The Friday Report – Issue 14 (published Saturday July 4th)
COVID-19 Actuaries Response Group – Learn. Share. Educate. Influence.
Every week, more is written on COVID-19 than any individual could possibly read. Collectively, the COVID‑19 Actuaries Response Group read more about the outbreak than most, so we’ve decided each Friday to provide you with a curated list of the key papers and articles that we’ve looked at recently.
Modelling – reports
Household secondary attack rate of COVID-19 and associated determinants in Guangzhou China: a retrospective cohort study; Jing, Q-L, Liu, M-J, et al
This paper uses a contact tracing dataset from Guangzhou, to estimate the probability that an infected individual will transmit COVID-19 to a susceptible individual, among both household and non-household contacts. The analysis is based on infections from 195 unrelated close contact groups between 7 January and 18 February 2020.
The risk of household infection was lower in the youngest age group compared to the oldest, and was found to be higher in households of six people or less than in larger households. The authors estimate that the local reproductive number (R) was 0.5 in Guangzhou, whereas the projected R if there had been no isolation of cases or quarantine of contacts was 0.6.
Excess deaths from COVID-19 and other causes – March-April 2020; Woolf; Chapman; Sabo et al
Estimation of excess deaths associated with the COVID-19 pandemic in the United States, March to May 2020; Weinberger; Chen; Cohen
These two brief papers look to estimate the excess deaths from COVID-19 in the United States. The first notes that the number of COVID-19 deaths reported in the early weeks of the pandemic may have captured only two-thirds of excess deaths in the US, with large increases in underlying causes other than COVID-19 including diabetes, Alzheimer disease, heart disease and cerebrovascular diseases. This finding is similar to analysis by ONS of data in England & Wales, as previously reported.
The second paper similarly finds that the number of deaths due to any cause increased by 122,000 from 1 March to 30 May 2020, which is 28% higher than the reported number of COVID-19 deaths.
Clinical and Medical News
Update on anti-viral drugs from the ‘RECOVERY’ trial
As previously reported, the ‘RECOVERY’ trial is a randomised trial of treatments to prevent death in patients hospitalised with COVID-19. Originally, the trial sought to study the effects of a Lopinavir-Ritonavir combination (anti-virals), Dexamethasone (a corticosteroid), Hydroxychloroquine (anti-malarial), Azithromycin (an antibiotic), convalescent plasma, and Tocilizumab (a ‘targeted therapy’).
As ongoing results have been analysed, Hydroxychloroquine is no longer being tested, and Dexamethasone is now only being tested in children. The most recent press release suggests that in this trial, the anti-viral drug combination of Lopinavir-Ritonavir do not appear to have significant mortality benefit in hospitalised COVID-19 patients . Consequently, this drug combo is no longer part of the RECOVERY trial.
In the last week we have heard from the Oxford-Astra Zeneca vaccine trial, and the BioNTech-Pfizer vaccine trial, on potential positive outcomes. However, there are still a number of hurdles ahead; these include durability of an antibody response, safety in larger numbers of patients, regulatory approval, and last, but not least, public acceptability and willingness to receive the vaccine.
In this up-to-date overview, COVID19 treatment tracker you can keep a track on the progress of vaccines and other treatments for COVID-19.
Blood clotting problems with COVID-19
Clinicians have been reporting that some patients with COVID-19 are manifesting abnormal clotting responses which can lead to, amongst other things, increased risk for stroke. This report presents the clinical characteristics from six confirmed COVID-19 patients with acute ischaemic stroke. The researchers note that although ischaemic stroke has been recognised as a complication of COVID-19 (usually with severe disease), the mechanisms and phenotype are not yet understood. This small study observes that COVID-associated ischaemic stroke is usually delayed, but can occur both early and later in the course of the disease, and that some patients may benefit from early anti-coagulant therapy.
Another study has also examined this phenomenon and attempted to explain the process. Patients admitted to Yale-New Haven Hospital between 13 April and 24 April 2020 with confirmed COVID-19 were analysed and blood markers for endothelial cell (cells which line the blood and lymph vessels) and platelet dysfunction were taken .
This study reports that these markers were elevated in COVID-19 ICU patients compared to non-ICU patients with two of the markers being significantly correlated with mortality. The endothelial cells may well be damaged in COVID-19 patients by the virus and are therefore unable to regulate the biochemicals that are necessary in balancing normal clotting responses.
The effect of frailty on survival in patients with COVID-19
A study entitled ‘COVID-19 in Older PEople’ (COPE) was created in order to establish the prevalence of frailty in patients with COVID-19 who were admitted to hospital, and investigate its influence on mortality and duration of hospital stay. Frailty is defined as “a medical syndrome with multiple causes and contributors that is characterised by diminished strength, endurance, and reduced physiologic function that increases an individual’s vulnerability for developing increased dependency and/or death”.
The COPE study is a multicentre European observational cohort study conducted at 11 hospitals in the UK and Italy. Between 27 February and 28 April 2020, 1,564 patients with COVID-19 were enrolled with a median age of 74 years. (IQR 61-83). Frailty was associated with both mortality and time to discharge from hospital after adjustment for age, sex, smoking status, and other comorbidities, exhibiting worsening clinical outcome with increasing frailty. The researchers conclude that the use of a clinical frailty scale (CFS) could be a useful addition to clinical decision-making.
Cancer and COVID-19
There are at least two studies that have been designed to analyse the characteristics and outcomes of people with cancer who also have COVID-19. The first, the COVID-19 and Cancer Consortium (CCC19) looks at the experience of patients in the USA, Canada, and Spain and assesses the association between all-cause mortality within 30 days of diagnosis of COVID-19, and potential prognostic variables using logistic regression analyses, partially adjusted for age, sex, smoking status, and obesity. This team report that patients with cancer appear to be at increased risk of mortality and severe illness due to SARS-CoV-2 infection, regardless of whether they have active cancer, are on anticancer treatment, or both.
The second report which included patients in the UK is called the UK Coronavirus Cancer Monitoring Project (UKCCMP). This study adds that recent chemotherapy use in patients with cancer before SARS CoV-2 infection was not significantly associated with increased mortality. Additionally, this study identified that the phenotype of diagnosed COVID-19 disease in over half of cancer patients is mild, but death from COVID-19 in this cohort was observed in a substantial proportion of patients. This mortality is higher than that observed in the general non-cancer UK population and is mainly driven by age, gender, and comorbidities.
Both studies are ongoing.
Digital tools against COVID-19
In the wake of the COVID-19 pandemic, there has been a surge in the development and deployment of digital public health technologies for pandemic management. Context-specific risks, cross-sectional issues, and ethical concerns are discussed in this excellent review . Flow modelling, proximity and contact tracing, quarantine compliance and symptom checkers are included and the authors propose a navigation aid to fill the ‘best-practice’ gap and provide immediate practical guidance by assisting involved decision-makers to work towards a coherently structured and iterative process.
Public Health England: Preliminary investigation into COVID-19 exceedances in Leicester: June 2020
This is a report by Public Health England, setting out the epidemiology of a COVID-19 outbreak in Leicester (which has led to a local reinstatement of lockdown provisions). Depending on how and where COVID-19 spreads after lockdown, this will presumably be the first in a series of reports into outbreaks of infection in particular geographic areas.
The report notes that 944 cases have been reported in Leicester over the last 14 days, significantly higher than the case rate in the remainder of the East Midlands and England as a whole. Because the proportion of tests returning positive is rising, this is suggestive of a genuine increase in numbers of new infections, rather than an artefact of increasing test rates.
The reason for the outbreak in Leicester is currently unclear, and the majority of recent infections are amongst people aged 18 to 65.
The manufacturers of a nearly 20-year-old tech product appear to be emerging as an unlikely beneficiary of the lockdown – with people spending more time at home, the Roomba has seen a resurgence in sales, with iRobot expecting to report much stronger earnings than previously predicted .
3 July 2020