A rapid review outlining the available evidence on a discrete topic or question relating to the current COVID-19 pandemic. Evidence includes grey and peer review literature. View all Evidence Checks by date of publication.
Large vessel occlusion strokes in COVID-19 patients
Added: 27 May 2020
- Small series of stroke in COVID-19 patients have been reported: o A letter in the New England Journal of Medicine (NEJM) featured five COVID-19 positive cases of new-onset symptoms of large-vessel stroke in patients younger than 50 years of age, who presented to a New York health system over a two-week period. o A letter in the British Medical Journal (BMJ) describes six consecutive cases of acute ischaemic stroke and COVID-19, all of which had large-vessel occlusion (LVO). o An article published in Brain, Behaviour and Immunity identified four patients with acute stroke and COVID-19 in New York, including two with LVO.
- Other case series have reported acute ischaemic stroke in patients with COVID-19 suggesting neurological manifestation of COVID-19. In two of these cases, patients had severe COVID-19 infections.
- A single case report of administration of intravenous rt-PA to an ischemic stroke COVID-19 positive patient has been published, with no bleeding reported.
- Other than this case report, there are no studies in stroke patients with COVID-19 looking at outcomes post alteplase treatment.
- Guidance for stroke patients with COVID-19 state that despite the concern of impaired recombinant tissue plasminogen activator (rt-PA) hepatic clearance, no data are available to suggest a greater risk or benefit with intravenous rt-PA.
Reducing adverse impacts of people with a lived experience of severe mental health issues during COVID-19
Added: 27 May 2020
- Extensive evidence shows premature mortality and significant morbidity for people living with severe mental health issues, compared to the general population. They are six times more likely to die from cardiovascular disease and four times more likely to die from respiratory disease. Health issues are exacerbated by homelessness and other social determinants.
- Expert opinion is that COVID-19 will adversely and disproportionately impact people with a lived experience of mental health issues, and if infected, they will have poorer outcomes.
- Several factors are considered to increase the risk of COVID-19 infection, mortality and mental health symptom relapse, including: o Person-related factors such as existing poor physical health and difficulty following strict quarantine precautions. o Provider-level factors such as structural design of facilities, communal spaces for in-patient activities, long lengths of stay in mental health facilities and infection control practices. o System-level factors such as limited access to community care either virtually or in-person, risk of interrupting medications and public health interventions that raise psychological distress.
- The peak advocacy body for mental health consumers in NSW (BEING) conducted consultations at the onset of COVID-19. It recommended a clear mental health plan for NSW, with provisions for people in inpatient units to access leave and to host visitors, and activities focused on web-based communication and skill-building strategies.
- Several clustered outbreaks have been described in the US and China. One study reported COVID-19 transmission to 50 patients and 30 medical staff in a mental health facility in China. The authors suggest that closed and crowded wards and limited space in which to implement social distancing measures were contributing factors in the outbreak.
Assessment and management of COVID-19 patients in the emergency department (ED)
Added: 25 May 2020
Updated: 26 May 2020
- Guidance on the assessment and management of patients with suspected or confirmed COVID-19 in the ED consistently prioritises limiting the spread of infection, identifying all cases, and estimating disease severity.
- Consistent with other guidance, the European Society for Emergency Medicine recommends that access to ED should be limited to those with severe respiratory symptoms or other organ compromises. Current World Health Organization guideline states that where possible, mild to moderate cases without other known risk factors can be managed in the community with advice on self-management of symptoms and self-isolation.
- The Australian Medical Association recommends that patients and healthcare professionals alert the hospital prior to the arrival of suspected cases to facilitate the preparation of appropriate safety controls and patient management. When patients directly present to the ED, it is recommended they are given a surgical mask, and screened and triaged away from other patients.
- Guidance consistently prescribe that assessment of suspected COVID-19 patients should occur in a dedicated single isolated room, to screen for the presence and severity of clinical symptoms (e.g. fever, coughing, shortness of breath), epidemiological risk factors (e.g. illness onset, travel history, previous contact with cases), potential known risk factors for more severe illness (e.g. old age, comorbidities), and differential diagnoses such as influenza.
- From the ED, patients are triaged and transferred based on their severity of illness to appropriate care settings, such as the community, in the general ward or intensive care unit (ICU).
- The Australian National COVID-19 Clinical Taskforce recommends that staff refer to local diagnostic testing criteria for SARS-CoV-2, noting that they may differ between states and territories. Diagnostic tests that have been shown to be informative in the ED, including nasopharyngeal or oropharyngeal swab polymerase chain reaction (PCR) tests. The Taskforce recommends performing further testing on all cases admitted to hospital, including laboratory testing, haematology, electrocardiogram (ECG) tests, and chest X-rays.
Homelessness and COVID-19
Added: 22 May 2020
Updated: 25 May 2020
- Homelessness is a significant social determinant of health. Expert opinion is that people experiencing homelessness may find it difficult to effectively quarantine, practice distancing measures or perform proper hand hygiene. This may exacerbate and amplify the spread of COVID-19
- Opinion suggests that people experiencing homelessness often have pre-existing medical conditions and limited access to healthcare, which may increase the impact of COVID-19 compared to general populations.
- Evidence suggests that infection control, isolation and quarantine were challenges in previous pandemics and epidemics. Lessons can be applied from HIV/AIDS, Tuberculosis, H1N1 and SARS, including the need to establish rapid communication between public health and homelessness service providers, ensuring providers have access to personal protective equipment, and identifying where and how people will be isolated and treated.
- Centers for Disease Control and Prevention (CDC) reported high proportions of positive COVID-19 test results upon universal testing in some shelters in the USA, suggesting the need for broader testing to prevent the spread of COVID-19 in these settings. Two USA studies also saw high proportions of people positive for COVID-19 after testing in homeless shelters.
- Guidance from CDC includes implementing infection control practices, applying distancing measures and promoting use of cloth face coverings within homelessness services.
- Guidance based on expert opinion suggests: - widespread distribution of accessible and up-to-date information on COVID-19 for people experiencing homelessness. Distribution can be through community partners including law enforcement. - providing providers of homelessness services with training to ensure effective screening and implementation of infectious disease protocols. - prioritising testing and flagging older people accessing services as a high risk for COVID-19.
- Western Australia State Government is conducting scenario planning to develop strategies to respond to potential outbreaks of COVID-19 in people experiencing homelessness including cluster outbreaks.
Guidance and underlying evidence about personal protective equipment (PPE) use during COVID-19
Added: 20 May 2020
Updated: 21 May 2020
What is the evidence base for that guidance?
- Personal protective equipment refers to specialised clothing or apparatus worn by an employee for protection against infectious materials or other hazards.
- Occupational health and safety guidance asserts PPE should be considered in the context of broader, more effective hazard reduction approaches such as elimination, engineering and administrative controls
- The core principles underpinning the use of PPE for infection control are: the safety of staff and patients is a priority at all times
- PPE selection is informed by the anticipated contact with body substance or pathogens and the evidence base about transmission
- a risk assessment approach is used to guide decisions about appropriate use.
Sanitising and covering large medical imaging equipment
Added: 8 May 2020
Updated: 20 May 2020
Which method is most effective in covering or protecting large medical imaging equipment for COVID-19?
Which method is most effective in sanitising linear accelerators and radiotherapy bunkers for COVID-19?
- There is a variety of options for disinfectants to use on medical imaging equipment. Most guidelines suggest compliance with equipment vendor guidance to find the safest disinfectant for each piece of equipment.
- Regulatory agencies (such as the Therapeutic Goods Agency) publish lists of approved disinfectants (Table 4).
- Specific disinfectants for machines during COVID-19 have included: isopropyl alcohol 70%, diluted bleach solution (6mg chlorine releasing disinfectant tablet to 1,000ml water), 2,000mg/L chlorine-containing disinfectant
- 500 to 1,000mg/L chlorine containing disinfectant
- and alcohol-containing disposable disinfectant wipes.
Renal replacement therapies for COVID-19 positive patients in ICU
Added: 12 May 2020
Updated: 20 May 2020
- COVID-19 most frequently presents as mild respiratory illness and can generally be managed outside the hospital. About 20% of patients require hospitalisation, and of those, a quarter require intensive care.
- ICU patients typically require management of hypoxaemic respiratory failure or hypotension requiring vasopressor support. Acute kidney injury is a less common complication but is associated with a significant risk for mortality.
- Available data suggests that the prevalence of acute kidney injury in COVID-19 patients is around 3-9% and is more common in patients with severe disease, reported in up to 30% of critically ill or deceased patients.
Immunosuppression and COVID-19
Added: 30 Apr 2020
Updated: 19 May 2020
- A systematic review showed that people with immunosuppression showed favourable disease course when compared to the general population. Cancer patients experienced more severe COVID-19 infections but did not necessarily have a poor prognosis. The review is subject to bias due to the limited number of included papers and small sample size.
- Additional small case series suggest that patients with immunosuppression generally have similar risk profiles to the general population in terms of COVID-19 outcomes and severity, however patients with cancer have been shown in some studies to have more severe disease. Results for transplant patients regarding disease severity varies and is based on small numbers.
- People with cancer provide the majority of the evidence on immunosuppression during COVID- 19. Expert opinion varies on whether cancer patients with a diagnosis of COVID-19 should continue cancer treatment. However there is agreement that decisions should be based on balancing risks and benefits of treatment in the context of the pandemic and infection control principles.
- A systematic review showed that there is no definitive evidence that specific cytotoxic drugs, low-dose methotrexate for autoimmune disease, NSAIDs, Janus kinase (JAK) kinase inhibitors or anti-TNFα agents are contraindicated in people with COVID-19.
- The National Institute for Health and Care Excellence (NICE) recommends continuing systemic anticancer treatment only if it is needed for urgent control of the cancer, and if possible, defer treatment until the patient has at least one negative test for COVID-19.
- NICE have also released guidance on children and young people who are immunocompromised with COVID-19.
Rapid evidence checks are based on a simplified review method and may not be entirely exhaustive, but aim to provide a balanced assessment of what is already known about a specific problem or issue. This brief has not been peer-reviewed and should not be a substitute for individual clinical judgement, nor is it an endorsed position of NSW Health.