Top 10: November 22

Copy-editor: Rob Camp


Thompson CN, Baumgartner J, Pichardo C, et al. COVID-19 Outbreak — New York City, February 29–June 1, 2020. MMWR 2020;69:1725–1729. Full-text:

During March–May 2020, approximately 203.000 laboratory-confirmed COVID-19 cases were reported to the NYC Department of Health and Mental Hygiene (DOHMH). The crude fatality rate (CFR) among confirmed cases was 9.2% overall and 32.1% among hospitalized patients. Incidence, hospitalization rates, and mortality were highest among Black/African American and Hispanic/Latino persons, as well as those who were living in neighborhoods with high poverty, aged ≥ 75 years, and with underlying medical conditions. Of note, the overall CFR of 9,2% is an overestimate because of under-ascertainment of cases, given the restrictive testing guidance and limited availability of tests during the first 2 months of the epidemic.



Volz E, Hill V, McCrone JT, et al. Evaluating the effects of SARS-CoV-2 Spike mutation D614G on transmissibility and pathogenicity. Cell November 18, 2020. Full-text:

Investigating the hypothesis for positive selection of Spike D614G in more than 25.000 whole genome SARS-CoV-2 sequences from the UK, not all approaches showed a conclusive signal of positive selection. However, population genetic analysis indicated that 614G increased in frequency relative to 614D in a manner consistent with a selective advantage. 614G was also associated with higher viral load and younger age of patients.



Van Dyke ME, Rogers TM, Pevzner E, et al. Trends in County-Level COVID-19 Incidence in Counties With and Without a Mask Mandate — Kansas, June 1–August 23, 2020. MMWR Morb Mortal Wkly Rep. ePub: 20 November 2020. Full-text:

Masks work! The governor of Kansas issued an executive order requiring wearing masks in public spaces, effective July 3, 2020, which was subject to county authority to opt out. After July 3, COVID-19 incidence decreased in 24 counties with mask mandates but continued to increase in 81 counties without mask mandates. By August 17–23, 2020, the 7-day rolling average COVID-19 incidence had decreased by 6% to 16 cases per 100.000 among mandated counties and increased by 100% to 12 per 100.000 among non-mandated counties.



Lewis JR. What Is Driving the Decline in People’s Willingness to Take the COVID-19 Vaccine in the United States? JAMA Health Forum. 2020; 1(11):e201393. Full-text:

People in the US are ready to move on from the COVID-19 pandemic, but when it comes to a vaccine, many have a wait-and-see attitude. Jarrett Ramos Lewis addresses the reasons. As we move toward having an approved COVID-19 vaccine, it is important to understand that for many, it will take time to feel comfortable and confident in getting the vaccine. While the politicization of the vaccine is to blame for some of that delay, the increased reluctance of people to get a COVID-19 vaccine runs much deeper than politics.



Oved K, Olmer L, Shemer-Avni Y, et al. Multi-center nationwide comparison of seven serology assays reveals a SARS-CoV-2 non-responding seronegative subpopulation. EClinical Med November 19, 2020. Full-text:

Serology assays from Roche, Abbott, Diasorin, BioMerieux, Beckman-Coulter, Siemens, and Mt. Sinai ELISA were used to analyze negative samples from 2391 individuals representative of the Israeli population, and 698 SARS-CoV-2 PCR positive patients. Immunoassay sensitivities were between 81,5% – 89,4% while specificities were between 97,7% – 100%, resulting in a profound impact on the expected Positive Predictive Value in low (< 15%) prevalence scenarios. No meaningful increase was detected in the false positive rate in children compared to adults. A positive correlation between disease severity and antibody titers, and no decrease in antibody titers in the first 8 weeks after PCR positivity was observed. The authors also identified a subgroup of symptomatic SARS-CoV-2 positive patients (~5%), who remained seronegative across a wide range of antigens, isotypes, and technologies.



Van den Borst B, Peters JB, Brink M, et al. Comprehensive health assessment three months after recovery from acute COVID-19. Clin Infect Dis 21 November 2020, ciaa1750. Full-text:

More on “long COVID-19”. All patients discharged after COVID-19 from the Radboud University Medical Centre, Nijmegen, The Netherlands, were consecutively invited to a multidisciplinary outpatient facility. Also, non-admitted patients with mild disease but with symptoms persisting > 6 weeks could be referred by general practitioners. Patients underwent a standardized assessment including measurements of lung function, chest CT/X-ray, 6-minute walk test, body composition, and questionnaires. Among 124 patients (27 mild, 51 moderate, 26 severe and 20 critical), lung diffusion capacity was below the lower limit of normal in 42% of discharged patients, and 22% had low exercise capacity. Problems in mental and/or cognitive function were found in 36% of patients. Health status was generally poor, particularly in the domains of functional impairment (64%), fatigue (69%) and quality of life (72%).


Kennedy M, Helfand BKI, Gou RY, et al. Delirium in Older Patients With COVID-19 Presenting to the Emergency Department. JAMA Netw Open, November 19. 2020;3(11):e2029540. Full-text:

In this retrospective cohort study of 817 patients older than 65 years with COVID-19 presenting at emergency departments (ED) of 7 US sites, 28% had delirium at presentation, and delirium was the sixth most common of all presenting signs and symptoms. Among delirious patients, 37% had no typical COVID-19 symptoms or signs, such as cough or fever. Factors associated with delirium (with adjusted relative risk, aRR between 1.1 and 2) were older than 75 years, living in a nursing home or assisted living, had prior use of psychoactive medication, vision impairment, hearing impairment, stroke, and Parkinson’s disease. Not very surprising: delirium was associated with ICU stay (aRR 1.67) and death (aRR 1.24).


Severe COVID-19

Fiacchini G, Tricò D, Ribechini A, et al. Evaluation of the Incidence and Potential Mechanisms of Tracheal Complications in Patients With COVID-19. JAMA Otolaryngol Head Neck Surg. Published online November 19, 2020. Full-text:

Giacomo Fiacchini and colleagues from Pisa, Italy demonstrate a high tracheal complication rate of invasive mechanical ventilation. In their cohort study of 98 patients with COVID-19 and severe respiratory failure, the incidence of full-thickness tracheal lesions or tracheoesophageal fistulas after prolonged (≥ 14 days) invasive mechanical ventilation was significantly higher in patients with COVID-19 (46,7%) than matched controls (2,2%). Attempts to prevent these lesions should be made and quickly recognized when they occur to avoid potentially life-threatening complications in ventilated patients with COVID-19.


Sun L, Hymowitz M, Pomeranz HD. Eye Protection for Patients With COVID-19 Undergoing Prolonged Prone-Position Ventilation. JAMA Ophthalmol. Published online November 19, 2020. Full-text:

Clinicians should also be aware of the possible presence of elevated intraocular pressure from periorbital edema due to direct compression of the eye and orbit, and optic disc edema and retinal hemorrhages, which may be associated with a hypercoagulable state, in patients in prolonged prone position. Lucy Sun and colleagues report on two patients with periorbital edema in the prone position with bilateral findings of optic disc edema and retinal hemorrhages as well as a substantial increase in intraocular pressure.



Adhikari EH, Moreno W, Zofkie AC, et al. Pregnancy Outcomes Among Women With and Without Severe Acute Respiratory Syndrome Coronavirus 2 Infection. JAMA Netw Open November 19. 2020;3(11):e2029256. Full-text:

Good news from Dallas, USA: in this cohort study of 252 SARS-CoV-2–positive and 3122 negative pregnant women tested in outpatient and inpatient settings at a large county medical center, adverse pregnancy outcomes were similar. Neonatal infection occurred in 3% of infants, predominantly among infants born to asymptomatic or mildly symptomatic women. Placental abnormalities were not associated with disease severity, and the rate of hospitalization was similar to rates among non-pregnant women.



Roarty C, Tonry C, McFetridge L, et al. Kinetics and seroprevalence of SARS-CoV-2 antibodies in children. Lancet Infect Dis November 19, 2020.  Full-text:

Antibody titers in children exposed to SARS-CoV-2 remain at a detectable level for at least 62 days.


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