L.; Guarino, B.“CDC says airborne transmission plays a role in coronavirus spread in a long-awaited update after a website error last month”, October 5, 2020 “Experts welcomed the CDC’s new guidance on airborne transmission – Linsey Marr, who studies aerosols at Virginia Tech and was an author of the Science letter: “I would like to emphasize that short-range airborne transmission when people are in close contact, meaning inhalation of aerosols, probably is more important than transmission by large droplets that are sprayed onto mucous membranes.” Source: U.S. CDC: How COVID-19 Spreads; SARS-CoV-2 and Potential Airborne Transmission. Why does the CFNU recommend the precautionary principle, and what is it? We are learning more and more about COVID-19 each day, and many of the assumptions we made about COVID-19 just a few months ago have been proven wrong. The U.S. CDC guidance now recognizes that COVID-19 may be spread at close range through respiratory droplets “when they are inhaled”, and that sometimes airborne transmission (which is the way measles, tuberculosis and chickenpox have spread) long-range transmission can occur under certain conditions. Guidance in Canada and the U.S. has also changed in favour of the public wearing homemade masks as we have discovered that asymptomatic and presymptomatic transmission account for a significant percentage of the spread of this novel coronavirus. In a nutshell, the precautionary principle, as applied to a novel, highly transmissable, virus such as this coronavirus, with a significant public health impact, requires governments and employers to begin with the highest level of protection, not the lowest, for health care workers, and then reduce the level of protection as the science emerges to justify this measure. Therefore, Canada must change its infection prevention and control guidance for health care professionals to recognize that the virus is being spread both through the inhalation of aerosolized particles at close range (less than 6 feet) and through long-range airborne transmission. In changing the guidance to recognize the risk of health care worker exposure to the aerosolized COVID-19 virus when infected patients/residents/clients breathe, talk, yell, sing, cough or sneeze, it must, at a minimum, mandate fit-tested NIOSH-approved N95 respirator masks or preferably better (i.e. elastomeric respirators, powered air-purifying respirators (PAPRs)) for those working in clinical areas considered aerosol-generating medical procedure area ‘hot zones’ (e.g., intensive care units (ICU), emergency rooms, operating rooms, post-anaesthetic care units and trauma centres) and for all workers caring for suspected or confirmed cases in designated COVID-19 units. The evidence The U.S. CDC’s recognition of both close-range inhalation of aerosolized particles and airborne transmission of the virus is based on months of evidence compiled by researchers around the world. While the PHAC has recognized close-range inhalation of aerosolized particles from both symptomatic and non-symptomatic individuals as a main route of transmission, unlike the U.S. CDC, it has failed to formally recognize long-range airborne transmission despite mounting evidence. From Occupational Health Clinics for Ontario Workers (OHCOW). Airborne Transmission: Risk and Control: Presentations by: Oudyk, J.; Hedges, K.; Marr, L.; Milton, D.; Smith, S.; Brosseau, L. Webinar topics include: “Ventilation and COVID-19”, “The role of infectious dose in COVID-19”, Selecting effective respiratory equipment for COVID-19”, “The role of droplets and aerosols in SARS CoV-2 transmission”, “Understanding and controlling SARS CoV-2 transmission”, and “Applying the hierarchy of controls in point-of-care risk assessments (PCRAs)”. From the Institut de recherche Robert-Sauvé en santé et en sécurité du travail (IRSST). Government of Quebec. “Respiratory Protection for Health Care Workers in the Context of SARS CoV-2 Transmission through Inhalation,” February 10, 2021 “The advice provided by international organizations is converging towards a model of COVID-19 transmission through inhalation of respiratory particles […]Medical masks are not respirators and do not protect workers from inhalable particles. Regardless of the level of protection of the medical mask (1, 2 or 3), even if the worker tries to adjust it properly, it is impossible to avoid leaks and to prevent inhalation of particles. […] To adequately protect healthcare workers, the IRSST recommends that respirators should be worn in areas where there is a risk of exposure to SARS-CoV-2.” From Nature. Editorial. “Coronavirus is in the air – there’s too much emphasis on surfaces,” February 2, 2021 “Now that it is agreed that the virus transmits through the air, in both large and small droplets, efforts to prevent spread should focus on improving ventilation or installing rigorously tested air purifiers. People must also be reminded to wear masks and maintain a safe distance. At the same time, agencies such as the WHO and the CDC need to update their guidance on the basis of current knowledge. Research on the virus and on COVID-19 moves quickly, so public-health agencies have a responsibility to present clear, up-to-date information that provides what people need to keep themselves and others safe.” From Journal of Hospital Infection. Tang, J. et al. “Dismantling myths on the airborne transmission of severe acute respiratory syndrome coronavirus (SARS CoV-2),” January 12, 2021 “This article gathers together and explores some of the most commonly held dogmas on airborne transmission in order to stimulate revision of the science in the light of current evidence. Six ‘myths’ are presented, explained, and ultimately refuted on the basis of recently published papers and expert opinion from previous work related to similar viruses. There is little doubt that SARS-CoV-2 is transmitted via a range of airborne particle sizes subject to all the usual ventilation parameters and human behaviour. Experts from specialties encompassing aerosol studies, ventilation, engineering, physics, virology and clinical medicine have joined together to present this review, in order to consolidate the evidence for airborne transmission mechanisms and offer justification for modern strategies for prevention and control of Covid-19 in healthcare and community.” From the Ontario Society of Professional Engineers. “Engineers call on Ontario to refocus efforts on airborne transmission of COVID-19,” January 12, 2021 “OSPE and its engineers believe there is a key piece to our defence against this virus that has not been properly addressed by the Ontario government – the need for proper ventilation and air filtration to stop the spread of the virus via infected aerosol particles in the air.” From the PHAC. “COVID-19: Guidance on indoor ventilation during the pandemic,” January 2021 “The virus causing COVID-19 is known to spread through droplets and aerosols, which represent a risk particularly to people who are in: enclosed spaces; indoor situations where people are in close proximity. The most important elements in reducing the risk of COVID-19 are preventive measures, such as: minimizing the number of persons in a place at the same time; maintaining a physical distance of at least 2 metres; using well-constructed, well-fitting masks; practising good hand and respiratory hygiene. In addition to these practices, adequate ventilation can contribute to reducing the risk of COVID-19 transmission in indoor settings.” From Masks4Canada.org. Signed by more than 363 physicians, scientists, occupational health and safety experts, engineers and nursing professionals.“Open letter to Dr. Theresa Tam, Minister Patty Hadju, Premiers and Medical Officers: There Is Still Time to Address Aerosol Transmission of COVID-19,” January 4, 2021 “We are deeply concerned by the recent increase in cases and hospitalizations across Canada. We urge to update the provincial COVID-19 guidelines workplace regulations and public communications to reflect the science – COVID-19 spreads through inhaled aerosols.” From International Journal of Infectious Disease. Hwang, S.E. et al. “Possible Aerosol Transmisison of COVID-19 Associated with an Outbreak in an Apartment in Seoul, South Korea, 2020,” December 17, 2020 Scientists have strongly implied the aerosol transmission of COVID-19; An outbreak occurred along two vertical lines in an apartment [building] in South Korea; The virus can be spread through the air duct by the (reverse) stack effect; Aerosol transmission indoors with insufficient ventilation need to be appreciated. From EurekAlert! TROPOS. “Corona pandemic could be better tackled by reducing aerosol transmission.” December 8, 2020 “Aerosols and their spread play an essential role in the transmission of COVID-19. However, the risk of transmission could be significantly reduced if more could be done to reduce indoor airborne viruses. The Working committee particulate matter (AAF) has therefore issued an statement with concrete recommendations. These include window ventilation, exhaust ventilation, air purification systems and CO2 measuring devices for indoor areas such as classrooms or transportation, and the increased use of N95 and FFP2 masks.” From Canadian Agency for Drugs and Technologies in Health (CADTH). Mr. William Dean, Dr. David Fisman, Dr. Jason Kindrachuk, Heather Logan. “CADTH COVID-19. Webinar – Community-Based Aerosol Transmission of COVID-19 and HVAC Systems.” December 3, 2020 “The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes COVID-19, spreads when an infected person breathes out, sneezes, coughs, or talks, thus putting virus-carrying liquid particles into the air where they can infect other people. Larger particles fall to the ground rapidly, while smaller particles, sometimes called aerosols, can linger in the air. Some infectious diseases — such as measles, tuberculosis, and influenza — are known to spread through heating, ventilation, and air conditioning (HVAC) systems, raising concern that the same may be true of COVID-19. In this webinar, a panel of experts will outline what is known about how COVID-19 is transmitted and discuss what the latest research shows about the potential role HVAC systems play in spreading or mitigating the risk of transmitting COVID-19.” From first10em.com. Morgenstern, J. “COVID-19 is spread by aerosols: an evidence review,” December 2, 2020 “The equally fallacious corollary to the Ro argument is that “if COVID-19 is transmitted through aerosols, we should see a lot of infections occurring over long distances”. Although it is true that aerosols will disperse much further than droplets, it is faulty logic to define the mode of transmission by the distance of transmission. The concentration of infectious particles falls dramatically with distance, even when those infectious particles are carried by aerosols. They are spread out through 3 dimensional space, and therefore decrease exponentially with distance. Although aerosols can transmit disease over long distances, they are much more likely to transmit disease over a short distance. (Chen 2020) This illogical step is so ingrained in the infectious diseases literature that most studies just assume droplet spread if there was close contact. This illogical assumption undermines a great deal of the existing infectious disease literature.” From the Canadian Institutes of Health Research. “CIHR: PHAC-CADTH-Best Brains Exchange – Transmission Routes for COVID-19: Implications for Public Health,” November 26, 2020 “All would agree that COVID-19 is transmitted by respiratory particles. That being said, a division exists among experts on defining the spectrum of respiratory particles, what is an aerosol, the degree of infectivity of the virus in aerosols, and what role aerosols may be playing in human-to-human transmission [….] if guidance is written based upon a model in which a given activity does not produce an aerosol, then measures put in place to mitigate transmission will reflect that model. However, if the model is shown to be incorrect and in fact aerosols are generated by that activity, and under certain circumstances are infectious, then the prevention advice will need to reflect the new model. Achieving an understanding of the nature of respiratory particles produced by humans and their potential to transmit COVID-19, is therefore fundamental to producing accurate guidance on transmission prevention.” From Scientific Reports. Nissen, K. et al. “Long-distance airborne dispersal of SARS CoV-2 in COVID-19 wards,” November 11, 2020 “…the apparent capability of the virus to be transported in air, as we present here, should raise concerns for the risk of infection in smaller, confined spaces in close proximity to contagious patients, i.e. all air in patients rooms, intensive care units, etc. during care for COVID-19 patients. This may be even more important concerning patients in earlier phases of disease, in which contagiousness may be high. This includes both symptomatic and asymptomatic SARS-CoV-2 infected persons in any confined space, such as homes, public transportation, restaurants, etc. The presented findings indicate airborne dissemination of SARS-CoV-2, especially considering the distance SARS-CoV-2 RNA was dispersed.” From the Public Health Agency of Canada (PHAC). “Emerging Evidence on COVID-19: Evidence Brief on SARS-CoV-2 Aerosol Transmission.” November 6, 2020 “Many experts maintain expelled respiratory particles containing infectious pathogens can occur in a continuum of sizes, and smaller respiratory particles (often termed aerosols) can remain suspended in air and disperse further distances than large respiratory droplets. It has been established that other pathogens that are transmitted through large droplets (e.g., Influenza, SARS-CoV-1, streptococcus pneumonia, and legionella) can also spread by aerosols in some settings and conditions. As such, virus particles in aerosols may play a role in SARS-CoV-2 infection transmission. This evidence brief summarizes studies providing evidence of potential aerosol transmission of SARS-CoV-2 published up to November 6, 2020.” From Environment International. Tang, S. et al. “Aerosol transmission of SARS CoV-2? Evidence, prevention and control,” November 2020 “Current evidence on SARS-CoV-2 has limitations, but is strongly indicative of aerosols as one of several routes of COVID-19 transmission. It should be noted that the equivalent evidence for contact and large droplet transmission is not available, but has been an unproven assumption from the outset.” From Lancet Respiratory Medicine. Editorial. “COVID-19 transmission up-in-the-air,” October 29, 2020 “As cases of COVID-19 increase globally, we need to more fully understand the transmission routes. It is crucial that we embrace new research and do not rely on recommendations based on old data so that clearer and more effective infection control guidance can be provided in the face of pandemic fatigue.” From National Academies of Sciences Engineering Medicine. “Airborne Transmission of SAR-CoV-2: Proceedings of a Workshop in Brief”, October 2020 Virtual Workshop held August 26-27, 2020 [all papers available] to address 4 critical questions: 1. What size aerosol particles and droplets are generated by people and how do they spread in air? 2. Which size aerosol particles and droplets are infectious and for how long? 3. What behavioral and environmental factors determine personal exposure to SARS-CoV-2? 4. What do we know about the relationship between infectious dose and disease for airborne SARS-CoV-2? From Science. Prather, K., Marr, L., Schooley, R.T., McDiarmid, M.A., Wilson, M.E., Milton, D.K. “Airborne Transmission of SARS-CoV-2″, October 16, 2020 “There is overwhelming evidence that inhalation of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) represents a major transmission route for coronavirus disease 2019 (COVID-19). Individuals with COVID-19, many of whom have no symptoms, release thousands of virus-laden aerosols and far fewer droplets when breathing and talking. Thus, one is far more likely to inhale aerosols than be sprayed by a droplet, and so the balance of attention must be shifted to protecting against airborne transmission. In addition to existing mandates of mask-wearing, social distancing, and hygiene efforts, we urge public health officials to add clear guidance about the importance of moving activities outdoors, improving indoor air using ventilation and filtration, and improving protection for high-risk workers.” From MedRxiv. Chen, P., Brobovitz, N., Premji, Z., Koopmans, M., Fisman, D.N., Gu, F.X. “Heterogenity in transmissibility and shedding SARS-CoV-2 via droplets and aerosols”, October 15, 2020 “Taken together, our findings provide a potential path forward for disease control. They highlight the disproportionate role of high-risk cases, settings and circumstances in propelling the COVID-19 pandemic. Since highly infectious cases, regardless of age or symptomatology, can rapidly shed SARS-CoV-2 via both droplets and aerosols, airborne spread should also be recognized as a transmission risk, including for superspreading. Strategies to abate infection should limit crowd numbers and duration of stay while reinforcing distancing and then widespread mask usage; well-ventilated settings can be recognized as lower risk venues.” From CBC News. Miller, A. “Canada still downplays risk of airborne spread of coronavirus despite WHO, CDC guidance”, October 10, 2020 “…infectious diseases specialist and medical microbiologist Dr. Raymond Tellier, who is also an associate medical professor at McGill University in Montreal, says that by acknowledging ventilation plays a role in curbing transmission of COVID-19, PHAC is admitting that aerosols are a significant route of transmission. That’s because ventilation does not change the risk of transmission via larger respiratory droplets or contact with contaminated surfaces. “If you promote avoiding a poorly ventilated indoor area, you implicitly admit that you accept aerosol transmission because the ventilation affects only aerosol transmission,” he said. “So if you are pushing ventilation, what are you talking about, if not aerosols?” From REA Project No. 16832 – Health Sciences Association of British Columbia. Murphy, J. “Update on Evidence for Aerosol Transmission of COVID-19 and Implications for Health Care Worker Respiratory Protection”, October 2, 2020 “Based on the emerging picture on the significance and potential dominance of aerosol transmission mode for COVID-19, and the substantial evidence of elevated risk among health care workers, it seems likely that near field aerosol transmission is happening in certain care setting interactions. Given the overall picture of the evidence on airborne transmission, it is likely that is occurring as a result of exposure to non-visible aerosols, and not “droplets” as wrongly conceived by the world’s major public health authorities.” From the Office of Chief Science Advisor. Government of Canada. “The role of bioaerosols and indoor ventilation in COVID-19 transmission,” September 28, 2020 “Close and prolonged contact is the most common route of SARS-CoV-2 transmission, which includes short-range inhalable particle transmission. While aerosol transmission over longer distances is possible, there are currently many unknowns about the conditions under which it could occur.” From International Journal of Infectious Diseases. Lednicky, J.A. et al. “Viable SARS-CoV-2 in the air of a hospital room with COVID-19 patients”, September 15, 2020 Highlights: Viable (infectious) SARS-CoV-2 was present in aerosols within the hospital room of COVID-19 patients. Airborne virus was detected in the absence of health-care aerosol-generating procedures. The virus strain detected in the aerosols matched the virus strain isolated from a patient with acute COVID-19. From Harvard Medical Grand Rounds. Fauci, A. “Video: COVID-19: Public Health and Scientific Challenges”, September 10, 2020 From CIDRAP. Van Beusekom, M. “Yet more data support COVID-19 aerosol transmission”, August 31, 2020 “Two studies published late last week in Clinical Infectious Diseases highlight the role of airborne spread of COVID-19 and the importance of efficient ventilation systems. One study found that patients can exhale millions of viral RNA particles per hour in the early stages of disease, and the second tied an outbreak affecting 81% of residents and 50% of healthcare workers at a Dutch nursing home to inadequate ventilation.” From Time Magazine. Jimenez, J-L. “COVID-19 is Transmitted Through Aerosols. We Have Enough Evidence. Now is the Time to Act”, August 25, 2020 “Droplets move ballistically—they fly like a cannonball from someone’s mouth and then travel through the air until they either hit something (worst case someone else’s eyes, mouth or nostrils) or fall to the ground. Aerosols on the other hand, act like smoke: after being expelled, they don’t fall to the ground, but rather disperse throughout the air, getting diluted by air currents, and being inhaled by others present in the same space. Contact tracing shows that, when it comes to COVID-19, being outdoors is 20 times safer than being indoors, which argues that aerosol transmission is much more important than droplets; outdoors, there’s plenty of air in which aerosols can become diluted; not so indoors.” From BMJ. Wilson, N. Editorials. “Airborne Transmission of COVID-19. Guidelines and governments must acknowledge the evidence and take steps to protect the public”, August 20, 2020 “In July, 239 scientists signed an open letter “appealing to the medical community and relevant national and international bodies to recognise the potential for airborne spread of covid-19.” Although the World Health Organization conceded that “airborne transmission cannot be ruled out,” the response was reserved and arguably mistaken in continuing to suggest that airborne and droplet transmission are discrete categories and that airborne transmission occurs only during medical “aerosol generating procedures.” From SSRN. Guenther, T. et al. “Investigation of a superspreading event preceding the largest meat processing plant-related SARS-Coronavirus 2 outbreak in Germany”, July 23, 2020 “Interpretation: Our results indicate climate conditions and airflow as factors that can promote efficient spread of SARS-CoV-2 via distances of more than 8 meters and provide insights into possible requirements for pandemic mitigation strategies in industrial workplace settings.” From The Lancet Respiratory Medicine. Fennelly, K.P. “Particle sizes of infectious aerosols: Implications for infection control“, July 24, 2020 “Studies of cough aerosols and of exhaled breath from patients with various respiratory infections have shown striking similarities in aerosol size distributions, with a predominance of pathogens in small particles (<5 μm). These are immediately respirable, suggesting the need for personal respiratory protection (respirators) for individuals in close proximity to patients with potentially virulent pathogens. There is no evidence that some pathogens are carried only in large droplets. Surgical masks might offer some respiratory protection from inhalation of infectious aerosols, but not as much as respirators [N95s]. However, surgical masks worn by patients reduce exposures to infectious aerosols to health-care workers and other individuals. The variability of infectious aerosol production, with some so-called super-emitters producing much higher amounts of infectious aerosol than most, might help to explain the epidemiology of super-spreading.” From medRxiv. Santarperia, J.L. et al. “The Infectious Nature of Patient-Generated SARS-CoV-2 Aerosol”, July 21, 2020 “Conclusion: Our results demonstrate that SARS-CoV-2 RNA exists in respired aerosols less than 5 µm in diameter; that aerosols containing SARS-CoV-2 RNA exist in particle modes that are produced during respiration, vocalization, and coughing; and that some fraction of the RNA-containing aerosols contain infectious virions. This study supports the use of efficient respiratory protection and airborne isolation precautions to protect from exposure to fine SARS-CoV-2 aerosol when interacting with infected individuals, regardless of symptoms or medical procedure being performed.” From McMaster University National Collaborating Centre for Methods and Tools. “COVID-19 Summary SARS-CoV-2 Virus Airborne Transmission”, Prepared for the Public Health Agency of Canada, July 10, 2020 (completed); July 24, 2020 (submitted) “Overview of the Evidence: Publications appearing in the emerging literature up to July 7, 2020 have informed this evidence brief. The available body of evidence is limited, largely theoretical, and does not specifically consider SARS-CoV-2 infectious dose or confirm the infectiousness of airborne particles. The theoretical and modeling evidence is of good quality. The available empirical and modeled evidence indicates there is some risk of SARS-CoV-2 virus laden aerosol and droplet dispersion at distances beyond two meters, while epidemiological evidence implicates airborne transmission of SARS-CoV-2 to have occurred in some indoor settings. Airborne infection transmission risks appear to be amplified in low temperature high humidity conditions, as well as in crowded and poorly ventilated areas where infected individuals may cough or speak loudly (i.e. sing, scream).” From MIT Technology Review. Patel, Neel V. “If the coronavirus is really airborne, we might be fighting it the wrong way”, July 11, 2020 “One of the biggest questions we still have about COVID-19 is how much of a viral load is needed to cause infection. The answer changes if we think it is aerosols that we need to worry about. Smaller particles won’t carry as large a viral load as bigger ones, but because they can linger in the air for much longer, it may not matter—they’ll build up in larger concentrations and get distributed more widely the longer an infected person is around to expel aerosolized virus. The more people you have coming in and out of an indoor space, the more likely it is that someone who is infected will show up. The longer those infected individuals spend in that space, the higher the concentration of virus in the air over time.” From Oxford Academic: Clinical Infectious Diseases. Morawska, L., Milton, D. and 237 scientists from 32 countries who support this Commentary. “It is Time to Address Airborne Transmission of COVID-19.”, July 6, 2020 “Studies by the signatories and other scientists have demonstrated beyond any reasonable doubt that viruses are released during exhalation, talking, and coughing in microdroplets small enough to remain aloft in air and pose a risk of exposure at distances beyond 1 to 2 m from an infected individual. […] It is understood that there is not as yet universal acceptance of airborne transmission of SARS-CoV2; but in our collective assessment there is more than enough supporting evidence so that the precautionary principle should apply. In order to control the pandemic, pending the availability of a vaccine, all routes of transmission must be interrupted. We are concerned that the lack of recognition of the risk of airborne transmission of COVID-19 and the lack of clear recommendations on the control measures against the airborne virus will have significant consequences: people may think that they are fully protected by adhering to the current recommendations, but in fact, additional airborne interventions are needed for further reduction of infection risk. […] The evidence is admittedly incomplete for all the steps in COVID-19 microdroplet transmission, but it is similarly incomplete for the large droplet and fomite modes of transmission. The airborne transmission mechanism operates in parallel with the large droplet and fomite routes, that are now the basis of guidance. We appeal to the medical community and to the relevant national and international bodies to recognize the potential for airborne spread of COVID-19. There is significant potential for inhalation exposure to viruses in microscopic respiratory droplets (microdroplets) at short to medium distances (up to several meters, or room scale), and we are advocating for the use of preventive measures to mitigate this route of airborne transmission.” From Atmosphere. Carducci, A. et al. “Covid-19 Airborne Transmission and Its Prevention: Waiting for Evidence or Applying the Precautionary Principle?” July 3, 2020 “Besides the predominant ways of transmission of SARS-CoV-2 (namely, contacts and large droplets) the airborne one is increasingly taken into consideration as a result of latest research findings. Nevertheless, this possibility has been already suggested by previous studies on other coronaviruses including SARS-CoV and MERS-CoV. To describe the state of the art of coronaviruses and airborne transmission, a systematic review was carried out using the PRISMA methodology. Overall, 64 papers were selected and classified into three main groups: laboratory experiments (12 papers), air monitoring (22) and epidemiological and airflow model studies (30). The airborne transmission of SARS-CoV-2 is suggested by the studies of the three groups, but none has yet obtained complete evidence. […] epidemiological investigations only hypothesize the airborne transmission as a possible explanation for some illness cases, but without estimating its attributable risk. Nevertheless, while waiting for more evidence, it is urgent to base advice on preventive measures, such as the use of masks, safe distancing and air ventilation, on the precautionary principle.” From Emerging Infectious Diseases Journal (Centers for Disease Control and Prevention). Fears, A.C. et al. “Persistence of severe acute respiratory syndrome coronavirus 2 in aerosol suspensions”, June 22, 2020 “We aerosolized severe acute respiratory syndrome coronavirus 2 and determined that its dynamic aerosol efficiency surpassed those for severe acute respiratory syndrome coronavirus and Middle East respiratory syndrome. Although we performed [the] experiment only once across severeral laboratories, our findings suggest retained infectivity and virion integrity for up to 16 hours in respirable-sized aerosols.” From Proceedings of the National Academy of Sciences of the United States of America. Zhang, R. et al. “Identifying airborne transmission as the dominant route for the spread of COVID-19”, June 11, 2020 “The inadequate knowledge on virus transmission has inevitably hindered development of effective mitigation policies and resulted in unstoppable propagation of the COVID-19 pandemic. In this work, we show that airborne transmission, particularly via nascent aerosols from human atomization, is highly virulent and represents the dominant route for the transmission of this disease.” From medRxiv. Evans, M. “Avoiding COVID-19: Aerosol Guidelines”, June 4, 2020 “The COVID-19 pandemic has brought into sharp focus the need to understand respiratory virus transmission mechanisms. In preparation for an anticipated influenza pandemic, a substantial body of literature has developed over the last few decades showing that the short-range aerosol route is an important, though often neglected transmission path. We develop a simple mathematical model for COVID-19 transmission via aerosols, apply it to known outbreaks, and present quantitative guidelines for ventilation and occupancy in the workplace.” From medRxiv. Santarpia, J.L. et al.”Aerosol and Surface Transmission Potential of SARS-CoV-2”, June 3, 2020 “During the initial isolation of 13 individuals with COVID-19 at the University of Nebraska Medical Center, we collected air and surface samples to examine viral shedding from isolated individuals. We detected viral contamination among all samples, indicating that SARS-CoV-2 may spread through both direct (droplet and person-to-person) as well as indirect mechanisms (contaminated objects and airborne transmission). Taken together, these finding support the use of airborne isolation precautions when caring for COVID-19 patients.” From medRxiv. Ma, J. et al. “Exhaled breath is a significant source of SARS-CoV-2 emission”, June 2, 2020 “Here, 35 COVID-19 subjects were recruited; exhaled breath condensate (EBC), air samples and surface swabs were collected and analyzed for SARS-CoV-2 using reverse transcription-polymerase chain reaction (RT-PCR). EBC samples had the highest positive rate (16.7%, n=30), followed by surface swabs (5.4%, n=242), and air samples (3.8%, n=26). COVID-19 patients were shown to exhale SARS-CoV-2 into the air at an estimated rate of 103-105 RNA copies/min; while toilet and floor surfaces represented two important SARS-CoV-2 reservoirs. Our results imply that airborne transmission of SARS-CoV-2 plays a major role in COVID-19 spread, especially during the early stages of the disease.” From Nature. Chia, P.Y. et al. “Detection of Air and Surface Contamination by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) in Hospital Rooms of Infected Patients”, May 29, 2020. “Understanding the particle size distribution in the air and patterns of environmental contamination of SARS-CoV-2 is essential for infection prevention policies. Here we screen surface and air samples from hospital rooms of COVID-19 patients for SARS-CoV-2 RNA. Environmental sampling is conducted in three airborne infection isolation rooms (AIIRs) in the ICU and 27 AIIRs in the general ward. 245 surface samples are collected. 56.7% of rooms have at least one environmental surface contaminated. High touch surface contamination is shown in ten (66.7%) out of 15 patients in the first week of illness, and three (20%) beyond the first week of illness (p=0.01, χ2 test). Air sampling is performed in three of the 27 AIIRs in the general ward, and detects SARS-CoV-2 PCR-positive particles of sizes >4µm and 1–4µm in two rooms, despite these rooms having 12 air changes per hour. This warrants further study of the airborne transmission potential of SARS-CoV-2.” Contact Us: Canadian Federation of Nurses Unions 2841 Riverside Drive Ottawa, ON K1V 8X7 Telephone: 613-526-4661 Toll Free: 1-800-321-9821 Fax: 613-526-1023 For media inquiries, please contact media@nursesunions.ca or call Ben René, communications officer, at: 613-406-5962. Lots more to read here: https://www.scientificamerican.com/article/protecting-against-covids-aerosol-threat/

Frequent neurocognitive deficits after recovery from mild COVID-19.

 

Frequent neurocognitive deficits after recovery from mild COVID-19.

Neuropsychiatric complications associated with coronavirus disease 2019 caused by the Coronavirus SARS-CoV-2 (COVID-19) are increasingly appreciated. While most studies have focussed on severely affected individuals during acute infection, it remains unclear whether mild COVID-19 results in neurocognitive deficits in young patients. Here, we established a screening approach to detect cognitive deficiencies in post-COVID-19 patients. In this cross-sectional study, we recruited 18 mostly young patients 20–105 days (median, 85 days) after recovery from mild to moderate disease who visited our outpatient clinic for post-COVID-19 care.

https://academic.oup.com/braincomms/article/2/2/fcaa205/5998660 The ‘third wave’: impending cognitive and functional decline in COVID-19 survivors https://youtu.be/55tIOhdzWdA https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7577658/ The landscape of cognitive function in recovered COVID-19 patients This study aims to evaluate the impacts of COVID-19 on cognitive functions in recovered patients and its relationship with inflammatory profiles. Twenty-nine patients recovered from COVID-19 as confirmed by negative nucleic tests for two consecutive times were recruited. A total of 29 age-, gender- and education-matched healthy controls were also recruited. The cognitive functions of all subjects were evaluated by the iPad-based online neuropsychological tests, including the Trail Making Test (TMT), Sign Coding Test (SCT), Continuous Performance Test (CPT), and Digital Span Test (DST). Blood samples from all patients were collected for examining inflammatory profiles, including interleukin-2 (IL-2), IL-4, IL-6, IL-10, tumor necrosis factor-α (TNF-α), interferon-γ (IFN-γ), and C-reactive protein (CRP). The relationship between cognitive functions and inflammatory profiles were analyzed by Pearson correlation. In results, although no significant differences were found in TMT, SCT, and DST between the two groups, patients with COVID-19 scored lower in the correct number of the second and third parts of CPT, they also scored higher in the missing number of the third part of CPT (all P < 0.05). In patients with COVID-19, there was a trend of significant difference for lower reaction time in the first and second parts of CPT (P = 0.050, and 0.051, respectively), as well as the lower correct number of the second part of CPT (P = 0.050). Correlation analysis showed that the reaction time for the first and second parts of CPT was positively correlated with the CRP levels (r = 0.557 and 0.410, P < 0.05). In conclusion, our findings indicated that cognitive impairments exist even in patients recovered from COVID-19, and might be possibly linked to the underlying inflammatory processes. Keywords: COVID-19, Cognitive function, Inflammation, CRP https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7324344/ Brain Damage And Hallucinations Associated With Even Mild Covid-19 Coronavirus Infection A new study has warned that potentially deadly brain disorders may be a symptom of Covid-19, even in people with otherwise mild disease. The research published today in the journal Brain, looked at 40 adult patients with Covid-19 in the U.K., finding that they showed symptoms of a wide range of serious brain diseases. Many of the patients had only mild typical Covid-19 symptoms such as fever or respiratory issues and for some, their neurological symptoms were the only sign they were sick. One 55-year old woman with no known current or historical mental illness was admitted to hospital with recognized Covid-19 symptoms including fever, cough and muscle aches. She was discharged after two weeks, having been treated with oxygen, but four days later her husband reported she was confused and behaving strangely. She then experienced hallucinations, reporting seeing lions and monkeys in her house, and became delusional and aggressive with her family and hospital staff. She was treated with anti-psychotic medication and her symptoms improved over the course of three weeks, although the study does not confirm whether she made a full recovery. Other neurological issues experienced by the Covid-19 patients, who ranged in age from 16-85, included more cases of delirium or psychosis, strokes and problems with peripheral nerves found in extremities like hands and feet. WHAT DOES THAT MEAN FOR THE NUMBER PEOPLE LISTED AS RECOVERED? https://www.forbes.com/sites/victoriaforster/2020/07/08/brain-damage-and-hallucinations-associated-with-even-mild-covid-19-coronavirus-infection/?sh=70901bc16d91 Kids' COVID cases on the rise, but most are mild, new data show While the proportion of COVID-19 cases in children has tripled or quadrupled since the start of the pandemic, it remains below their proportion of the US population, and hospitalizations and deaths are uncommon—although racial minorities and those with public insurance and underlying conditions appear to be at higher risk for serious outcomes, according to two new studies. Case growth rate by region, month In the first study, published late last week in Pediatrics, researchers from the American Academy of Pediatrics and the Children's Hospital Association analyzed COVID-19 case data from the websites of 49 state health departments that report cases by age, as well as from two cities and two territories, starting Apr 16. https://www.cidrap.umn.edu/news-perspective/2020/11/kids-covid-cases-rise-most-are-mild-new-data-show CDC: Most Kids Dying From Coronavirus Had Underlying Conditions — Enormous racial-ethnic disparities revealed as well https://www.medpagetoday.com/infectiousdisease/covid19/88630 COVID-19 in children with underlying chronic respiratory diseases: survey results from 174 centres. https://openres.ersjournals.com/content/6/4/00409-2020 https://www.health.harvard.edu/diseases-and-conditions/coronavirus-outbreak-and-kids https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html COVID-19 guidance for schools Kindergarten to Grade 12 https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/health-professionals/guidance-schools-childcare-programs.html Coronavirus disease (COVID-19): Prevention and risks https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/prevention-risks.html Coronavirus disease (COVID-19): Schools https://www.who.int/news-room/q-a-detail/coronavirus-disease-covid-19-schools#:~:text=Current%20evidence%20suggests%20that%20people,information%20is%20still%20needed. Coronavirus digest: British variant more dangerous for children Germany has warned the British variant spreading through Europe is more dangerous. Meanwhile, Hong Kong has suspended administering the BioNTech-Pfizer vaccine over a packaging issue. Follow DW for the latest. https://www.dw.com/en/coronavirus-digest-british-variant-more-dangerous-for-children/a-56966798 Merkel says British coronavirus variant more dangerous to children BERLIN (Reuters) - A variant of the coronavirus first detected in Britain, and now spreading in Germany, is more dangerous to young people, Chancellor Angela Merkel said on Wednesday. “The British mutant, and this is the difference with the spring, is proven to be more dangerous in children and young people so we need to put the protection of schools more front and centre than with the original virus,” she told lawmakers. https://www.reuters.com/article/uk-health-coronavirus-germany-merkel-idUKKBN2BG20J https://www.theguardian.com/world/2021/mar/23/merkel-germany-covid-british-variant-easter-lockdown Merkel says British variant more dangerous to children – latest updates https://www.trtworld.com/life/merkel-says-british-variant-more-dangerous-to-children-latest-updates-45266 https://www.npr.org/sections/coronavirus-live-updates/2021/02/11/966823691/germanys-merkel-warns-coronavirus-variants-could-destroy-gains-against-pandemic https://www.tribuneindia.com/news/world/merkel-says-british-coronavirus-variant-more-dangerous-to-children-229901 https://www.mayoclinic.org/diseases-conditions/coronavirus/in-depth/coronavirus-in-babies-and-children/art-20484405 Toddler with pre-existing conditions becomes youngest person in B.C. to die of COVID-19 B.C.’s top doctor says a two-year-old child has died as a result of COVID-19, becoming the youngest person in the province to die of the disease. Provincial health officer Dr. Bonnie Henry said the child lived in the Fraser Health region and was receiving care at BC Children’s Hospital in Vancouver. https://globalnews.ca/news/7771954/bc-2-year-old-dies-covid-19/ 2020: Patients with underlying conditions were 12 times as likely to die of covid-19 as otherwise healthy people, CDC finds People with underlying medical conditions such as heart disease and diabetes were hospitalized six times as often as otherwise healthy individuals infected with the novel coronavirus during the first four months of the pandemic, and they died 12 times as often, according to a federal health report Monday. https://www.washingtonpost.com/health/2020/06/15/patients-with-underlying-conditions-were-12-times-more-likely-die-covid-19-than-otherwise-healthy-people-cdc-finds/ Updated Mar. 29, 2021: Underlying Medical Conditions Associated with High Risk for Severe COVID-19: Information for Healthcare Providers. Purpose: This webpage provides an evidence-based resource for healthcare providers caring for patients with underlying medical conditions who are at higher risk of developing severe outcomes of COVID-19. Severe outcomes are defined as hospitalization, admission to the intensive care unit (ICU), intubation or mechanical ventilation, or death. This page summarizes data from preprinted and published studies that were included in a literature review conducted by subject-matter experts. The summary of information reflects current evidence regarding underlying medical conditions and is intended to help healthcare providers make informed decisions about patient care and increasing the awareness of risk among their patients. This page is distinct from the People with Certain Medical Conditions webpage which is intended for the general public. https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-care/underlyingconditions.html COVID-19 cases, new syndrome on the rise among children, especially Latino children https://calmatters.org/health/coronavirus/2021/01/covid-new-syndrome-children/ https://www.businessinsider.com/majority-kids-died-covid-19-children-of-color-2021-2 https://www.npr.org/sections/coronavirus-live-updates/2020/09/16/913365560/the-majority-of-children-who-die-from-covid-19-are-children-of-color https://services.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/children-and-covid-19-state-level-data-report/ https://www.aappublications.org/news/2020/12/29/covid-2million-children-122920 The most terrifying thing': Some Covid-19 patients are suffering severe psychosis 'There's something happening' As Belluck explains, while the virus that causes Covid-19 was initially considered primarily a respiratory disease, more and more patients are reporting a host of other symptoms, including neurological, cognitive, and psychological effects. And among these cases is a small but growing number of patients who are experiencing severe "post-Covid psychosis," providers say. For example, a patient named Ivan Agerton—a 49-year-old documentary photographer living in Seattle, who had no personal or family history of mental illness—began experiencing crippling paranoia and auditory hallucinations weeks after recovering from a mild case of Covid-19. He believed that his neighbors were spying on his family and that police were tracking his movements. "Like a light switch—it happened this fast—this intense paranoia hit me," Agerton said. "It was really single-handedly the most terrifying thing I've ever experienced in my life." In another case, Hisam Goueli, a psychiatrist, helped treat a physical therapist in her early 40s who sought help at South Oaks Hospital in New York after she started to hear a voice telling her to kill herself and harm her children. The woman, who had never experienced psychiatric symptoms before, said the symptoms started just months after recovering from a mild case of Covid-19. Goueli said he was initially unsure whether her case was Covid-related. "But then," he said, "we saw a second case, a third case and a fourth case, and we're like, 'There's something happening.'" Indeed, while the overall number of these cases remains low—and experts expect the cases to remain rare—the reports aren't merely anecdotal, Belluck reports. A British study of neurological and psychiatric symptoms among 153 Covid-19 patients found that 10 study participants presented with "new-onset psychosis." Similarly, another study identified 10 such patients at a hospital in Spain. Much about the condition remains a mystery, experts say While experts don't think this trend is unique to Covid-19—psychotic episodes have sporadically occurred amid other viruses, including the 1918 flu and the SARS and MERS coronaviruses—they note that much about post-Covid psychosis remains a mystery, Belluck writes. Cheat sheet: Tele-behavioral health Currently, experts hypothesize that this condition may be associated with how the immune system responds to the virus, including vascular issues or inflammation. "Some of the neurotoxins that are reactions to immune activation can go to the brain, through the blood-brain barrier, and can induce this damage," said Vilma Gabbay, a co-director of the Psychiatry Research Institute at Montefiore Einstein, who has treated two patients with post-Covid psychosis. As Robert Yolken, a neurovirology expert at Johns Hopkins University School of Medicine, explained, the immune systems of some patients who've physically recovered from Covid-19 remain activated because of "delayed clearance of a small amount of virus." And that continuing activation of the immune system, according to Emily Severance, an expert in schizophrenia at Johns Hopkins, is currently the leading hypothesis into other brain-related symptoms of Covid-19, such as brain fog and memory loss. It's reasonable to think that post-Covid psychosis may stem from "something similar happening in the brain," she said. In fact, the variety of symptoms may depend on what part of the brain is affected by the ongoing immune response, Yolken said. He noted that "some people have neurological symptoms, some people psychiatric and many people have a combination." A different expression of psychosis—and an ambiguous recovery According to experts, the experience of psychosis among Covid-19 patients seems to differ significantly from how psychosis typically presents. Webinar series: 'Stay Up to Date' on the latest with Covid-19 For instance, while paranoid delusions typically accompany schizophrenia during late adolescence or dementia in elder adults, post-Covid-19 psychosis so far seems to primarily affect patients in their 30s, 40s, and 50s. "It's very rare for you to develop this type of psychosis in this age range," Goueli said. In addition, while most people experiencing psychosis generally "don't have insight into their symptoms," several patients with post-Covid psychosis were aware that something was off, according to Veronika Zantop, a psychiatrist who helped treat Agerton. There's also little consistency in symptoms among those affected by post-Covid-19 psychosis, Belluck writes, although several patients reported experiencing only mild Covid-19. For example, some patients experiencing post-Covid-19 psychosis feel urges to hurt themselves or others, much like Goueli's patient, while others—such as Agerton—experience deep paranoia rather than any violent impulses. Moreover, while some patients require weeks of hospitalization to identify the right medications, others improve relatively quickly. Goueli's patient, for instance, was hospitalized for four weeks before doctors found a regimen of medicine that alleviated her symptoms and enabled her to return home. She's currently "95% perfect," Goueli said. And while some patients seem to experience just a one-off episode, others struggle with relapses. For his part, Agerton was hospitalized in a psychiatric ward twice for his psychosis. While he's now returned home and says he's improving, he's still not 100%. "There's this fear of how long is this going to happen," he said. "How long am I going to live with this?" Ultimately, however, experts hope that studying these individual cases and larger pieces of research can shed light on what remains a challenging and difficult situation. "We don't know what the natural course of this is," Goueli said. "There are just so many unanswered questions" (Belluck, New York Times, 12/28/2020; Belluck, New York Times, 3/22). How Covid-19 will impact behavioral health services Highest-priority behavioral health moves amid Covid-19 crisis strategy The Covid-19 pandemic is rapidly increasing the need for behavioral health services. But there are significant gaps and barriers that stand in the way of people getting the help they need. Download our take to learn how health systems can prioritize addressing the immediate needs of both staff and patients, especially those with preexisting behavioral health needs or comorbid conditions. https://www.advisory.com/en/daily-briefing/2021/03/26/covid-psychosis

What Causes Schizophrenia?

https://www.webmd.com/schizophrenia/what-causes-schizophrenia

Causes - Schizophrenia

The exact causes of schizophrenia are unknown. Research suggests a combination of physical, genetic, psychological and environmental factors can make a person more likely to develop the condition.

Some people may be prone to schizophrenia, and a stressful or emotional life event might trigger a psychotic episode. However, it's not known why some people develop symptoms while others do not.

Want to know more?

https://www.nhs.uk/mental-health/conditions/schizophrenia/causes/

The COVID-19 Virus May Have Been in Humans For Years, Study Suggests

The study raises some interesting possibilities regarding the origin of the new coronavirus. One of the scenarios suggests the virus may have been circulating harmlessly in human populations for quite a while before it became the pandemic that's now stopped the world in its tracks.

"It is possible that a progenitor of SARS-CoV-2 jumped into humans, acquiring [new genomic features] through adaptation during undetected human-to-human transmission," the team from the US, UK and Australia writes in the study.

"Once acquired, these adaptations would enable the pandemic to take off and produce a sufficiently large cluster of cases."

The researchers analysed genomic data available from SARS-CoV-2 and other similar coronaviruses, showing that the receptor-binding domain (RBD) sections of SARS-CoV-2 spike proteins were so effective at binding to human cells, they had to be caused by natural selection.

"By comparing the available genome sequence data for known coronavirus strains, we can firmly determine that SARS-CoV-2 originated through natural processes," said one of the researchers, immunologist Kristian Andersen at Scripps Research.

"Two features of the virus, the mutations in the RBD portion of the spike protein and its distinct backbone, rules out laboratory manipulation as a potential origin for SARS-CoV-2."

https://www.sciencealert.com/the-new-coronavirus-could-have-been-percolating-innocently-in-humans-for-years

The chronic neuropsychiatric sequelae of COVID‐19: The need for a prospective study of viral impact on brain functioning.. Physicians treating people hospitalized with COVID-19 report that a large number experience delirium, and that the condition disproportionately affects older adults. An April 2020 study in Strasbourg, France, found that 65% of people who were severely ill with coronavirus had acute confusion — a symptom of delirium1. Data presented last month at the annual meeting of the American College of Chest Physicians by scientists at the Vanderbilt University Medical Center in Nashville, Tennessee, showed that 55% of the 2,000 people they tracked who were treated for COVID-19 in intensive-care units (ICUs) around the world had developed delirium. These numbers are much higher than doctors are used to: usually, about one-third of people who are critically ill develop delirium, according to a 2015 meta-analysis2 (see ‘How common is delirium?’). Physicians treating people hospitalized with COVID-19 report that a large number experience delirium, and that the condition disproportionately affects older adults. An April 2020 study in Strasbourg, France, found that 65% of people who were severely ill with coronavirus had acute confusion — a symptom of delirium1. Data presented last month at the annual meeting of the American College of Chest Physicians by scientists at the Vanderbilt University Medical Center in Nashville, Tennessee, showed that 55% of the 2,000 people they tracked who were treated for COVID-19 in intensive-care units (ICUs) around the world had developed delirium. These numbers are much higher than doctors are used to: usually, about one-third of people who are critically ill develop delirium, according to a 2015 meta-analysis2 (see ‘How common is delirium?’). https://www.nature.com/articles/d41586-020-03360-8 https://content.iospress.com/articles/journal-of-alzheimers-disease/jad200589 https://www.news-medical.net/news/20201022/Recovered-COVID-19-patients-exhibit-cognitive-deficits.aspx COVID-19 cognitive deficits after respiratory assistance in the subacute phase: A COVID-rehabilitation unit experience Introduction COVID-19 complications can include neurological, psychiatric, psychological, and psychosocial impairments. Little is known on the consequences of SARS-COV-2 on cognitive functions of patients in the sub-acute phase of the disease. We aimed to investigate the impact of COVID-19 on cognitive functions of patients admitted to the COVID-19 Rehabilitation Unit of the San Raffaele Hospital (Milan, Italy). Material and methods 87 patients admitted to the COVID-19 Rehabilitation Unit from March 27th to June 20th 2020 were included. Patients underwent Mini Mental State Evaluation (MMSE), Montreal Cognitive Assessment (MoCA), Hamilton Rating Scale for Depression, and Functional Independence Measure (FIM). Data were divided in 4 groups according to the respiratory assistance in the acute phase: Group1 (orotracheal intubation), Group2 (non-invasive ventilation using Biphasic Positive Airway Pressure), Group3 (Venturi Masks), Group4 (no oxygen therapy). Follow-ups were performed at one month after home-discharge. Results Out of the 87 patients (62 Male, mean age 67.23 ± 12.89 years), 80% had neuropsychological deficits (MoCA and MMSE) and 40% showed mild-to-moderate depression. Group1 had higher scores than Group3 for visuospatial/executive functions (p = 0.016), naming (p = 0.024), short- and long-term memory (p = 0.010, p = 0.005), abstraction (p = 0.024), and orientation (p = 0.034). Group1 was younger than Groups2 and 3. Cognitive impairments correlated with patients’ age. Only 18 patients presented with anosmia. Their data did not differ from the other patients. FIM (<100) did not differ between groups. Patients partly recovered at one-month follow-up and 43% showed signs of post-traumatic stress disorder. Conclusion Patients with severe functional impairments had important cognitive and emotional deficits which might have been influenced by the choice of ventilatory therapy, but mostly appeared to be related to aging, independently of FIM scores. These findings should be integrated for correct neuropsychiatric assistance of COVID-19 patients in the subacute phase of the disease, and show the need for long-term psychological support and treatment of post-COVID-19 patients. Read more here: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0246590 There is one inevitable conclusion from these studies: COVID infection frequently leads to brain damage — particularly in those over 70. While sometimes the brain damage is obvious and leads to major cognitive impairment, more frequently the damage is mild, leading to difficulties with sustained attention. https://www.health.harvard.edu/blog/the-hidden-long-term-cognitive-effects-of-covid-2020100821133#:~:text=There%20is%20one%20inevitable%20conclusion,to%20difficulties%20with%20sustained%20attention. Coronavirus Resource Center. COVID-19 survivors face a sharply elevated risk of developing psychiatric or neurologic disorders in the six months after they contract the virus — a danger that mounts with symptom severity, new research shows. https://www.medscape.com/viewarticle/948882 One-Third of COVID-19 Survivors Develop a Brain Disorder. Large study finds psychiatric, neurological illnesses common within 6 months after infection As many as 1 in 3 COVID-19 survivors experience a mental health or neurological disorder within six months of a coronavirus infection, according to a large study published this week in The Lancet Psychiatry. These latest findings add to a growing body of evidence that show COVID-19 can have serious and potentially long-lasting effects on the brain. Researchers analyzed data from more than 236,000 patients diagnosed with COVID-19 and found that about 34 percent were diagnosed with a neurological or mental health disorder following their bout with the coronavirus. For nearly 13 percent of these patients, it was their first time receiving such a diagnosis. https://www.aarp.org/health/conditions-treatments/info-2021/brain-disorders-in-covid-survivors.html COVID-19: 1 in 3 diagnosed with brain or mental health condition A study suggests that in the United States in 2020, around a third of COVID-19 survivors were diagnosed with a neurological or mental health condition within 6 months of their COVID-19 diagnoses. Anxiety and mood disorders were the most common diagnoses. Neurological conditions, such as stroke and dementia, occurred less often but were more common among people with severe COVID-19. The overall effect of these disorders, many of which are chronic, may be substantial for health and social care systems due to the scale of the pandemic. https://www.medicalnewstoday.com/articles/covid-19-1-in-3-diagnosed-with-brain-or-mental-health-condition How COVID-19 can damage the brain Some people who become ill with the coronavirus develop neurological symptoms. Scientists are struggling to understand why. https://www.nature.com/articles/d41586-020-02599-5 The hidden long-term cognitive effects of COVID-19 https://www.health.harvard.edu/blog/the-hidden-long-term-cognitive-effects-of-covid-2020100821133 COVID-19’s Effects on the Brain. Autopsy studies have yet to find clear evidence of destructive viral invasion into patients’ brains, pushing researchers to consider alternative explanations of how SARS-CoV-2 causes neurological symptoms. When epidemics and pandemics washed over humanity through the ages, watchful doctors noticed that in addition to the usual, mostly respiratory ailments, the illnesses also seemed to trigger neurological symptoms. One British throat specialist observed in the late 1800s that influenza appeared to “run up and down the nervous keyboard stirring up disorder and pain in different parts of the body with what almost seems malicious caprice.” Indeed, some patients during the 1889–92 influenza pandemic reportedly became afflicted with psychoses, paranoia, stabbing pains, and nerve damage. Similarly, scholars have linked the 1918 flu pandemic to parkinsonism, neuropsychiatric disorders, and a broadly coinciding outbreak of the “sleeping sickness” encephalitis lethargica, which would often arrest patients in a coma-like state—although researchers still debate whether the two are causally connected. That SARS-CoV-2, the culprit of the COVID-19 pandemic, is also associated with neurological symptoms isn’t entirely surprising, given some evidence that its close relatives, MERS-CoV and SARS-CoV-1, have been associated with neurological symptoms too. But the proportion of patients developing such symptoms—and their mounting collective numbers—has startled some scientists. When the news broke early last year that some 36 percent of COVID-19 patients in Wuhan hospitals were developing impaired consciousness, seizures, sensory impairments, and other neurological symptoms, “that floored me,” remarks Shibani Mukerji, a neuroinfectious disease specialist at Massachusetts General Hospital. https://www.the-scientist.com/news-opinion/covid-19s-effects-on-the-brain-68369 How Covid-19 can damage the brain. For Julie Helms, it started with a handful of patients admitted to her intensive care unit at Strasbourg University Hospital in northeast France in early March 2020. Within days, every single patient in the ICU had Covid-19 – and it was not just their breathing difficulties that alarmed her. “They were extremely agitated, and many had neurological problems – mainly confusion and delirium,” she says. “We are used to having some patients in the ICU who are agitated and require sedation, but this was completely abnormal. It has been very scary, especially because many of the people we treated were very young – many in their 30s and 40s, even an 18-year-old.” Helms and her colleagues published a small study in the New England Journal of Medicine documenting the neurological symptoms in their Covid-19 patients, ranging from cognitive difficulties to confusion. All are signs of “encephalopathy” (the general term for damage to the brain) – a trend that researchers in Wuhan had noticed in coronavirus patients there in February. https://www.bbc.com/future/article/20200622-the-long-term-effects-of-covid-19-infection https://www.hopkinsmedicine.org/health/conditions-and-diseases/coronavirus/how-does-coronavirus-affect-the-brain How COVID-19 attacks the brain Researchers are scrambling to understand just how COVID-19 impacts the brain and what scientists can do to prevent long-term damage https://www.apa.org/monitor/2020/11/attacks-brain Taking a Closer Look at COVID-19’s Effects on the Brain While primarily a respiratory disease, COVID-19 can also lead to neurological problems. The first of these symptoms might be the loss of smell and taste, while some people also may later battle headaches, debilitating fatigue, and trouble thinking clearly, sometimes referred to as “brain fog.” All of these symptoms have researchers wondering how exactly the coronavirus that causes COVID-19, SARS-CoV-2, affects the human brain. In search of clues, researchers at NIH’s National Institute of Neurological Disorders and Stroke (NINDS) have now conducted the first in-depth examinations of human brain tissue samples from people who died after contracting COVID-19. Their findings, published in the New England Journal of Medicine, suggest that COVID-19’s many neurological symptoms are likely explained by the body’s widespread inflammatory response to infection and associated blood vessel injury—not by infection of the brain tissue itself [1]. The NIH team, led by Avindra Nath, used a high-powered magnetic resonance imaging (MRI) scanner (up to 10 times as sensitive as a typical MRI) to examine postmortem brain tissue from 19 patients. They ranged in age from 5 to 73, and some had preexisting conditions, such as diabetes, obesity, and cardiovascular disease. The team focused on the brain’s olfactory bulb that controls our ability to smell and the brainstem, which regulates breathing and heart rate. Based on earlier evidence, both areas are thought to be highly susceptible to COVID-19. Indeed, the MRI images revealed in both regions an unusual number of bright spots, a sign of inflammation. They also showed dark spots, which indicate bleeding. A closer look at the bright spots showed that tiny blood vessels in those areas were thinner than normal and, in some cases, leaked blood proteins into the brain. This leakage appeared to trigger an immune reaction that included T cells from the blood and the brain’s scavenging microglia. The dark spots showed a different pattern, with leaky vessels and clots but no evidence of an immune reaction. https://directorsblog.nih.gov/2021/01/14/taking-a-closer-look-at-the-effects-of-covid-19-on-the-brain/ COVID-19 and the brain: What do we know so far? What do we currently know about the effects of SARS-CoV-2 on the brain? In this feature, we round up the emerging evidence. https://www.medicalnewstoday.com/articles/how-does-sars-cov-2-affect-the-brain How COVID-19 Affects the Brain COVID-19 has resulted in more than 120 million cases and 2.6 million deaths to date. Respiratory and gastrointestinal symptoms are accompanied by short- and long-term neuropsychiatric symptoms (NPs) and long-term brain sequelae. Some patients present with anosmia, cognitive and attention deficits (ie, brain fog), new-onset anxiety, depression, psychosis, seizures, and even suicidal behavior.1,2 These present before, during, and after respiratory symptoms and are unrelated to respiratory insufficiency,1 suggesting independent brain damage. Follow-ups conducted in Germany and the United Kingdom found post–COVID-19 NPs in 20% to 70% of patients, even in young adults, and lasting months after respiratory symptoms resolved,1 suggesting brain involvement persists. Entering through angiotensin-converting enzyme 2 receptors,2 SARS-CoV-2 can damage endothelial cells leading to inflammation, thrombi, and brain damage. Moreover, systemic inflammation leads to decreased monoamines and trophic factors and activation of microglia, resulting in increased glutamate and N-methyl-d-aspartate (NMDA)3 and excitotoxicity (Figure). These insults induce new-onset or re-exacerbation of preexisting NPs. https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2778090 https://www.npr.org/sections/health-shots/2021/01/05/953705563/how-covid-19-attacks-the-brain-and-may-cause-lasting-damage https://www.kff.org/coronavirus-covid-19/issue-brief/the-implications-of-covid-19-for-mental-health-and-substance-use/#:~:text=In%20addition%20to%20increased%20anxiety,associated%20with%20increases%20in%20suicides. ‘I Feel Like I Have Dementia’: Brain Fog Plagues Covid Survivors The condition is affecting thousands of patients, impeding their ability to work and function in daily life. https://www.nytimes.com/2020/10/11/health/covid-survivors.html Long-Term Neurologic Symptoms Emerge in COVID-19 — Hospitalized patients show deficits including cognitive impairment 6 months later https://www.medpagetoday.com/infectiousdisease/covid19/90587 Impending cognitive and functional decline in COVID-19 survivors. https://bjanaesthesia.org/article/S0007-0912(20)30993-4/pdf Cognitive impact of COVID-19: looking beyond the short term https://alzres.biomedcentral.com/articles/10.1186/s13195-020-00744-w https://jnnp.bmj.com/content/early/2020/11/19/jnnp-2020-325173 Cognition and COVID-19 – What we know Nearly a year on from the first outbreak of COVID-19, we still have a lot to learn about how the virus works and affects our health. In this article Operational Scientist, Iona Pickett, explores our current understanding of the neuropsychological consequences of COVID-19, in particular the impact on cognitive function. Nearly a year on from the first outbreak of COVID-19, we still have a lot to learn about how the virus works and affects our health. It is becoming increasingly clear though that many patients recovering from COVID-19 are also experiencing neurological, psychiatric, and cognitive problems (1-4). These symptoms are estimated to be present in up to a third of COVID-19 patients who have been hospitalised(3,4).These symptoms also appear to persist long after recovery from the initial infection, with detrimental effects on patient quality of life(3, 5-7). With a vaccine on the horizon, and hopefully an end to the pandemic, it is time to start assessing the needs of COVID-19 survivors and providing support for their long-term recovery. This article explores our current understanding of the neuropsychological consequences of COVID-19, in particular the impact on cognitive function. https://www.cambridgecognition.com/blog/entry/cognition-and-covid-19-what-we-know

Altered global brain signal in schizophrenia

This study identified elevated global brain signal variability in schizophrenia, but not bipolar illness. This variability was related to schizophrenia symptoms. A commonly used analytic procedure in neuroimaging, global signal regression, attenuated clinical effects and altered inferences. Furthermore, local voxel-wise variance was increased in schizophrenia, independent of global signal regression. Finally, neurobiologically grounded computational modeling suggests a putative mechanism, whereby altered overall connection strength in schizophrenia may underlie observed empirical results.

https://www.pnas.org/content/111/20/7438

If the patient is a danger to himself or others and is unwilling to seek treatment, they can be involuntarily committed to a hospital and held for a period of evaluation usually lasting three to seven days. A court order is required for involuntary commitment to be extended.11

Film and news media have characterized schizophrenia as a violent condition, however, the majority of people with schizophrenia are not violent. The majority of violent crime is committed by individuals who do not suffer from this disorder. The risk of violence in schizophrenia drops dramatically when treatment is in place.12

https://www.psycom.net/paranoid-schizophrenia

Did I Have It and Not Know It?

Signs That You May Have Had COVID-19.

The COVID-19 virus may have been around longer than we originally thought. So people may have had the virus and recovered from it without knowing. Some telltale signs could indicate that you’re one of those people.

https://www.webmd.com/lung/ss/slideshow-signs-had-covid

https://www.euronews.com/2020/06/02/analysis-has-covid-19-been-with-us-longer-than-we-thought

https://newseu.cgtn.com/news/2020-07-07/COVID-19-may-have-been-around-for-years-says-Oxford-scientist-RWg38I6FOM/index.html

https://www.npr.org/sections/coronavirus-live-updates/2020/12/01/940395651/coronavirus-was-in-u-s-weeks-earlier-than-previously-known-study-says

https://www.ctvnews.ca/health/coronavirus/study-hints-covid-19-may-have-been-in-the-u-s-as-early-as-december-1.5106080

https://nypost.com/2020/12/01/covid-19-was-likely-in-us-weeks-earlier-than-thought-study/

https://www.sciencealert.com/the-new-coronavirus-could-have-been-percolating-innocently-in-humans-for-years

https://www.healthline.com/health-news/people-believe-unproven-conspiracy-theories-about-covid-19

25% of People Believe Unproven Conspiracy Theories About COVID-19

https://www.healthline.com/health-news/people-believe-unproven-conspiracy-theories-about-covid-19

https://www.nytimes.com/2020/04/08/world/europe/coronavirus-conspiracy-theories.html

2018: Burden of schizophrenia increasing globally.

Schizophrenia is a complex mental disorder, with typical onset in late adolescence or early adulthood. Despite intensive and ongoing research, outcomes from best-practice treatment are often suboptimal. A systematic review based on 50 outcome studies reported that the median proportion of people with schizophrenia who met clinical and social recovery criteria was only 13.5%.1

In addition to poor recovery outcomes, those living with schizophrenia have a significantly reduced life expectancy.2 High excess mortality is found across all age groups3 and this differential mortality gap between those with and without schizophrenia may have increased in recent decades.4 Schizophrenia has also been linked to higher rates of comorbid illnesses and most excess deaths are due to underlying physical illnesses, especially chronic diseases such as coronary heart disease, stroke, type II diabetes, respiratory diseases, and some cancers.2 Unnatural causes, including suicide, account for less than 15% of excess deaths.3

Findings from the 2016 global burden of disease study indicated that population growth and aging has led to an increasing disease burden attributable to schizophrenia globally, especially in middle-income countries.

“Developing health services for schizophrenia will require robust and informative epidemiological estimates, including estimates of the number of people living with schizophrenia in a given population and how these have changed over time — estimates that are currently unavailable for schizophrenia,” Fiona J. Charlson, MIPH, PhD, of the University of Queensland School of Public Health in Australia, and the Institute for Health Metrics and Evaluation at University of Washington, and colleagues wrote. “Recent innovations in statistical modeling, as part of the global burden of disease studies, have allowed for the derivation of detailed and comparable epidemiological estimates for schizophrenia by age, sex, geography, and year.”

Charlson and colleagues reported the global disease burden study 2016 estimates of schizophrenia prevalence and burden of disease. In this systematic review, the researchers identified studies reporting the prevalence, incidence, remission and/or excess mortality relating to schizophrenia, then entered estimates into the Bayesian meta-regression tool used in the 2016 global disease burden study to obtain prevalence for 20 age groups, seven super-regions, 21 regions and 195 countries/territories. They obtained burden of disease estimates for schizophrenia by multiplying the prevalence specifically for age, sex, year and location.

In total, 129 individual data sources were included in the systematic review. The results showed that the prevalent cases rose from 13.1 (95% uncertainty interval [UI], 11.6–14.8) million in 1990 to 20.9 (95% UI, 18.5–23.4) million cases in 2016 worldwide. According to the global disease burden study, schizophrenia contributes 13.4 (95% UI, 9.9–16.7) million years of life lived with disability to the worldwide burden of disease.

Analysis demonstrated that the estimated global age-standardized point prevalence of schizophrenia in 2016 was 0.28% (95% UI, 0.24–0.31), with no differences between sexes. Furthermore, there were no large differences between age-standardized point prevalence rates across countries or regions globally.

Globally, an estimated 21 million people are living with schizophrenia and this number will continue to rise with population ageing and growth, according to the researchers. The findings showed that most people live in low- and middle-income countries.

“Health systems in low- and middle-income countries need to prepare for this increase, but existing evidence-based interventions have been poorly implemented, with only 31% of people with schizophrenia accessing treatment in low- and middle-income countries, where the overall mental disorders treatment gap is as high as 89%,” Charlson and colleagues wrote in Schizophrenia Bulletin.

Differences in disability adjusted life years per income status showed that the burden of schizophrenia experienced in lower- and upper-middle income countries was roughly four times that experienced by high-income countries, largely due to the growing populations of these lower income countries.

“This calls for an urgent scaling up of services to respond to serious mental disorders such as schizophrenia,” the researchers wrote. “Health systems in most countries are unprepared for this escalating burden and without action to scale-up services, a lack of effective treatment for this debilitating mental disorder will critically impact individuals and their families.” – by Savannah Demko

https://academic.oup.com/schizophreniabulletin/article/44/6/1195/4995547

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7214712/

https://www.healio.com/news/psychiatry/20180525/burden-of-schizophrenia-increasing-globally#:~:text=Globally%2C%20an%20estimated%2021%20million,growth%2C%20according%20to%20the%20researchers.

People With Schizophrenia Have Increased Risk of Dying From COVID-19, Research Reveals..

Mark Olfson, M.D., MPH

Professor, Epidemiology and Psychiatry

Columbia University Medical Center

A newly published study based on data from a 2020 peak period of the pandemic in New York City indicates that people previously diagnosed with schizophrenia or a schizophrenia spectrum disorder who contracted a COVID-19 infection had a significantly increased risk of mortality. Specifically, their risk of death from COVID within 45 days of infection was 2.7 times the risk in people without a psychiatric diagnosis who contracted COVID.

The observed increase in COVID mortality risk for people on the schizophrenia spectrum was second highest in the study, following the elevated risk associated with age. By comparison, people who had previously suffered heart failure had 1.6 times the risk of those without a psychiatric diagnosis, while those with a history of diabetes had 1.27 times the risk.

The mortality risk within 45 days of COVID diagnosis was also elevated in people who had a recent diagnosis of mood disorders, after demographic factors were factored into the calculation. But this excess risk was not present statistically after various medical risk factors were taken into consideration.

There was no observed relation detected between COVID-related mortality and a stable, established mood disorder or with recent or previously established anxiety disorders.

The study, appearing in JAMA Psychiatry, was based on medical records complied in the spring of 2020 at the NYU Langone Medical Center in New York. Donald C. Goff, M.D., of NYU Langone was senior member of the team. He is a 2009 and 2003 BBRF Independent Investigator. The team also included 2005 BBRF Distinguished Investigator Mark Olfson, M.D., MPH, of Columbia University.

Electronic medical records of 26,540 patients tested within the multi-center NYU Langone health system were the basis for the study. Of these, 7,348 tested positive for COVID-19; 53% were women and the average age was about 54.

75 (1%) of those receiving a positive COVID test had a history of schizophrenia; 564 (7.7%) had a history of a mood disorder; and 360 (4.9%) had a history of an anxiety disorder. The sample was demographically diverse and reflected a consecutive stream of adult patients tested in the NYU Langone system between March 3 and May 31, 2020. Outcomes including mortality (death or discharge to a hospice) were monitored for 45 days following each positive COVID diagnosis.

A systematic study led by BBRF Scientific Council member Nora Volkow, M.D., and based on the electronic health records of over 61 million American adults recently found that people with a diagnosis of a mental disorder within the last 12 months have a significantly increased risk for COVID-19 infection and tend to have worse outcomes than people infected with COVID-19 who don’t have a mental disorder.

Results of the new study revealing the elevated risk of death in people with schizophrenia in the 45 days following a COVID infection should be important, the researchers said, in “guiding clinical decision-making, including the need for enhanced monitoring and targeted interventions” in such patients.

The result in schizophrenia may have reflected “unmeasured medical comorbidities,” the researchers said. But they also pointed out that “the risk remained significantly increased after adjustment for multiple established risk factors.”

It has been noted previously that people with severe mental illness are more likely to live in crowded housing, institutional or otherwise, and may either lack or eschew the need for personal protective equipment to avoid COVID inflection. Yet the increased risk of death from COVID seen in people with schizophrenia may also indicate the presence of biological factors related to schizophrenia or to treatments for it that the current study was not designed to detect, the researchers said.

The team speculates that among the biological factors that may make people with schizophrenia more vulnerable to COVID infection are dysregulation of the body’s immune system, deficits in cellular immunity, and irregularities in immune-system signaling. Evidence for all of these has been generated in many previous studies of schizophrenia, including studies of the genes that tend to be perturbed in people who have the illness.

Unable based on their study to forge more precise biological linkages, the researchers stressed the practical clinical need of “targeted interventions for patients with severe mental illness to prevent worsening health disparities” in circumstances such as are being faced now in the continuing COVID pandemic.

The Brain & Behavior Research Foundation is a nonprofit 501 organization that funds mental health research. It was originally called the National Alliance for Research on Schizophrenia & Depression or the acronym for that, NARSAD. It received its nonprofit ruling in 1981.

https://www.bbrfoundation.org/about

https://www.bbrfoundation.org/content/people-schizophrenia-have-increased-risk-dying-covid-19-research-reveals

Schizophrenia Tied to Higher Risk of COVID-19 Death

— Increased mortality risk not seen with mood and anxiety disorders

People with schizophrenia may face a higher risk for severe COVID-19, a new study suggested.

Compared with COVID-19 patients without a psychiatric disorder, those previously diagnosed with schizophrenia spectrum disorder had more than a two times higher risk for mortality within 45 days of a confirmed case (odds ratio 2.67, 95% CI 1.48-4.80), reported Katlyn Nemani, MD, of New York University Langone Medical Center in New York, and colleagues.

https://www.medpagetoday.com/infectiousdisease/covid19/90905

Schizophrenia is 2nd highest risk factor for dying of COVID-19, after age. By Yasemin Saplakoglu - Staff Writer January 27, 2021.

"It is both expected but also surprising."

Schizophrenia may be one of the highest risk factors for dying from COVID-19, second only to age, according to a new study.

Previous studies had found that people with mental illnesses, particularly depression and schizophrenia — a condition that causes distortions in thinking and perception — had a higher risk of becoming infected with SARS-CoV-2, the virus that causes COVID-19. But it was not known whether mental disorders were also associated with a risk of dying from COVID-19.

In the new study, researchers looked at health records from 260 outpatient clinics and four hospitals across New York City, based on data published by the New York University electronic health record; Of 26,540 patients tested (around 4,500 patients were excluded for various reasons), 7,348 adults tested positive COVID-19 between March 3 and May 31.

https://www.livescience.com/schizophrenia-covid-19-death-risk-factor.html

2021: Schizophrenia diagnosis among top risk factors for mortality in COVID-19 patients

Schizophrenia spectrum disorder diagnosis appeared to be a significant risk factor for mortality among individuals with COVID-19, according to results of a retrospective cohort study published in JAMA Psychiatry.

“The increased incidence of COVID-19 among individuals with mental disorders has been reported in at least [two] nationwide cohort studies in the US, with depression and schizophrenia associated with the highest infection risk in one sample,” Katlyn Nemani, MD, of the department of psychiatry at New York University Langone Medical Center, and colleagues wrote. “This association may be attributable to socioeconomic and environmental factors that contribute to exposure (eg, crowded housing, institutional settings and lack of personal protective equipment). Because outcomes may differ by diagnosis, it is important to determine which infected patients are at increased risk [for] adverse outcomes.”

https://www.healio.com/news/psychiatry/20210128/schizophrenia-diagnosis-among-top-risk-factors-for-mortality-in-covid19-patients

2020: Severe mental illness and risks from COVID-19

People living with SMI may also be at risk of worse outcomes from COVID-19 than the general population. A range of clinical syndromes are associated with COVID-19, from asymptomatic or mild disease to severe infection with complications such as acute respiratory distress syndrome, with high associated mortality (15). Risk factors for severe infection are highly prevalent in the SMI population. For example, increased rates of obesity, cardiovascular disease and chronic obstructive pulmonary disease are found in people with SMI (16). In part, this may reflect lifestyle factors, including smoking and physical inactivity, but also is a consequence of psychiatric medication side-effects. In particular, atypical antipsychotics are associated with a metabolic syndrome encompassing weight gain, hyperlipidemia and impaired glucose control (17). These factors have been associated with severe infection with SARS-CoV-2 (16). There are additional concerns relating to clozapine, the gold-standard antipsychotic for treatment-resistant schizophrenia (18). Clozapine is associated with haematological side effects including neutropenia and rarely life-threatening agranulocytosis (19), resulting in cessation of clozapine treatment if white cell counts are less than < 3.0 x 109/L (21). Prior to COVID-19, clozapine treatment has been associated with a higher rate of hospital admissions due pneumonia (although the mechanism is debated) (20). However, there is concern that interruption of clozapine treatment, in the case of low white cell count during SARS-CoV-2 infection, may in fact pose a greater challenge to safely managing a COVID-19 infected patient, due to risk of relapse of their psychotic disorder (22). Theoretical concerns have also been raised about benzodiazepines, which are associated with depression of respiratory function, and COVID-19 infection outcomes (3). Finally, access to healthcare may affect outcomes following infection with SARS-CoV-2 in people with SMI. It has previously been shown that people with SMI experience reduced access to healthcare, for example through delayed presentation, misattribution of symptoms and stigmatising attitudes of health professionals (16).

https://www.cebm.net/covid-19/severe-mental-illness-and-risks-from-covid-19/

New Research on COVID-19 & Psychosis

A new study led by Dr. Ellie Brown at the National Centre of Excellence in Youth Mental Health in Australia has found that the stress caused by COVID-19 may increase the incidence of psychosis.

https://www.bcss.org/new-research-on-covid-19-psychosis/

https://www.bcss.org/covid-19-supporting-someone-living-with-schizophrenia/

JANUARY 27, 2021

expert reaction to COVID and schizophrenia

A study as published in JAMA Psychiatry looks at Psychiatric Disorders and mortality among COVID-19 patients.

Prof James MacCabe, Professor of Epidemiology and Therapeutics, Institute of Psychiatry Psychology and Neuroscience, Kings College London, said:

“The increased death rate from COVID-19 in people with schizophrenia is a cause for concern. We know that people with severe mental illness have higher overall mortality and often face reduced access to healthcare. They may be less likely to present to healthcare settings, and may be subject to healthcare rationing in some settings. These disparities in access to healthcare may be especially severe in the USA, where this study was conducted. To put the findings into context, the magnitude of the effect is comparable to that seen in physical health conditions including diabetes and neurological diseases. Crucially, this study did not take obesity into account which may account for some or even all of the effect. The most closely comparable study is probably that conducted in South Korea, which found that people with depression were slightly more likely to die from COVID-19 than schizophrenia, suggesting that these findings may vary in different healthcare systems. It will therefore be important to examine this effect in the UK and to address inequalities in access to healthcare in people with severe mental illness.”

Dr Sameer Jauhar, Senior Research Fellow and JMAS Sim Fellow, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, said:

“We have known for a number of years that people with major mental illness, such as schizophrenia, have decreased life expectancy, which varies depending on the country and health system, and can be as much as 10-15 years less than the general population.

“There is an older literature from around ten years ago, suggesting that people with schizophrenia and pneumonia were almost twice as likely to be admitted to ITU than people with pneumonia who did not have a diagnosis of schizophrenia.

“Therefore the findings of this study, where people with schizophrenia and COVID-19 were more likely to die than the general population and people with other mental illness such as mood and anxiety disorders, are plausible.

“The authors of this study were able to control for a number of factors that may have been associated with this increase mortality risk, such as smoking, heart disease and race.

“It should be borne in mind that the findings are based on data from 75 people with schizophrenia and CO-VID 19, and therefore though plausible, should be interpreted cautiously.

“The authors talk about immune function being compromised, and whilst that may well be the case (and there is a small level of increased risk from genetic studies to support this), there are a myriad of factors that could be at play here, including barriers to accessing care early, and perhaps an interplay between these social factors and vulnerability in this population of people.

“In my opinion this study has practical implications-these are a vulnerable group of people, and should be targeted for vaccines, in much the same way as other people at increased mortality risk from CO-VID 19. Parity for people with severe mental illness has been a slogan for a number of years, and the findings from this study underline this.”

https://www.sciencemediacentre.org/expert-reaction-to-covid-and-schizophrenia/

COVID Especially Risky With Schizophrenia

THURSDAY, Jan. 28, 2021 (HealthDay News) -- Schizophrenia is second only to age when it comes to risk factors for dying from COVID-19, new research suggests.

People with this mental illness are known to be at greater risk for contracting COVID-19, but the new study shows they are also more likely to die from this virus.

"Old age is still the most important risk factor for dying of COVID-19, but in our study, schizophrenia surpassed even heart, lung and kidney disease," said study author Dr. Donald Goff, director of the Institute for Psychiatric Research at NYU Langone in New York City.

"We believe that people with schizophrenia should be prioritized in terms of receiving COVID 19 vaccinations and encouraged to observe safety precautions," said Goff, who is also a psychiatry professor at NYU Langone.

https://www.webmd.com/lung/news/20210128/covid-especially-risky-with-schizophrenia

Association of Psychiatric Disorders With Mortality Among Patients With COVID-19

https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2775179

Severe mental illness: reassessing COVID-19 vaccine priorities

As evidence mounts that patients with severe mental illness are at increased risk of severe COVID-19, some countries are reassessing their vaccine priority strategies. Nayanah Siva reports.

“The evidence is really very clear. We have well over six studies now published with data from US, the UK, Denmark, and Sweden all showing the same thing”, Livia De Picker, University Psychiatric Hospital Campus Duffel, Antwerp, Belgium, told The Lancet. “Patients with severe mental illness, which is patients with psychotic disorder, bipolar disorder, or severe depression, are at a significantly increased risk of being hospitalised or dying from COVID.”

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)00429-3/fulltext

COVID-19 vaccination for people with severe mental illness: why, what, and how?

Psychiatric disorders, and especially severe mental illness, are associated with an increased risk of severe acute respiratory syndrome coronavirus 2 infection and COVID-19-related morbidity and mortality. People with severe mental illness should therefore be prioritised in vaccine allocation strategies. Here, we discuss the risk for worse COVID-19 outcomes in this vulnerable group, the effect of severe mental illness and psychotropic medications on vaccination response, the attitudes of people with severe mental illness towards vaccination, and, the potential barriers to, and possible solutions for, an efficient vaccination programme in this population.

https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(20)30564-2/fulltext

COVID-19 Psychosis: A Potential New Neuropsychiatric Condition Triggered by Novel Coronavirus Infection and the Inflammatory Response?

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7236749/

'Alarming Finding' in Schizophrenia Patients With COVID-19

https://www.medscape.com/viewarticle/944844

COVID-19 vaccine and people living with severe mental illness

https://www.rethink.org/advice-and-information/covid-19-support/covid-19-vaccine-and-people-living-with-severe-mental-illness/

The most terrifying thing': Some Covid-19 patients are suffering severe psychosis

'There's something happening'

As Belluck explains, while the virus that causes Covid-19 was initially considered primarily a respiratory disease, more and more patients are reporting a host of other symptoms, including neurological, cognitive, and psychological effects. And among these cases is a small but growing number of patients who are experiencing severe "post-Covid psychosis," providers say.

For example, a patient named Ivan Agerton—a 49-year-old documentary photographer living in Seattle, who had no personal or family history of mental illness—began experiencing crippling paranoia and auditory hallucinations weeks after recovering from a mild case of Covid-19. He believed that his neighbors were spying on his family and that police were tracking his movements.

"Like a light switch—it happened this fast—this intense paranoia hit me," Agerton said. "It was really single-handedly the most terrifying thing I've ever experienced in my life."

In another case, Hisam Goueli, a psychiatrist, helped treat a physical therapist in her early 40s who sought help at South Oaks Hospital in New York after she started to hear a voice telling her to kill herself and harm her children. The woman, who had never experienced psychiatric symptoms before, said the symptoms started just months after recovering from a mild case of Covid-19.

Goueli said he was initially unsure whether her case was Covid-related. "But then," he said, "we saw a second case, a third case and a fourth case, and we're like, 'There's something happening.'"

Indeed, while the overall number of these cases remains low—and experts expect the cases to remain rare—the reports aren't merely anecdotal, Belluck reports. A British study of neurological and psychiatric symptoms among 153 Covid-19 patients found that 10 study participants presented with "new-onset psychosis." Similarly, another study identified 10 such patients at a hospital in Spain.

Much about the condition remains a mystery, experts say

While experts don't think this trend is unique to Covid-19—psychotic episodes have sporadically occurred amid other viruses, including the 1918 flu and the SARS and MERS coronaviruses—they note that much about post-Covid psychosis remains a mystery, Belluck writes.

Cheat sheet: Tele-behavioral health

Currently, experts hypothesize that this condition may be associated with how the immune system responds to the virus, including vascular issues or inflammation. "Some of the neurotoxins that are reactions to immune activation can go to the brain, through the blood-brain barrier, and can induce this damage," said Vilma Gabbay, a co-director of the Psychiatry Research Institute at Montefiore Einstein, who has treated two patients with post-Covid psychosis.

As Robert Yolken, a neurovirology expert at Johns Hopkins University School of Medicine, explained, the immune systems of some patients who've physically recovered from Covid-19 remain activated because of "delayed clearance of a small amount of virus."

And that continuing activation of the immune system, according to Emily Severance, an expert in schizophrenia at Johns Hopkins, is currently the leading hypothesis into other brain-related symptoms of Covid-19, such as brain fog and memory loss. It's reasonable to think that post-Covid psychosis may stem from "something similar happening in the brain," she said.

In fact, the variety of symptoms may depend on what part of the brain is affected by the ongoing immune response, Yolken said. He noted that "some people have neurological symptoms, some people psychiatric and many people have a combination."

A different expression of psychosis—and an ambiguous recovery

According to experts, the experience of psychosis among Covid-19 patients seems to differ significantly from how psychosis typically presents.

Webinar series: 'Stay Up to Date' on the latest with Covid-19

For instance, while paranoid delusions typically accompany schizophrenia during late adolescence or dementia in elder adults, post-Covid-19 psychosis so far seems to primarily affect patients in their 30s, 40s, and 50s. "It's very rare for you to develop this type of psychosis in this age range," Goueli said.

In addition, while most people experiencing psychosis generally "don't have insight into their symptoms," several patients with post-Covid psychosis were aware that something was off, according to Veronika Zantop, a psychiatrist who helped treat Agerton.

There's also little consistency in symptoms among those affected by post-Covid-19 psychosis, Belluck writes, although several patients reported experiencing only mild Covid-19. For example, some patients experiencing post-Covid-19 psychosis feel urges to hurt themselves or others, much like Goueli's patient, while others—such as Agerton—experience deep paranoia rather than any violent impulses.

Moreover, while some patients require weeks of hospitalization to identify the right medications, others improve relatively quickly. Goueli's patient, for instance, was hospitalized for four weeks before doctors found a regimen of medicine that alleviated her symptoms and enabled her to return home. She's currently "95% perfect," Goueli said.

And while some patients seem to experience just a one-off episode, others struggle with relapses. For his part, Agerton was hospitalized in a psychiatric ward twice for his psychosis. While he's now returned home and says he's improving, he's still not 100%. "There's this fear of how long is this going to happen," he said. "How long am I going to live with this?"

Ultimately, however, experts hope that studying these individual cases and larger pieces of research can shed light on what remains a challenging and difficult situation. "We don't know what the natural course of this is," Goueli said. "There are just so many unanswered questions" (Belluck, New York Times, 12/28/2020; Belluck, New York Times, 3/22).

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The Covid-19 pandemic is rapidly increasing the need for behavioral health services. But there are significant gaps and barriers that stand in the way of people getting the help they need. Download our take to learn how health systems can prioritize addressing the immediate needs of both staff and patients, especially those with preexisting behavioral health needs or comorbid conditions.

https://www.advisory.com/en/daily-briefing/2021/03/26/covid-psychosis

COVID-19 and schizophrenia: A potentially deadly combination.

A study conducted in a major New York City hospital system in 2020 found that people with schizophrenia have 2.7 times the overall risk of dying within 45 days if they are infected with the COVID-19 virus. Higher mortality was not seen in people with depression or anxiety who contracted the virus.

People living with schizophrenia are uniquely vulnerable to COVID-19 and completely missing from Canada’s National Advisory Committee on Immunization’s recommendations for vaccine distribution, which prioritizes seniors, front-line health-care workers and Indigenous communities in the first stage.

Those with schizophrenia are almost three times more likely to die from COVID-19 than those without the serious mental illness, making it second only to age as a risk factor for mortality, according to a study in JAMA Psychiatry.

The study included more than 7,000 adults with confirmed COVID-19 in a large New York health system. It found that a pre-existing diagnosis of schizophrenia was significantly associated with an increased risk of death, even after adjusting for other demographic and medical risk factors.

In fact, schizophrenia was found to be a distinct, and more deadly COVID-19 risk factor than heart, lung and kidney disease — even while it is well-established that those with schizophrenia often also have multiple co-morbid conditions, such as COPD or diabetes, that put them at further risk, say advocates.

https://theconversation.com/covid-19-and-schizophrenia-a-potentially-deadly-combination-155476

https://www.psychiatryadvisor.com/home/topics/schizophrenia-and-psychoses/people-with-schizophrenia-at-risk-for-covid-19-hospitalization/

2019: Is the global prevalence rate of adult mental illness increasing? Systematic review and meta-analysis.

The question whether mental illness prevalence rates are increasing is a controversially debated topic. Epidemiological articles and review publications that look into this research issue are often compromised by methodological problems. The present study aimed at using a meta‐analysis technique that is usually applied for the analysis of intervention studies to achieve more transparency and statistical precision.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7214712/

https://www.theguardian.com/society/2019/jun/03/mental-illness-is-there-really-a-global-epidemic

https://www.psychiatryadvisor.com/home/topics/general-psychiatry/is-the-worldwide-prevalence-of-mental-illness-increasing-dramatically/

https://onlinelibrary.wiley.com/doi/10.1111/acps.13083