Patients with symptomatic COVID-19 were more likely than uninfected controls to report some form of restaurant dining — including indoor, patio and outdoor seating — in the 2 weeks prior to symptom onset, CDC researchers found.
Compared to controls without COVID-19, case patients were more than twice as likely to have reported dining at a restaurant (adjusted OR 2.4, 95% CI 1.5-3.8), reported Kiva Fisher, PhD, of the CDC, and colleagues.
When the analysis was restricted to case patients with close contact to anyone with confirmed COVID-19, case patients were still more likely to report having visited a bar/coffee shop (aOR 3.9, 95% CI 1.5-10.1) or restaurant (aOR 2.8, 95% CI 1.9-4.3) than control patients, albeit with wider confidence intervals, Fisher’s group wrote in the Morbidity and Mortality Weekly Report.
Not surprisingly a substantially larger proportion of case patients reported close contact with a person with COVID-19 versus controls (42% vs 14%, respectively).
This data was previewed at the National Academy of Sciences and Medicine (NASEM) workshop on airborne transmission as part of the growing “circumstantial evidence” suggesting airborne transmission may play a role in COVID-19 spread.
“Reports of exposures in restaurants have been linked to air circulation,” the authors wrote. “Direction, ventilation, and intensity of airflow might affect virus transmission, even if social distancing measures and mask use are implemented according to current guidance.”
Researchers examined data from adults tested for SARS-CoV-2 at one of 11 Influenza Vaccine Effectiveness in the Critically Ill (IVY) Network sites in July. COVID-19 cases were confirmed via PCR testing for SARS-CoV-2 from respiratory specimens. For every case, control patients who tested negative for SARS-CoV-2 were matched based on age, sex and study location. The investigators then followed up with phone interviews. After screening, Fisher and colleagues had 154 case patients and 160 controls for analysis.
Controls were significantly more likely to be non-Hispanic white, have a college degree or higher and report at least one underlying chronic medical condition compared to cases. Self-reported mask compliance was high in both groups, with 71% of cases and 74% of controls reporting always using face coverings in public. About half of close contacts reported (51%) were family members.
About half of all participants reporting going shopping or visiting someone inside of a home with 10 people or less at least once in the 14 days prior to symptom onset. However, there was no difference between cases and controls in reported shopping, gatherings in homes irrespective of the number of guests, going to an office or salon, using public transportation, patronizing a bar or coffee shop, or attending church/religious gatherings.
Overall, 107 participants said they’d gone to a restaurant and 21 to a bar or coffee shop. Cases not only outnumbered controls in these groups, but were also significantly more likely to report that “almost all patrons” at the establishments weren’t wearing masks or maintaining safe distances.
“Implementing safe practices to reduce exposures to SARS-CoV-2 during on-site eating and drinking should be considered to protect customers, employees, and communities and slow the spread of COVID-19,” Fisher and colleagues concluded.
By Molly Walker, Associate Editor, MedPage Today
Nursing was the most common occupation and residential care facilities were the most common reported job setting for healthcare professionals (HCPs) with COVID-19, CDC researchers found.
In a subset of six jurisdictions reporting occupational type or job setting for HCPs with COVID-19, 30% of infected HCPs were nurses — twice the proportion of nurses in the healthcare workforce (15%) — and two-thirds of cases were in nursing and residential care settings, reported Michelle Hughes, PhD, of the CDC, and colleagues in Morbidity and Mortality Weekly Report.
Similar to previously reported U.S. data, HCPs with COVID-19 who were male, age 65 or older, or nonwhite, or had underlying medical conditions, were particularly likely to have died.
The researchers cited workers in long-term care facilities as those most in need of attention during the pandemic.
“During the COVID-19 pandemic, multiple challenges in long-term care settings have been identified, including inadequate staffing and PPE, and insufficient training in infection prevention and control,” Hughes and colleagues wrote. “As the pandemic continues, it is essential to meet the health and safety needs of HCPs serving populations requiring long-term care.”
Even HCPs who do not provide direct patient care, such as administrative staff members and environmental service workers, were at risk, Hughes and colleagues also emphasized. About 19% of cases among HCPs had such jobs.
They added that their count probably underestimated the number of healthcare professionals with COVID-19, especially among asymptomatic individuals, given that job status was only available for 22% of COVID-19 cases reported to CDC. It was added to the CDC case report form in May.
The data — which covered Feb. 12 to July 16, 2020 — included 641 deaths in healthcare professionals with COVID-19. More recent statistics from the CDC indicates 162,328 cases of COVID-19 and 710 deaths as of Sept. 23 among U.S. healthcare professionals.
In the MMWR analysis, which covered about 100,000 COVID-affected HCPs who met inclusion criteria, median age was 41, and 79% were women. Of those with race/ethnicity data available, 47% were non-Hispanic white, 26% were Black, 12% were Hispanics or Latinos of any race, and 9% were Asian.
Among HCPs with data on underlying medical conditions, 44% had at least one of 10 underlying medical conditions. Cardiovascular disease (18%) was the most common, followed by chronic lung disease (16%) and diabetes (13%). Cardiovascular disease and diabetes mellitus were most common in those who died.
Hospitalization and intensive care unit admission status were available for only a portion of HCP cases; however, 8% of those with known status were hospitalized and 5% were admitted to an ICU.
By Molly Walker, Associate Editor, MedPage Today
Before COVID-19 hit New York City, Mount Sinai Morningside Hospital had a flexible, 24-hour visitor policy for patients in the intensive care unit (ICU).
People would visit their loved ones at any hour of the day, coming and going as they pleased. Doctors and nurses said the constant support of family members was beneficial to these gravely ill patients.
Now, per New York State Department of Health guidelines that apply to all areas of the hospital, visitors are limited to one 4-hour session per day, and only one person is allowed at the bedside at a time. At Morningside, that has to be done between the hours of 10 a.m. and 6 p.m. so visitors can undergo temperature and symptom checks before being permitted on the floors.
Morningside ICU physicians and nurses told MedPage Today those visitation policies are too restrictive, especially as staff have become more adept at managing COVID-19 transmission risk.
“It’s particularly challenging for this community because these families have a lot of restrictions,” said Mirna Mohanraj, MD, an ICU physician at Morningside (formerly St. Luke’s Hospital), which predominantly serves minority patients from Harlem and the Bronx. “Not everyone has a flexible job they can leave for 4 hours. They don’t have the financial resources to hire childcare.”
In an emailed statement, the New York State Department of Health said that hospitals “can authorize visits longer than four hours depending on a patient’s status and condition” and noted that labor & delivery patients, pediatric patients, and those with intellectual or developmental disabilities can have a support person at all times.
“This policy remains in place to safeguard and maintain the health and wellbeing of patients, staff and visitors while the need to contain the spread of COVID-19 continues,” the statement read.
The new visitation rules are a vast improvement from the disease peak, when visitors were barred from hospitals altogether and patients died alone. But while the policy may be sufficient for patients elsewhere in the hospital, it poses particular challenges for the ICU, Mohanraj said.
“The ICU is such a dynamic place, things change frequently and unexpectedly,” she said. “It’s traumatic for a family member not to be present when things are changing rapidly.”
Morningside ICU charge nurse Jessica Montanaro, MSN, RN, said while the visitation rules “make sense on regular floors, you have more grave situations [in the ICU]. You’re dealing with death and difficult decisions. In truly grave situations, people need more support. It should be a different situation for the ICU.”
Mohanraj said the literature “shows that having family at the bedside can be beneficial to patients” in the ICU, which is why many ICUs have adopted flexible visitor policies in recent years.
“Family members can provide emotional and psychological support,” she said. “Often, they’re the ones re-orienting patients, moving their legs, alerting the nurses to issues like pain control or a bedpan.”
“They’re also the constant reminder of the full lives that patients had before they got to the ICU,” she added. “And it helps the family develop trust in us as their healthcare team.”
Hospital administrators have allowed exceptions on a case-by-case basis, as called for by the state guidelines. But that means more time spent trying to cut through red tape, and the possibility of request denials.
Eric Gottesman, MD, medical director of the ICU at North Shore University Hospital in Manhasset, New York, which was also hit hard during the COVID-19 peak, said administrators there typically make exceptions to the visitor rule for end-of-life discussions.
“We follow the guidelines but if there’s an emergent issue, we do stray a little,” Gottesman told MedPage Today. “We try to bend, not break.”
Gottesman was similarly accustomed to a liberal visitation policy before COVID-19 hit. The new policy “puts more pressure on us by having to tell patients about the limitations,” he said. “Also, if we’re on rounds and no family member is present to take in the info, we have to come back and do it over.”
So what changes would ICU doctors and nurses like to see?
Family members should be able to stay for longer than 4 hours, Mohanraj said, especially if that person is the patient’s only visitor. That visitor should also be allowed to return to the bedside after they’ve left (right now, once a visitor leaves a hospital floor, they’re not allowed to return).
Finally, Mohanraj said nighttime visits would be especially helpful because ICU patients who experience delirium typically get worse at night, so the additional family support might alleviate related issues.
Safety is the first priority, she said, and thus far preventing transmission among visitors “has been perfectly manageable,” especially as very few patients with COVID-19 remain in the hospital, she said.
ICU providers in New York hospitals say the trauma of seeing families separated during the peak of the crisis has stuck with them, and makes their current push to have family members around more urgent.
In the beginning of the crisis, visitors weren’t allowed unless a patient was imminently dying — but that’s not always easy to call, Montanaro said.
“We had difficult cases where we would allow one family member to come up and stand in the patient’s doorway, say their goodbyes, and then the patient didn’t pass,” Montanaro said.
As policies eased over time, and patients could have two visitors, she recalled a case of a dying mother with three family members who wanted to say goodbye — her husband and two sons.
“That family had to choose which son would say goodbye to their mother,” she said. “So many things about that experience will haunt us for the rest of our lives.”
Among older former cigarette smokers, a strong correlation was shown between smoking duration and health, with longer smoking history associated with greater risk for poor overall health, chronic obstructive pulmonary disease (COPD), and chronic disease, according to CDC research.
In national data, for people ages 65 and older who had once smoked but quit, a linear association was seen between years of active smoking and risk for fair or poor health, reported Ellen A. Kramarow, PhD, of the CDC in Atlanta, in National Health Statistics Reports.
Based on data from the 2018 National Health Interview Survey (NHIS) and adjusted for age, sex, race, and Hispanic origin and education, the analysis linked several negative health outcomes with increasing smoking duration:
- Poor or fair health: 17.8% (smoking duration ≤10 years), 20.3% (>10 and <25 years) , 23.4% (25 to <40 years), and 28.5% (≥40 years)
- COPD: 9.1%, 12.2%, 20.3%, and 32.7%
- At least four chronic conditions: 18.1%, 17.2%, 23.3%, and 26.1%
- Limitations on social life: 8.6%, 9.1%, 10.7%, and 14.2%
Kramarow told MedPage Today that while the health benefits of quitting smoking are numerous and well characterized, less is known about the health risks associated with smoking in the past among older former smokers.
Older adults in the U.S. are more likely than younger adults to have a history of smoking, with former smokers making up 21% of the 2018 NHIS population overall, and 40% of survey participants who were ages 65 and older. This 40% represented nearly half of men in the 65-plus age group and a third of women.
Quitting smoking is associated with immediate and long-term health benefits, such as improved lung function and reduced risk of heart attack and stroke.
Among the former smokers, ages 65 and older, who participated in the 2018 NHIS, more than half reported smoking for 25 years or more, with 23.5% smoking for 40 or more years, and 31% smoking for 25 to 40 years.
Some 18% reported smoking for less than a decade, and 27.6% reported smoking for more than 10 years and less than 25 years.
Roughly three-fourths of the older former smokers had started smoking by age 20, and 93% of those who smoked for less than a decade reported quitting 40 years earlier or more.
Conversely, among older former smokers who smoked for 40-plus years, 37.4% reported quitting within the last 5 years, and 57.3% reported quitting more than 5 years and less than 25 years before participating in the 2018 survey.
The analysis divided the older former smokers into four smoking duration categories: 10 years or less, more than 10 years and less than 25 years, 25 to less than 40 years, and 40 years or more.
Kramarow noted that the study had significant limitations, including the inability to control for how long ago a former smoker quit. Smoking length was established based on answers to the questions; “How old were you when you first started to smoke fairly regularly?” and “How long has it been since you quit smoking cigarettes?”
“There may be independent effects of time since quitting on health among older adult former smokers,” she wrote. “Measured at one point in time, it is difficult to separate the impact of number of years smoked from time since quitting because they are so highly correlated.”
Information was also lacking on the intensity of smoking — whether the former smokers had been light or heavy smokers. The survey also did not ask about use of other tobacco products.
Despite the limitations, Kramarow told MedPage Today that the findings bolster evidence of a dose-response relationship between smoking and poor health, and she said clinicians caring for older patients should ask about smoking history.
“When considering the health of older people, it is worth keeping in mind that a significant proportion are former smokers,” she said. “Smoking history is probably still relevant, even if someone stopped smoking decades ago.”
Kramarow disclosed no relevant relationships with industry.
National Health Statistics Reports
Source Reference: Kramarow EA “Health of former cigarette smokers aged 65 and over: United States, 2018” National Health Statistic Report Report 2020; No. 145.
Nurses are increasingly being forced to reuse N95 masks, sometimes for five days or longer, and growing numbers of nurses said they feel unsafe reusing masks even after they were decontaminated, according to the latest in a series of nursing surveys.
That’s the worrying message Tuesday from the American Nurses Association, which reported its latest results from 21,500 nurses responding between July 24 and Aug. 14. (The survey was sent to approximately 170,000 ANA members and 300,000 non-members.)
“It is troubling that six months — six months — into the COVID-19 pandemic, nurses continue to report that PPE [personal protective equipment] shortages persist, and reuse practices of single use PPE are on the rise, despite a lack of standard practices and evidence of safety,” said Ernest Grant, PhD, RN, the ANA’s president, which represents some four million nurses.
The answers revealed that 68% of nurses said they were required to reuse N95 masks in the two weeks before taking the survey, compared with 62% who responded in the May survey, and 58% were reusing masks for five days or more compared with 43% in May.
Additionally, 62% felt unsafe with reusing masks and 55% felt unsafe using decontaminated masks, both similar to rates found in the May survey.
One nurse in a large hospital in Texas responded that her unit was given five N95 masks in March. She said that even “to this day we’re still having to use these masks,” according to Grant.
That, he said, gives a picture of the anxiety nurses are feeling.
Because of what they consider insufficient PPE, nurses struggle with anxiety, depression, and feelings of being overwhelmed. “We feel uncomfortable and unsafe that we’re having to reuse these,” said Grant, “because there’s still no guarantee that — yes they’ve undergone decontamination, but there’s always the potential that as they are continually re-decontaminated, is there possibly a breakdown in the structure that may allow for the virus to penetrate?”
That is definitely a risk, said Tener Veenema, PhD, MPH, RN, of the Johns Hopkins Center for Health Security, during a webcast Tuesday to announce the survey results.
Decontamination procedures eventually will break down the integrity of the mask, she said. “The seal will no longer be a tight fit and the mask will lose its filtration efficiency, not only putting the nurse at risk but the patients and everyone else in that hospital or healthcare setting. This is why it’s really critical to pay attention to the science behind the use of masks and respirators and the science behind decontamination.”
Jennifer Gil, RN, who works in the emergency trauma department at Thomas Jefferson University Hospital in Philadelphia, said she and many of her nursing colleagues are operating “in crisis mode.” The situation has had an “immense personal impact to our physical and mental health as we place ourselves and our families in harm’s way.”
Frequently, Gil said, she hears comments of desperation from her colleagues, as well as herself, with words like “I am not sure how I can do this much longer” and “I never thought I would consider leaving nursing.”
Asked if the ANA has heard of nurses receiving poor quality N95 masks or fake N95 masks, Grant responded that it’s a “huge concern” that is putting lives in danger. He said the ANA hopes the Trump administration and the Coronavirus Task Force will work hard to stop those sales.
The organization has heard from nurses complaining that the batches of masks they’re provided said to be N95 are “are either counterfeit or that they’re not true N95 masks,” adding big concerns that breaks in the barrier will make it easy for the virus to enter “and infect the caregiver, and then subsequently they take it home to their loved ones, and worse yet, some of their colleagues, and some other patients that they may be caring for,” Grant said.
Hospitals and other facilities spend a lot of money on these masks that they give to their nursing personnel, only to later learn they aren’t what they thought they purchased, he said.
Veenema emphasized problems with reusing re-decontaminated N95 masks over time.
Survey data, she said, indicated nurses were being asked to reuse their N95 masks beyond the 5-day “contingency limit” specified by the CDC, which she called “very concerning.”
“Masks may be contaminated with other things than SARS-CoV-2. MRSA is in hospitals. Clostridium difficile is in hospitals. Things splash up on masks: blood, saliva, fluids. All these things were the rationale behind the single time use.”
There is no end in sight to these problems, said Grant, who predicted a mounting toll on the healthcare workforce for another six months to a year, with no reliable vaccine.
Veenema added that the problems nurses face with COVID-19 are compounded by wildfires in the West, hurricanes, and other disruptions with climate change. These “have rendered the United States vulnerable across a number of different levels,” she said, adding that the PPE shortage, at least, is correctable.
In a news release, the ANA called for federal leaders to approve full use of the Defense Production Act to increase domestic production of PPE, pass the Medical Supply Chain Emergency Act of 2020 or other legislation that achieves the same goal, and expand investment in testing and public health infrastructure.
The ANA issued its warnings as unions representing nurses have filed lawsuits and workplace complaints accusing hospitals of failing to protect workers with adequate PPE, refusing to test workers, or requiring them to return to work while still COVID-positive.