Top 10: August 22

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By Christian Hoffmann &
Bernd S. Kamps


This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give it early visibility.

22 August


Hatcher SM, Agnew-Brune C, Anderson M, et al. COVID-19 Among American Indian and Alaska Native Persons — 23 States, January 31–July 3, 2020. MMWR Morb Mortal Wkly Rep 2020, published 19 August 2020. Full-text:

American Indian and Alaska Native (AI/AN) persons appear to be disproportionately affected by the COVID-19 pandemic. Now Sarah Hatcher et al. report that the overall COVID-19 incidence among American Indian and Alaska Native (AI/AN) persons was 3.5 times that among white persons (594 per 100,000 AI/AN population compared with 169 per 100,000 white population). The authors discuss the factors which most likely contributed to the observed elevated incidence.


Jiménez MC, Cowger TL, Simon LE, Behn M, Cassarino N, Bassett MT. Epidemiology of COVID-19 Among Incarcerated Individuals and Staff in Massachusetts Jails and Prisons. JAMA Netw Open 2020;3(8). Full-text:

Of 14 987 individuals incarcerated across Massachusetts facilities, 1032 confirmed cases of COVID-19 were reported among incarcerated individuals (n = 664) and staff (n = 368) as of July 8, 2020. The rate of COVID-19 among incarcerated individuals was nearly 3 times that of the Massachusetts general population and 5 times the US rate. Monik Jiménez et al. stress that access to testing without coercion, decarceration, and contact tracing are necessary to decrease harm from COVID-19 to incarcerated people and their communities.



Link-Gelles R, DellaGrotta AL, Molina C, et al. Limited Secondary Transmission of SARS-CoV-2 in Child Care Programs — Rhode Island, June 1–July 31, 2020. MMWR Morb Mortal Wkly Rep. ePub: 21 August 2020. Full-text:

Ruth Link-Gelles et al. report a possible secondary transmission in four of the 666 child care programs in Rhode Island that had been allowed to reopen. The apparent absence of secondary transmission within the other 662 child care programs was likely the result of efforts to contain SARS-CoV-2 transmission, in particular maximum class sizes and use of face masks for adults. The authors conclude that adherence to current CDC recommendations remains critical to reducing transmission in child care settings, including wearing of masks by adults, limiting mixing between established student-teacher groups, staying home when ill, and cleaning and disinfecting frequently touched surfaces.



Please cite this article as: Stites EC, Wilen CB. The Interpretation of SARS-CoV-2 Diagnostic Tests. Med 2020, published 21 August. Full-text:

There is evidence that physicians struggle with proper probabilistic test interpretation. Here, Edward Stites and Craig Wilen provide answers to questions such as, Should asymptomatic individuals be tested? What does it mean to test positive (or negative)? How shall we interpret tests for “immunity passports”? They review the general principles of SARS-CoV-2 test interpretation and warn that improper utilization can potentially have unintended negative consequences.



Nachtigall I, Lenga P, Jóźwiak K, et al. Clinical course and factors associated with outcomes among 1904 patients hospitalized with COVID-19 in Germany: an observational study. Clin Microbiol Infect 2020, published 18 August. Full-text:

In Germany, the COVID-19 pandemic has been associated with a lower case fatality rate (CFR) compared with other Western and Central European countries. The reason? Age! During the first COVID-19 wave in spring 2020, the median age of SARS-CoV-2 infected people in Germany was much lower than in Italy, for example. As younger people have a more benign clinical course, the national CFR remained low. However, once German patients with COVID-19 were admitted to an intensive care unit (ICU), the mortality rate was 29% and thus comparable to other European countries. This is the result of a retrospective cohort study of 1904 patients (median age: 73 years) admitted to a national network of German hospitals, by Irit Nachtigall, Julius Dengler and colleagues. As expected, the authors also find that the most prominent risk factors for death are male sex, preexisting lung disease, and increased patient age. The mortality rates in detail:

Overall 17%
  • Patients admitted to the ICU
    • Ventilated
    • Non-ventilated



Yueh B. The Worst Patient—A Physician With COVID-19. JAMA Otolaryngol Head Neck Surg 2020, published 20 August. Full-text:

As an accomplished surgeon who has missed fewer than 2 weeks of work in 30 years, proud that you operated 2 weeks later with a broken leg and ankle ski lift accident, how could you possibly accept to miss week after week with COVID-19? Bevan Yueh had a hard time. Read about denial, whistleblowers, 500 cc spirometry and nightmares.



Spinner CD, Gottlieb RL, Criner GJ, et al. Effect of Remdesivir vs Standard Care on Clinical Status at 11 Days in Patients With Moderate COVID-19: A Randomized Clinical Trial. JAMA 2020, published 21 August. Full-text:

In this open-label trial, Christoph D. Spinner et al. found that hospitalized patients with moderate COVID-19 (pulmonary infiltrates and room-air oxygen saturation >94%) who received a 5-day course of remdesivir had a better clinical status compared with those randomized to standard care at 11 days after initiation of treatment. There were no significant differences between the remdesivir and standard care groups in

  • duration of oxygen therapy
  • duration of hospitalization
  • all-cause mortality

The authors acknowledge that the differences in clinical status between the remdesivir and control groups is of uncertain clinical importance.

Our forecast: remdesivir will be remembered as the AZT of the COVID-19 pandemic – cumbersome to administrate, low efficacy. As soon as truly efficient drugs will be available, remdesivir will sink quietly into oblivion. The first nail in the remdesivir coffin is dexamethasone. As Erin McCreary and Derek Angus conclude in their editorial: “Whether remdesivir offers incremental benefit over corticosteroids, which are widely available and inexpensive, is unknown.” (McCreary EK, Angus DC. Efficacy of Remdesivir in COVID-19. JAMA 2020, published 21 August. Full-text:


Severe COVID

Manson JJ, Crooks C, Naja M, et al. COVID-19-associated hyperinflammation and escalation of patient care: a retrospective longitudinal cohort study. Lancet Rheumatol 2020, published 21 August. Full-text:

Jessica Manson et al. define a phenotype of COVID-19-associated hyperinflammation (COV-HI) by measurement of readily available routine clinical parameters:

  1. C-reactive protein (greater than 150 mg/L or doubling within 24 h from greater than 50 mg/L) and 2)


  1. Ferritin (greater than 1500 μg/L)

Of patients with COV-HI on admission, 36/90 patients (40%) died during follow-up compared with 46/179 (26%) of the patients without COV-HI on admission, indicating the existence of a high-risk inflammatory phenotype. The authors conclude that COV-HI might be useful to stratify patient groups in trial design. See also the critical comment by Kiran Reddy and colleagues (Reddy K, Rogers AJ, McAuley DF: Delving beneath the surface of hyperinflammation in COVID-19. Lancet Rheumatol 2020, published 21 August. Full-text:



Dolhnikoff M, Ferreira Ferranti J, de Almeida Monteiro RA, et al. SARS-CoV-2 in cardiac tissue of a child with COVID-19-related multisystem inflammatory syndrome. Lancet Child Adolesc Health 2020, published 20 August. Full-text:

In a post-mortem analysis of cardiac tissue by electron microscopy, Marisa Dolhnikoff et al. report identified spherical viral particles of 70–100 nm in diameter, consistent in size and shape with the Coronaviridae family, in the extracellular compartment and within several cell types—cardiomyocytes, capillary endothelial cells, endocardium endothelial cells, macrophages, neutrophils, and fibroblasts. The autopsy showed myocarditis, pericarditis, and endocarditis, with intense and diffuse tissue inflammation, and necrosis of cardiomyocytes. The authors conclude that clinical, echocardiographic, and laboratory findings strongly indicated that heart failure was the main determinant of the fatal outcome.



Rubin EJ, Baden LR, Morrissey S. Covid-19 and Contact Tracing. N Engl J Med 2020; 383:e73. Access:

In this audio interview (27:42), the editors discuss the use of contact tracing to limit the spread of SARS-CoV-2 and the challenges posed by certain characteristics of the virus.


Society & Prevention

Smith D. Obama’s stark message: America must save itself from Trump. The Guardian 2020, published 20 August. Full-text:

No comment needed.



If you read Spanish, read Jan C, Enano VL. Del autorrastreo en La Rioja al fin de las ‘party boats’ en Baleares, así aplica cada comunidad las medidas de Sanidad. El País 2020, published 22 August. Full-text:

Cecilia Jan and Virginia López Enano present detailed to-do lists elaborated by the Spanish government and regional authorities in view of the second pandemic COVID-19 wave. A precious read of >5,000 words!