COVID-19 research covers taste and smell alterations, incidence in nursing homes and shelters, resource allocation policies

Alterations in taste and smell are common among patients with mild cases of COVID-19, according to a research letter published in JAMA on April 22. Italian researchers conducted a telephone survey of patients who had tested positive for SARS-CoV-2 and had been found suitable for home management as mildly symptomatic. Any altered sense of smell or taste was reported by 64.4% (95% CI, 57.3% to 71.0%) of 202 respondents. Of these 130 patients, 34.6% also reported a blocked nose. More than half also reported fatigue, dry or productive cough, or fever. Loss of taste or smell occurred before other symptoms in 11.9%, at the same time in 22.8%, and after in 26.7%. It was the only symptom in six patients and was more common among women than men. “If these results are confirmed, consideration should be given to testing and self-isolation of patients with new onset of altered taste or smell during the COVID-19 pandemic,” the authors concluded.

Another study, published by the New England Journal of Medicine on April 24, found that the virus spread through a Seattle skilled nursing facility before patients were symptomatic. Twenty-three days after the first positive test result, 57 of 89 residents (64%) tested positive. Of 48 residents who participated in point-prevalence surveys and tested positive, 27 (56%) were asymptomatic at testing, 24 of whom subsequently developed symptoms (median time to onset, 4 days). Eleven patients were hospitalized, and 15 died. The authors concluded that focusing infection control only on symptomatic residents was not sufficient to prevent transmission. “A new approach that expands Covid-19 testing to include asymptomatic persons residing or working in skilled nursing facilities needs to be implemented now,” agreed an accompanying editorial.

Other research published in the past week provided information about outcomes and prevalence of COVID-19 in the U.S. A case series, published by JAMA on April 22, described 5,700 patients with COVID-19 admitted to 12 hospitals in New York City, Long Island, and Westchester County, New York. Their median age was 63 years, and 39.7% were women. At triage, 30.7% of patients were febrile, 17.3% had a respiratory rate greater than 24 breaths/min, and 27.8% received supplemental oxygen. Of the 2,634 patients who had been discharged or had died by the study end point, 14.2% were treated in the ICU, 12.2% were on mechanical ventilation, 3.2% required renal replacement therapy, and 21% died. The mortality rate among those on mechanical ventilation was 88.1%. The readmission rate was 2.2%, with a median time to readmission of three days. The authors noted that among other limitations, the absence of outcome data on patients who remained hospitalized at the end of the study may have biased the findings.

A report from MMWR on April 22 assessed the prevalence of COVID-19 in homeless shelters, based on testing of 1,192 residents and 313 staff members in 19 homeless shelters in four cities. When testing followed identification of a cluster, there were high rates of positive tests in both groups: 36% of residents and 30% of staff in Boston; 66% and 16%, respectively, in San Francisco; and 17% of both in Seattle. Testing in shelters with one or no reported cases found much lower prevalence of infection (5% of residents and 1% of staff in Seattle, 4% of residents and 2% of staff in Atlanta).

On April 27, the Infectious Diseases Society of America (IDSA) released part 2 of its COVID-19 guideline, addressing infection prevention. For conventional settings and usual care, it recommended use of a surgical mask or N95 (or N99 or PAPR) respirator; for aerosol-generating procedures, an N95 was recommended. In contingency or crisis settings, the recommendations also allow for a reprocessed respirator as an option, as well as adding a face shield or surgical mask as a cover for an N95 to allow extended use or reuse. The panel did not make any recommendation on double gloves versus single gloves or shoe covers.

On April 20, the IDSA issued a primer on antibody testing, covering areas such as test quality and interpretation and additional research needs. In a recent letter to clinicians, the FDA recommended use of serological antibody tests to help identify people who may have been exposed to or have recovered from COVID-19 but notes that clinicians should be aware of their limitations and should not use them as the sole basis for diagnosis.

A survey conducted in late March and published by Annals of Internal Medicine on April 24 found that ventilator triage policies are uncommon even in hospitals with bioethics programs. Of 67 surveyed bioethics program directors, 36 (53.7%) said their hospitals did not yet have a policy. Among the 26 unique policies analyzed (three from state health departments), the most frequently cited triage criteria were benefit (25 policies), need (14 policies), age (13 policies), conservation of resources (10 policies), and lottery (9 policies).

An accompanying Ideas and Opinions article said that some current or proposed methods for allocating resources during the pandemic are discriminatory and stressed that using universal do-not-resuscitate orders, social worth, and life-years to triage care contravenes fairness and conflicts with ethical principles.

Current information from ACP about COVID-19, including the continually updated “COVID-19: An ACP Physician's Guide” and research from Annals of Internal Medicine, can be accessed at the ACP COVID-19 Resource Hub. ACP also recently released a Chapter action toolkit that Chapters can use to advance COVID-19-related policies at the state level.