COVID-19 Research Roundup 5: 10/19/20–10/25/20

Summaries from new articles and research papers exploring COVID-19, disparities, schools, novel treatments, and prevention strategies for 10/26/20–11/1/20.

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Executive Summary

Remdesivir was approved by the Food and Drug Administration (FDA) as a treatment in patients hospitalized with COVID-19. Tocilizumab was not shown to have therapeutic benefit in reducing clinical worsening in patients hospitalized with COVID-19. Scientists indicated that transmission of SARS-CoV-2 from surfaces and objects was not a significant form of transmission. Obesity was identified as an important factor in risk for severe COVID-19 disease course and mortality, with implications for future development of a COVID-19 vaccine. Vertical transmission of SARS-CoV-2 from mother to their newborn was not observed.

Drug companies working closely with the U.S. government and backed by $10 billion of taxpayer money, have developed, tested and scaled up a half-dozen potential vaccines at unprecedented speed. Still, the challenge lies in getting a successful vaccines to hundreds of millions of people. Concerns are increasing about the low rates of trial participation in important subgroups, especially Black communities.

More conversations have ensued to find a way to put students back in classrooms as research continues to show the jarring affects of online learning on learning and development. The CDC may shorten the mandatory quarantine for younger students, especially since elementary schools have shown impressively low transmission rates. Other experts are also advocating for more testing accessibility so that schools may be able to integrate more comprehensive testing protocols as more and more districts prepare to reopen in the near future.

If you have any questions or comments concerning this report or previous reports, or have any suggestions for future reports, please email them to dihicovidnc@gmail.com. We would love any and all feedback! Additionally, the personal emails of the authors can be found here: christopher.honeycutt@duke.edu, joanne.kim@duke.edu, tamara.tran@duke.edu. Thank you!

Important Statistics/Quotes

• In the study by Salvarani et al. published in JAMA Internal Medicine, “seventeen patients of 60 (28.3%) in the tocilizumab arm and 17 of 63 (27.0%) in the standard care group showed clinical worsening within 14 days since randomization (rate ratio, 1.05; 95% CI, 0.59–1.86). Two patients in the experimental group and 1 in the control group died before 30 days from randomization, and 6 and 5 patients were intubated in the 2 groups, respectively.”
• In the study by Hermine et al. published in JAMA Internal Medicine, “at day 14, 12% (95% CI −28% to 4%) fewer patients needed noninvasive ventilation (NIV) or mechanical ventilation (MV) or died in the Tocilizumab (TCZ) group than in the usual care (UC) group (24% vs 36%, median posterior hazard ratio [HR] 0.58; 90% CrI, 0.33–1.00), with a posterior probability of HR less than 1 of 95.0%, achieving the predefined efficacy threshold. The HR for MV or death was 0.58 (90% CrI, 0.30 to 1.09). At day 28, 7 patients had died in the TCZ group and 8 in the UC group (adjusted HR, 0.92; 95% CI 0.33–2.53). Serious adverse events occurred in 20 (32%) patients in the TCZ group and 29 (43%) in the UC group (P = .21).”

COVID-19 & the Education System

CDC Considers Shorter Covid-19 Quarantines for Children. The Wall Street Journal.

• The CDC is reconsidering the number of days schoolchildren who have come in contact with COVID-19-positive individuals should quarantine for in order to keep students in the classroom. While data is still being actively collected and analyzed, several public health officials at the CDC are seriously considering allowing children who have tested negative to cut their quarantines short. This reconsideration is a result of several parents, teachers, and school administrators voicing concerns over the implications of a 14-day quarantine on a child’s ability to learn; many found the mandated quarantine period “disruptive” to a child’s education. It is also worth noting that new research suggests that younger children may be less likely to transmit the virus: a study conducted by Yale University found that children do not contribute to the spread of the virus if they follow certain safety guidelines (i.e. wearing masks, social distancing, and washing their hands). It seems likely that as additional conclusive research is conducted, students may be able to return to classrooms more quickly after a potential encounter with a COVID-positive individual.

The Missing Piece — SARS-CoV-2 Testing and School Reopening. New England Journal of Medicine.

• The Los Angeles Unified School District launched a very unique program which entails testing more than 700,000 students and staff for COVID-19. The district’s ambitious undertaking is quite unusual as many school re-openings have excluded or failed to include concrete testing protocols. Further, while the CDC, American Academy of Pediatrics, National Academies of Sciences, Engineering, and Medicine, and state officials have stated the importance of preparing districts for COVID-19 outbreaks, little substantive guidance on testing has been provided. Documents that are currently available advise schools to gain access to testing by contacting local public health departments, but many will only provide tests for symptomatic individuals. Consequently, many schools have focused on screening for symptoms, even though 40% of COVID-19 cases are asymptomatic.
• There is a clear need for improving testing access and making it an integral part of plans to reopen schools.
• However, testing for COVID-19 presents three challenges for school districts: access to testing is limited, results take too much time, and the logistics are quite complex and daunting. Many schools do not have the financial means or resources to find independent contractors for testing purposes and public health departments are often limited in terms of capacity. Furthermore, test results often take days, complicating the quarantine process and communication efforts to students and their families. From a school administration standpoint, therefore, the entire testing process is overwhelming, as they must consider the accuracy and implementation of such protocols.
• In order to address these needs, the United States must consider routine screening guidelines and develop accessible, rapid-testing options for school districts. Additional COVID-19 relief packages should provide appropriations and assistance to school districts and enable them to scale up any testing programs. Further, the government should continue to fund the development of novel testing procedures, such as rapid antigen and saliva-based tests.

Schoolchildren Seem Unlikely to Fuel Coronavirus Surges, Scientists Say. The New York Times.

• When some schools reopened in the fall, the nation braced for a series of outbreaks that fortunately never came. At this time, schools do not seem to be contributing much to community transmission rates of COVID-19 (as seen in data from the U.S. and Britain). Elementary schools are especially less prone to become hotspots for the virus. While this research is still far from conclusive, many public health officials and leaders are becoming more comfortable with the idea that children are not driving transmission rates. After all, children under the age of 10 are mostly unaffected by the coronavirus and are less likely to transmit it to other kids or adults.
• “The more and more data that I see, the more comfortable I am that children are not, in fact, driving transmission, especially in school settings,” said Brooke Nichols, an infectious disease modeler at the Boston University School of Public Health.
• The new evidence has sparked some serious conversations on balancing safety and education. Parents and faculty members have expressed concerns over keeping students out of school, stating that elementary schools should at least offer in-person learning options. While the risks may not be zero, more and more research has shown the detrimental effects of keeping students out of the classrooms.
• “Children are not being prioritized, and they’re missing out on all the positive things about going to school,” Dr. Jenkins, an infectious disease expert at Boston University, said. “I don’t understand why we’re not as a community getting together and deciding that schools need to be a priority and making them as safe as we can.”

Further literature:

Politics, Markets, and Pandemics: Public Education’s Response to COVID-19. EdWorkingPapers.

‘Out of Control’: When Schools Opened in a Virus Hot Spot. New York Times.

3 COVID-19 education trends set to persist post-pandemic. Education Dive.

Physical distancing in schools for SARS-CoV-2 and the resurgence of rhinovirus. The Lancet.

Adams: How to Avoid Needless COVID School Closings & Treat All New York City Students Equally. The 74.

Disparities Among Race, Ethnicity, & Geography

Risk for In-Hospital Complications Associated with COVID-19 and Influenza — Veterans Health Administration, United States, October 1, 2018–May 31, 2020. CDC.

• Hospitalized patients with COVID-19 in the Veterans Health Administration had a more than five times higher risk for in-hospital death and increased risk for 17 respiratory and nonrespiratory complications than did hospitalized patients with influenza. The risks for sepsis and respiratory, neurologic, and renal complications of COVID-19 were higher among non-Hispanic Black or African American and Hispanic patients than among non-Hispanic White patients.
• The risk for respiratory complications was high: compared with patients with influenza, patients with COVID-19 had two times the risk for pneumonia, 1.7 times the risk for respiratory failure, 19 times the risk for ARDS, and 3.5 times the risk for pneumothorax, underscoring the severity of COVID-19 respiratory illness relative to that of influenza. Clinicians should be vigilant for symptoms and signs of a spectrum of complications among hospitalized patients with COVID-19 so that interventions can be instituted to improve outcomes and reduce long-term disability.

Trustworthiness before Trust — Covid-19 Vaccine Trials and the Black Community. New England Journal of Medicine.

• As the race to develop a vaccine for Covid-19 has reached phase 3 clinical trials, concerns are increasing about the low rates of trial participation in important subgroups, including Black communities. Recent data show that although Black people make up 13% of the U.S. population, they account for 21% of deaths from Covid-19 but only 3% of enrollees in vaccine trials. This problem threatens both the validity and the generalizability of the trial results and is of particular concern in vaccine trials, in which differences in lifetime environmental exposures can result in differences in immunologic responses that could affect both safety and efficacy.
• A crucial barrier to greater participation of Black people in Covid-19 trials is the deep and justified lack of trust that many Black Americans have for the health care system in general and clinical research in particular. This distrust is often traced to the legacy of the infamous syphilis study at Tuskegee, in which investigators withheld treatment from hundreds of Black men in order to study the natural history of the disease. But the distrust is far more deeply rooted, in centuries of well-documented examples of racist exploitation by American physicians and researchers.
• There are many ways to earn and deserve increased trust. First, trial sponsors and regulatory agencies can ensure that the informed-consent process is exemplary, including ensuring that all relevant aspects of the design and conduct of the clinical trials are maximally transparent. Second, all clinical research depends on people who are willing to accept the risks posed by trial participation in order to improve health for the people who come after them. Third, politicization of the vaccine trials has engendered widespread mistrust among the general public. The joint pledge by nine pharmaceutical companies that they will “stand with science” and not submit a vaccine for approval until it has been thoroughly vetted for safety and efficacy is welcome, but earning trust will require credible evidence that this pledge is being honored. Fourth, to earn and deserve trust from prospective trial participants, we must ensure that they will receive appropriate medical care if they are injured as a result of receiving an experimental vaccine.

Amid pandemic, U.S. has seen 300,000 ‘excess deaths,’ with highest rates among people of color. Stat News.

• Excess deaths are defined as the number of deaths overall during a particular period of time compared to how many people die during the stretch in a normal year. Now, in the most updated count to date, researchers at the Centers for Disease Control and Prevention have found that nearly 300,000 more people in the United States died from late January to early October this year compared the average number of people who died in recent years. Just two-thirds of those deaths were counted as Covid-19 fatalities, highlighting how the official U.S. death count — now standing at about 220,000 — is not fully inclusive.
• To be exact, the researchers reported that 299,028 more people died from Jan. 26 to Oct. 3 this year than on average during the same stretch from 2015 to 2019. Excess deaths also occurred at higher rates among Latinx, Asian, American Indian, and Black people than among white people, mirroring the disparities in official U.S. Covid-19 death counts.
• Most likely, the excess deaths account for some otherwise untallied Covid-19 deaths — those who may have died without being tested or who died at home and whose deaths were not counted as caused by the coronavirus. But the 300,000 number probably also includes people who died because they were scared to seek out medical care because of the pandemic or had their care interrupted, and because of other causes. One limitation of the study, the researchers noted, was that the U.S. population is growing and getting older, so more deaths might have occurred in 2020 versus recent years without a pandemic, making a direct comparison harder.

Further literature:

• Excess Deaths Associated with COVID-19, by Age and Race and Ethnicity — United States, January 26–October 3, 2020. CDC.
• Minority Populations Struggle More With Covid-19, 23andMe Study Shows. Wall Street Journal.

Infection Prevention and Treatment Strategies

FDA approves remdesivir as treatment for COVID-19 patients in hospital. USA Today.

• On Thursday, the U.S. Food and Drug Administration (FDA) approved remdesivir as a treatment for patients with COVID-19 requiring hospitalization. Remdesivir was previously authorized by the FDA for emergency use authorization. It is now the only drug approved by the FDA for treatment of COVID-19. The drug is a nucleotide analogue that acts to inhibit viral replication, including that of SARS-CoV-2. Remdesivir is made by Gilead Sciences Inc. and additionally goes by the brand name Veklury. A large study conducted by the National Institutes of Health (NIH) showed that remdesivir reduced the time to recovery for patients hospitalized with COVID-19 from 15 to 10 days. A subsequent study conducted by the World Health Organization (WHO) found that remdesivir induced no reduction in COVID-19 related mortality.

Effect of Tocilizumab vs Standard Care on Clinical Worsening in Patients Hospitalized With COVID-19 Pneumonia. JAMA Internal Medicine. Effect of Tocilizumab vs Usual Care in Adults Hospitalized With COVID-19 and Moderate or Severe Pneumonia. JAMA Internal Medicine.

• Dexamethasone, an anti-inflammatory steroid drug, was previously shown by the RECOVERY trial to reduce risk for intubation and death in patients with severe, COVID-19-associated pneumonia. The mechanism of the therapeutic nature of dexamethasone is reduction of the hyperinflammatory state associated with the “cytokine storm” and lung damage induced by SARS-CoV-2. Severe COVID-19 and COVID-19-associated mortality are associated with increased IL-6 signaling, an important pro-inflammatory cytokine. This suggests the potential for targeting IL-6 with antagonists to reduce the hyperinflammatory state of patients with severe COVID-19.
• Tocilizumab is a monoclonal antibody that acts as an IL-6 antagonist and has had promising results in preliminary observational studies in treatment of patients hospitalized with COVID-19. A prospective, randomized, open-label clinical trial of tocilizumab did not find any statistically significant reduction in clinical worsening in patients hospitalized with COVID-19 compared with a control group receiving supportive care. Clinical worsening was defined as entry into the intensive care unit with invasive mechanical ventilation, death from all causes, or clinical aggravation documented by the finding of a Pao2/Fio2 ratio less than 150 mm Hg, whichever came first. Patients were enrolled in the study in hospitals in Italy between March 31 and June 11, 2020. In total, there were 60 patients assigned to the tocilizumab treatment group and 66 assigned to the control group receiving supportive care. Patients in the experimental arm received intravenous tocilizumab within 8 hours from randomization (8 mg/kg up to a maximum of 800 mg), followed by a second dose after 12 hours. Overall, blinded, placebo-controlled randomized clinical trials are needed to confirm the results of this study and evaluate the therapeutic benefit of tocilizumab at different stages of COVID-19 infection.
• The results of another clinical trial assessing the effect of tocilizumab administration on World Health Organization (WHO) 10-point clinical progression scale (CPS) were published in the same journal on the same day (Tuesday, October 20, 2020). The randomized clinical trial was cohort-embedded, investigator-initiated, multicenter, open-label, and bayesian. It investigated patients with COVID-19 and moderate or severe pneumonia requiring at least 3 L/min of oxygen but without ventilation or admission to the intensive care unit and was conducted between March 31, 2020, to April 18, 2020, with follow-up through 28 days. Patients were enrolled from 9 university hospitals in France. of 131 total patients, 64 were assigned to the tocilizumab treatment group and 67 were assigned to the usual care group, which included antibiotic agents, antiviral agents, corticosteroids, vasopressor support, and anticoagulants. Overall, TCZ did not reduce WHO-CPS scores lower than 5 at day 4 but might have reduced the risk of needed noninvasive ventilation, mechanical ventilation, or death by day 14. No difference on day 28 mortality was found. Similarlyl to the other study, further studies are necessary for confirming these preliminary results.

Stop wiping down groceries and focus on bigger risks, say experts on coronavirus transmission. The Washington Post.

• Fomite transmission of SARS-CoV-2, which means transmission of the virus via surfaces or objects on which the virus is persisting, has been categorized by scientists as not being a significant way in which individuals are infected. Droplets and aerosols produced by infected individuals are much more significant paths of transmission of SARS-CoV-2. People need not disinfect groceries and other purchased items after returning home. However, fomite transmission can be something to worry about in certain scenarios, such as those in which there is a large concentration of people who are touching certain shared surfaces and/or objects. Such a scenario could be a public restroom near a crowded airport lounge or handrails in a crowded subway in a city. Classification of scenarios into low, medium, and high risk is an important practice and can help people determine courses of action in a world generallly lacking scenarios with absolutely no risk. Outdoor areas are generally much safer than indoor areas for SARS-CoV-2 transmission, as heat, light, and air flow can all contribute to reduction in viral persistence on surfaces and objects. Finally, use of hand soap and water or alcohol-based antiseptics are preferable over antibacterial hand soaps, as these can promote selection for antibiotic resistance while simultaneously not killing any SARS-CoV-2 viral particles.

Further literature:

• Latin America’s embrace of an unproven COVID treatment is hindering drug trials. Nature.
• Scientists have a powerful new tool for controlling the coronavirus: its own genetic code. The Washington Post.
• CDC expands definition of ‘close contacts,’ after study suggests Covid-19 can be passed in brief interactions. STAT.
• Double threat of COVID-19 and influenza. The Lancet.
• Influenza control during the COVID-19 pandemic. The Lancet.
• Universal mask use could save 130,000 U.S. lives by the end of February, new study estimates. STAT.
• Convalescent plasma in the management of moderate covid-19 in adults in India: open label phase II multicentre randomised controlled trial (PLACID Trial). The BMJ.

The Race for a Vaccine

Unprecedented vaccine trials on track to begin delivering results. Washington Post.

• Drug companies, working closely with the U.S. government and fueled by an infusion of more than $10 billion of taxpayer money, have developed, tested and scaled up a half-dozen potential vaccines at unprecedented speed.
• On Thursday, independent advisers to the Food and Drug Administration will convene their first full-day meeting to lay the groundwork for their coming consequential deliberations on whether to recommend specific vaccines for public use. Those decisions will not be binding on the FDA, but the agency typically follows the recommendations of its advisory committees.
• No vaccine has yet been proved safe and effective, some trials have been paused, and candidates still may fail. Once a company has gathered what it considers compelling evidence, regulatory review will take a few weeks. Most significant, the challenges of getting successful vaccines to hundreds of millions of people still loom after the science succeeds. So does the job of persuading Americans that vaccines, while powerful tools, are not panaceas and must be regarded as one of several strategies they must use to protect themselves against the novel coronavirus.

STAT-Harris Poll: The share of Americans interested in getting Covid-19 vaccine as soon as possible is dropping. Stat News.

• The share of Americans who say they are likely to get a Covid-19 vaccine as soon as it’s available is dropping. Overall, 58% of the U.S. public said they would get vaccinated as soon as a vaccine was available when asked earlier this month, down considerably from 69% who said the same thing in mid-August.
• The decline is notably more pronounced among Black Americans than among white individuals. According to a poll querying 2,050 people online from October 7 to 10th, 59% of white Americans indicated they would get vaccinated as soon as a vaccine is ready, a decline from 70% in mid-August. Only 43% of Black individuals said they would pursue a vaccine as soon as it was available, a sharp drop from 65% in mid-August.
• Suggests growing concern that the regulatory approval process for a Covid-19 vaccine has been politicized by the Trump administration in the run-up to the presidential election.

Covid-19 Vaccines to Be Stored Secretly Under Tight Security. Wall Street Journal.

• Health authorities, hospitals and pharmaceutical companies are storing Covid-19 vaccines in secure, undisclosed locations and taking other steps to protect the shots against theft.
• Vaccine makers such as Pfizer Inc. are deploying GPS software for tracking distribution and plotting fake shipments in dummy trucks to confuse criminals. Glassmaker Corning Inc. is equipping vials with black-light verification to curb counterfeiting. Some hospitals expected to be among the first vaccination sites are beefing up their pharmacies’ security systems.
• The goal is protecting the shots against professional thieves who have a long history of targeting valuable medicines, and have pilfered Covid-19 tests, masks and other personal protective equipment during the coronavirus pandemic.
• Despite such measures, industry officials and logistics specialists worry the shots could be vulnerable to theft at weak links in the supply chain, such as distribution centers, truck stops and hospitals with lax security.

Further literature:

• Sinovac coronavirus vaccine offered by Chinese city for emergency use costs $60. Reuters.
• Why this week’s meeting of an FDA advisory panel on Covid-19 vaccines matters. Stat News.
• Pfizer Sets Up Its ‘Biggest Ever’ Vaccination Distribution Campaign. Wall Street Journal.
• Oxford Developed Covid Vaccine, Then Scholars Clashed Over Money. Wall Street Journal.
• Answering Key Questions About COVID-19 Vaccines. JAMA.

Infection Rates and Disease Course in Children

How obesity could create problems for a COVID vaccine. Nature.

• COVID-19 clinical research has continued to show that obese individuals are at a higher risk to experience severe COVID-19 disease courses and die from COVID-19, even when controlling for disease states that tend to be associated with obesity, including hypertension and diabetes. These disparities in outcomes likely stem from multiple realities. First, obese patients can be harder to care for in the hospital, with one apt example being increased difficulty intubating severe COVID-19 patients when hooking them up to ventilators. Second, insulin resistance tends to appear as a precursor to diabetes in obese patients and could exacerbate the metabolic effects of COVID-19. Adipose tissue also expresses high levels of angiotensin converting enzyme 2 (ACE2), the receptor that SARS-CoV-2 uses to bind to and enter into host cells, resulting in adipose tissue acting somewhat like a viral reservoir. Third, and most worrisome, the effects of obesity on the immune system have important implications for obesity-related disparities in COVID-19 outcomes. Obese individuals can have constitutively active immune systems, resulting in some constant basal level of inflammation. This constant immune stimulation can “exhaust” the immune system, paradoxically resulting in decreased efficacy of T cell responses to viral infection. Congruently, obese individuals and have a harder time clearing the virus, indicated by the finding that the SARS-CoV-2 infection lingers in obese individuals for approximately five days longer than in lean individuals. Finally, obese individuals tend to have altered microbiomes with decreased microbial diversity compared with lean individuals.
• These factors suggest that COVID-19 vaccines could have decreased efficacy in obese individuals. Previous research on influenza, hepatitis B, and rabies vaccines showed reduced immune responses in obese individuals compared with lean individuals. Such potential differences in vaccine efficacy need to be considered in the coming months for public health benefit. There is potential for stratified data for obese and non-obese participants in vaccine trials to come about, but this has not been confirmed from the top vaccine candidates undergoing Phase 3 clinical trials.

Outcomes of Neonates Born to Mothers With Severe Acute Respiratory Syndrome Coronavirus 2 Infection at a Large Medical Center in New York City. JAMA Pediatrics.

• In two large academic hospitals in New York, New York, a retrospective cohort analysis was completed for outcomes of neonates born to mothers with positive test results for SARS-CoV-2 or suspected SARS-CoV-2 infection. 101 neonates born to 100 mothers were included in the study. In total, 82 newborns were admitted to well-baby nurseries and 19 newborns were admitted to neonatal intensive care units. Newborns in the well-baby nurseries roomed in with their mothers, who were required to wear masks. No evidence of vertical transmission of SARS-CoV-2, meaning transmission from mother to neonate, was found. Maternal severe or critical COVID-19 was associated with newborns born approximately one week earlier and at an increased risk of requiring phototherapy compared with maternal asymptomatic or mild COVID-19. These findings indicate that in the COVID-19 pandemic, separation of mothers infected with SARS-CoV-2 from their newborns may not be necessary and direct breastfeeding appears to be safe.

Clinical Manifestations and Outcomes of Critically Ill Children and Adolescents with Coronavirus Disease 2019 in New York City. The Journal of Pediatrics.

• A retrospective observational study of children 1 month to 21 years admitted March 14 to May 2, 2020, to 9 New York City pediatric intensive care units (PICUs) with severe acute respiratory syndrome coronavirus 2 infection. Of 70 children admitted to PICUs, median age was 15 (IQR 9, 19) years; 61.4% male; 38.6% Hispanic; 32.9% black; and 74.3% with comorbidities. Fever (72.9%) and cough (71.4%) were the common presenting symptoms. Twelve patients (17%) met severe sepsis criteria; 14 (20%) required vasopressor support; 21 (30%) developed acute respiratory distress syndrome (ARDS); 9 (12.9%) met acute kidney injury criteria; 1 (1.4%) required renal-replacement therapy, and 2 (2.8%) had cardiac arrest. For treatment, 27 (38.6%) patients received hydroxychloroquine; 13 (18.6%) remdesivir; 23 (32.9%) corticosteroids; 3 (4.3%) tocilizumab; and 1 (1.4%) anakinra; no patient was given immunoglobulin or convalescent plasma. Forty-nine (70%) patients required respiratory support: 14 (20.0%) noninvasive mechanical ventilation, 20 (28.6%) invasive mechanical ventilation (IMV), 7 (10%) prone position, 2 (2.8%) inhaled nitric oxide, and 1 (1.4%) extracorporeal membrane oxygenation. Nine (45%) of the 20 patients requiring IMV were extubated by day 14 with median IMV duration of 218 (IQR 79, 310.4) hours. Presence of ARDS was significantly associated with duration of PICU and hospital stay, and lower probability of PICU and hospital discharge at hospital day 14 (P < .05 for all). The study concluded that critically ill children with COVID-19 predominantly are adolescents, have comorbidities, and require some form of respiratory support. The presence of ARDS is significantly associated with prolonged PICU and hospital stay.

Further literature:

• Guillain-Barré Syndrome in a Child With COVID-19 Infection. Pediatrics.
• The Role of COVID-19 in Transitioning to a Better Pediatric Payment Model. Pediatrics.

Live Trackers/Important Links

1. Where Schools are Reopening in the U.S.
2. Johns Hopkins Coronavirus Resource Center
3. The Washington Post COVID-19 Vaccine Tracker
4. The New York Times COVID-19 Vaccine Tracker
5. The Washington Post Global COVID-19 Spread Tracker
6. The New York Times North Carolina COVID-19 Spread Tracker
7. Duke COVID-19 Testing Tracker
8. University of North Carolina at Chapel Hill COVID-19 Tracker
9. The New York Times State Reopening and Closing Tracker
10. Brown University School COVID Response Dashboard