Symptoms, viral loads, and rebound among COVID-19 outpatients treated with nirmatrelvir/ritonavir compared to propensity score matched untreated individuals.

BACKGROUND: Nirmatrelvir/ritonavir (N/R) reduces severe outcomes among patients with COVID-19; however, rebound after treatment has been reported. We compared symptom and viral dynamics in community-based individuals with COVID-19 who completed N/R and similar untreated individuals. METHODS: We identified symptomatic participants who tested SARS-CoV-2 positive and were N/R eligible from a COVID-19 household transmission study: index cases from ambulatory settings and their households were enrolled, collecting daily symptoms, medication use, and respiratory specimens for quantitative PCR for 10 days, March 2022-May 2023. Participants who completed N/R (treated) were propensity score matched to untreated participants. We compared symptom rebound, viral load (VL) rebound, average daily symptoms, and average daily VL by treatment status measured after N/R completion or, if untreated, seven days after symptom onset. RESULTS: Treated (n=130) and untreated participants (n=241) had similar baseline characteristics. After treatment completion, treated participants had greater occurrence of symptom rebound (32% vs 20%; p=0.009) and VL rebound (27% vs 7%; p<0.001). Average daily symptoms were lower among treated participants compared to untreated participants without symptom rebound (1.0 vs 1.6; p<0.01), but not statistically lower with symptom rebound (3.0 vs 3.4; p=0.5). Treated participants had lower average daily VLs without VL rebound (0.9 vs 2.6; p<0.01), but not statistically lower with VL rebound (4.8 vs 5.1; p=0.7). CONCLUSIONS: Individuals who completed N/R experienced fewer symptoms and lower VL but were more likely to have rebound compared to untreated individuals. Providers should still prescribe N/R, when indicated, and communicate possible increased rebound risk to patients.

Household Transmission of Influenza A Viruses in 2021-2022.

Importance: Influenza virus infections declined globally during the COVID-19 pandemic. Loss of natural immunity from lower rates of influenza infection and documented antigenic changes in circulating viruses may have resulted in increased susceptibility to influenza virus infection during the 2021-2022 influenza season. Objective: To compare the risk of influenza virus infection among household contacts of patients with influenza during the 2021-2022 influenza season with risk of influenza virus infection among household contacts during influenza seasons before the COVID-19 pandemic in the US. Design, Setting, and Participants: This prospective study of influenza transmission enrolled households in 2 states before the COVID-19 pandemic (2017-2020) and in 4 US states during the 2021-2022 influenza season. Primary cases were individuals with the earliest laboratory-confirmed influenza A(H3N2) virus infection in a household. Household contacts were people living with the primary cases who self-collected nasal swabs daily for influenza molecular testing and completed symptom diaries daily for 5 to 10 days after enrollment. Exposures: Household contacts living with a primary case. Main Outcomes and Measures: Relative risk of laboratory-confirmed influenza A(H3N2) virus infection in household contacts during the 2021-2022 season compared with prepandemic seasons. Risk estimates were adjusted for age, vaccination status, frequency of interaction with the primary case, and household density. Subgroup analyses by age, vaccination status, and frequency of interaction with the primary case were also conducted. Results: During the prepandemic seasons, 152 primary cases (median age, 13 years; 3.9% Black; 52.0% female) and 353 household contacts (median age, 33 years; 2.8% Black; 54.1% female) were included and during the 2021-2022 influenza season, 84 primary cases (median age, 10 years; 13.1% Black; 52.4% female) and 186 household contacts (median age, 28.5 years; 14.0% Black; 63.4% female) were included in the analysis. During the prepandemic influenza seasons, 20.1% (71/353) of household contacts were infected with influenza A(H3N2) viruses compared with 50.0% (93/186) of household contacts in 2021-2022. The adjusted relative risk of A(H3N2) virus infection in 2021-2022 was 2.31 (95% CI, 1.86-2.86) compared with prepandemic seasons. Conclusions and Relevance: Among cohorts in 5 US states, there was a significantly increased risk of household transmission of influenza A(H3N2) in 2021-2022 compared with prepandemic seasons. Additional research is needed to understand reasons for this association.

The Impact of the COVID-19 Pandemic on Mental Health, Occupational Functioning, and Professional Retention Among Health Care Workers and First Responders.

BACKGROUND: The COVID-19 pandemic has greatly affected front-line health care workers (HCW) and first responders (FR). The specific components of COVID-19 related occupational stressors (CROS) associated with psychiatric symptoms and reduced occupational functioning or retention remain poorly understood. OBJECTIVES: Examine the relationships between total and factored CROS, psychiatric symptoms, and occupational outcomes. DESIGN: Observational, self-report, single time-point online assessment. PARTICIPANTS: A total of 510 US HCW (N = 301) and FR (N = 200) with occupational duties affected by the COVID-19 pandemic. MAIN OUTCOMES AND MEASURES: CROS were assessed using a custom 17-item questionnaire. Post-traumatic stress disorder (PTSD), depression, insomnia, and generalized anxiety symptoms were assessed using the PTSD Checklist-5 (PCL5), Patient Health Questionnaire-9 (PHQ9), Insomnia Severity Index (ISI), and General Anxiety Disorder-7 (GAD7). Respondents' likelihood of leaving current field and occupational functioning were assessed with 2-item PROMIS subscales. Relationships were modeled using multivariable regression. Open-ended responses were coded using rapid template analysis. RESULTS: CROS total scores correlated significantly with all four psychiatric symptom domains (R's = .42-.53), likelihood of leaving one's current occupation (R = .18), and trouble doing usual work (R = .28), all p's < .001. Half of HCW indicated a decreased likelihood of staying in their current occupation as a result of the pandemic. CROS were fit to a 3-factor model consisting of risk, demoralization, and volume factors. All CROS factors were associated with psychiatric symptom burden, but demoralization was most prominently associated with psychiatric symptoms and negative occupational outcomes. Among psychiatric symptoms, PTSD symptoms were most strongly associated with negative occupational outcomes. Open-ended statements emphasized lack of protection and support, increased occupational demands, and emotional impact of work duties. CONCLUSIONS AND RELEVANCE: These results demonstrate potentially treatable psychiatric symptoms in HCW and FR experiencing CROS, impacting both wellbeing and the health care system. Mitigating CROS, particularly by addressing factors driving demoralization, may improve HCW and FR mental health, occupational functioning, and retention.

Telemedicine Use by Older Adults in a COVID-19 Epicenter.

BACKGROUND: In early 2020, New York City was the epicenter of the Coronavirus disease 2019 (COVID-19) pandemic in the United States. Older adults were at especially high risk. Telemedicine (TM) was used to shift care from overburdened emergency departments (EDs) to provide health care to a community in lockdown. TM options presented unique challenges to our diverse older adult population, including visual, hearing, cognitive, and language limitations. OBJECTIVE: Our objective was to evaluate the use of TM during the peak of the pandemic in New York City. METHODS: We conducted a retrospective chart review of patients 65 years and older evaluated remotely via TM during our pandemic surge. Chart extraction was performed by six emergency physicians. Outcomes included demographics, technical limitations, rates of ED referral, and 30-day mortality. RESULTS: During the study period, a total of 140 encounters were reviewed. The mean age was 73 years. Overall, 20% of patients in the cohort were emergently referred to the ED. Use of TM by this age cohort increased 20-fold as compared with a similar time frame pre-pandemic. ED referral was highest in those over 75 (45.9% > 75 years). Forty-three percent used family to assist. Thirty-day mortality was 7%. CONCLUSION: TM use by older adults grew substantially at our institution during our initial COVID-19 surge. The same-day emergent referral rate and mortality rate reflect the high acuity represented in this cohort and points to the need for telehealth providers that are trained in triage and emergency medicine with a knowledge of local resource availability.

Bacteremia in Adults Admitted from the Emergency Department with Laboratory-Confirmed Respiratory Syncytial Virus.

BACKGROUND: Collecting blood cultures from patients admitted from the emergency department (ED) with acute respiratory infection (ARI) is common, but the rate of secondary bacteremia in adult patients admitted from the ED with ARI associated with respiratory syncytial virus (RSV) is unknown. Indiscriminate collection of blood cultures can be associated with contaminated blood cultures and increased inappropriate antimicrobial use and health care costs. OBJECTIVE: This study sought to determine the rate and etiology of secondary bacteremia, factors associated with secondary bacteremia, and factors associated with collecting blood cultures in the ED, in adults hospitalized with RSV. METHODS: We performed a retrospective substudy using data from a prospective study of adults admitted with RSV infections during two respiratory seasons (October 2017 to April 2018 and October 2018 to April 2019). Blood cultures were collected at the discretion of ED providers. We compared demographic and clinical characteristics among those with and without secondary bacteremia and among those with and without blood cultures collected using multivariate logistic regression models. RESULTS: Of the 365 hospitalized RSV-positive patients (mean age 68.8 years), 269 (73.7%) had blood cultures collected in the ED and 18 (6.7%) patients had secondary bacteremia, most commonly from a nonrespiratory source (n = 13). Patients with asthma and chronic obstructive pulmonary disease were significantly less likely to have secondary bacteremia. Patients who were immunocompromised, met systemic inflammatory response syndrome criteria, or had pneumonia described on chest x-ray reports were more likely to have blood cultures collected. CONCLUSIONS: Overall, 6.7% of adults hospitalized with RSV infections had secondary bacteremia, more commonly from nonrespiratory sources.

Frailty assessment tools in the emergency department: A geriatric emergency department guidelines 2.0 scoping review.

Objective: Given the aging population and growing burden of frailty, we conducted this scoping review to describe the available literature regarding the use and impact of frailty assessment tools in the assessment and care of emergency department (ED) patients older than 60 years. Methods: A search was made of the available literature using the Covidence system using various search terms. Inclusion criteria comprised peer-reviewed literature focusing on frailty screening tools used for a geriatric population (60+ years of age) presenting to EDs. An additional search of PubMed, EBSCO, and CINAHL for articles published in the last 5 years was conducted toward the end of the review process (January 2023) to search specifically for literature describing interventions for frailty, yielding additional articles for review. Exclusion criteria comprised articles focusing on an age category other than geriatric and care environments outside the emergency care setting. Results: A total of 135 articles were screened for inclusion and 48 duplicates were removed. Of the 87 remaining articles, 20 were deemed irrelevant, leaving 67 articles for full-text review. Twenty-eight were excluded for not meeting inclusion criteria, leaving 39 full-text studies. Use of frailty screening tools were reported in the triage, care, and discharge decision-making phases of the ED care trajectory, with varying reports of usefulness for clinical decision-making. Conclusion: The literature reports tools, scales, and instruments for identifying frailty in older patients at ED triage; multiple frailty scores or tools exist with varying levels of utilization. Interventions for frailty directed at the ED environment were scant. Further research is needed to determine the usefulness of frailty identification in the context of emergency care, the effects of care delivery interventions or educational initiatives for front-line medical professionals on patient-oriented outcomes, and to ensure these initiatives are acceptable for patients.

The relative contribution of COVID-19 infection versus COVID-19 related occupational stressors to insomnia in healthcare workers.

Objective/Background: Healthcare workers have experienced high rates of psychiatric symptom burden and occupational attrition during the COVID-19 pandemic. Identifying contributory factors can inform prevention and mitigation measures. Here, we explore the potential contributions of occupational stressors vs COVID-19 infection to insomnia symptoms in US healthcare workers.Patients/Methods: An online self-report survey was collected between September 2020 and July 2022 from N = 594 US healthcare workers, with longitudinal follow-up up to 9 months. Assessments included the Insomnia Severity Index (ISI), the PTSD Checklist for DSM-5 (PCL-5), and a 13-item scale assessing COVID-19 related occupational stressors. Results: Insomnia was common (45% of participants reported at least moderate and 9.2% reported severe symptoms at one or more timepoint) and significantly associated with difficulty completing work-related tasks, increased likelihood of occupational attrition, and thoughts of suicide or self-harm (all p<.0001). In multivariable regression with age, gender, and family COVID-19 history as covariates, past two-week COVID-related occupational stressors, peak COVID-related occupational stressors, and personal history of COVID-19 infection were all significantly related to past two-week ISI scores (ß = 1.7 ± 0.14SE, ß = 0.08 ± 0.03, and ß = 0.69 ± 0.22 respectively). Although similar results were found for the PCL-5, when ISI and PCL-5 items were separated by factor, COVID-19 infection was significantly related only to the factor consisting of sleep-related items. Conclusions: Both recent occupational stress and personal history of COVID-19 infection were significantly associated with insomnia in healthcare workers. These results suggest that both addressing occupational stressors and reducing rate of COVID-19 infection are important to protect healthcare workers and the healthcare workforce.

The relative contribution of COVID-19 infection versus COVID-19 related occupational stressors to insomnia in healthcare workers.

Objective/Background: Healthcare workers have experienced high rates of psychiatric symptom burden and occupational attrition during the COVID-19 pandemic. Identifying contributory factors can inform prevention and mitigation measures. Here, we explore the potential contributions of occupational stressors vs COVID-19 infection to insomnia symptoms in US healthcare workers. Patients/Methods: An online self-report survey was collected between September 2020 and July 2022 from N=594 US healthcare workers, with longitudinal follow-up up to 9 months. Assessments included the Insomnia Severity Index (ISI), the PTSD Checklist for DSM-5 (PCL-5), and a 13-item scale assessing COVID-19 related occupational stressors. Results: Insomnia was common (45% of participants reported at least moderate and 9.2% reported severe symptoms at one or more timepoint) and significantly associated with difficulty completing work-related tasks, increased likelihood of occupational attrition, and thoughts of suicide or self-harm (all p<.0001). In multivariable regression with age, gender, and family COVID-19 history as covariates, past two-week COVID-related occupational stressors, peak COVID-related occupational stressors, and personal history of COVID-19 infection were all significantly related to past two-week ISI scores (ß=1.7±0.14SE, ß=0.08±0.03, and ß=0.69±0.22 respectively). Although similar results were found for the PCL-5, when ISI and PCL-5 items were separated by factor, COVID-19 infection was significantly related only to the factor consisting of sleep-related items. Conclusions: Both recent occupational stress and personal history of COVID-19 infection were significantly associated with insomnia in healthcare workers. These results suggest that both addressing occupational stressors and reducing rates of COVID-19 infection are important to protect healthcare workers and the healthcare workforce.

Oral Microbiome Alterations and SARS-CoV-2 Saliva Viral Load in Patients with COVID-19.

Bacterial-viral interactions in saliva have been associated with morbidity and mortality for respiratory viruses such as influenza and SARS-CoV. However, such transkingdom relationships during SARS-CoV-2 infection are currently unknown. Here, we aimed to elucidate the relationship between saliva microbiota and SARS-CoV-2 in a cohort of newly hospitalized COVID-19 patients and controls. We used 16S rRNA sequencing to compare microbiome diversity and taxonomic composition between COVID-19 patients (n = 53) and controls (n = 59) and based on saliva SARS-CoV-2 viral load as measured using reverse transcription PCR (RT-PCR). The saliva microbiome did not differ markedly between COVID-19 patients and controls. However, we identified significant differential abundance of numerous taxa based on saliva SARS-CoV-2 viral load, including multiple species within Streptococcus and Prevotella. IMPORTANCE Alterations to the saliva microbiome based on SARS-CoV-2 viral load indicate potential biologically relevant bacterial-viral relationships which may affect clinical outcomes in COVID-19 disease.

Protecting the front line: a cross-sectional survey analysis of the occupational factors contributing to healthcare workers' infection and psychological distress during the COVID-19 pandemic in the USA.

OBJECTIVE: The COVID-19 pandemic has been associated with significant occupational stressors and challenges for front-line healthcare workers (HCWs), including COVID-19 exposure risk. Our study sought to assess factors contributing to HCW infection and psychological distress during the COVID-19 pandemic in the USA. DESIGN: We conducted a cross sectional survey of HCWs (physicians, nurses, emergency medical technicians (EMTs), non-clinical staff) during May 2020. Participants completed a 42-item survey assessing disease transmission risk (clinical role, work environment, availability of personal protective equipment) and mental health (anxiety, depression and burn-out). SETTING: The questionnaire was disseminated over various social media platforms. 3083 respondents from 48 states, the District of Columbia and US territories accessed the survey. PARTICIPANTS: Using a convenience sample of HCWs who worked during the pandemic, 3083 respondents accessed the survey and 2040 participants completed at least 80% of the survey. PRIMARY OUTCOME: Prevalence of self-reported COVID-19 infection, in addition to burn-out, depression and anxiety symptoms. RESULTS: Participants were largely from the Northeast and Southern USA, with attending physicians (31.12%), nurses (26.80%), EMTs (13.04%) with emergency medicine department (38.30%) being the most common department and specialty represented. Twenty-nine per cent of respondents met the criteria for being a probable case due to reported COVID-19 symptoms or a positive test. HCWs in the emergency department (31.64%) were more likely to contract COVID-19 compared with HCWs in the ICU (23.17%) and inpatient settings (25.53%). HCWs that contracted COVID-19 also reported higher levels of depressive symptoms (mean diff.=0.31; 95% CI 0.16 to 0.47), anxiety symptoms (mean diff.=0.34; 95% CI 0.17 to 0.52) and burn-out (mean diff.=0.54; 95% CI 0.36 to 0.71). CONCLUSION: HCWs have experienced significant physical and psychological risk while working during the COVID-19 pandemic. These findings highlight the urgent need for increased support for provider physical and mental health well-being.