Rapid Tests for Influenza, Respiratory Syncytial Virus, and Other Respiratory Viruses: A Systematic Review and Meta-analysis

An Update on Advances in COVID-19 Laboratory Diagnosis and Testing Guidelines in India

The declaration of COVID-19 as a global pandemic has warranted the urgent need for technologies and tools to be deployed for confirming diagnosis of suspected cases. Diagnostic testing for COVID-19 is critical for understanding epidemiology, contract-tracing, case management, and to repress the transmission of the SARS-CoV-2. Currently, the Nucleic Acid Amplification Test (NAAT)-based RT-PCR technique is a gold standard test used for routine diagnosis of COVID-19 infection. While there are many commercially available RT-PCR assay kits available in the market, selection of highly sensitive, specific, and validated assays is most crucial for the accurate diagnosis of COVID-19 infection. Laboratory diagnosis of SARS-CoV-2 is extremely important in the disease and outbreak management. Development of rapid point of care tests with better sensitivity and specificity is the critical need of the hour as this will help accurate diagnosis and aid in containing the spread of SARS-CoV-2 infection. Early detection of viral infection greatly enhances implementation of specific public health intervention, such as infection control, environmental decontamination, and the closure of specific high-risk zones. Large-scale sequencing of SARS-CoV-2 genome isolated from affected populations across the world needs to be carried to monitor mutations that might affect performance of molecular tests. Creation of genome repositories and open-source genetic databases for use by global researchers is clearly the way forward to manage COVID-19 outbreak and accelerate vaccine development. This review summarizes various molecular diagnostics methods, technical guidelines, and advanced testing strategies adopted in India for laboratory diagnosis of COVID-19.

Management of Coronavirus Disease 2019 (COVID-19) Pandemic: From Diagnosis to Treatment Strategies

Following the emergence of severe acute respiratory syndrome (SARS) in 2002 and the Middle East respiratory syndrome (MERS) in 2012, the world is now combating a third large-scale outbreak caused by a coronavirus, the coronavirus disease 2019 (COVID-19). After the rapid spread of SARS-coronavirus (CoV)-2 (the virus causing COVID-19) from its origin in China, the World Health Organization (WHO) declared a Public Health Emergency of International Concern (PHEIC) on January 30, 2020. From the beginning of the COVID-19 pandemic, a significant number of studies have been conducted to better understand the biology and pathogenesis of the novel coronavirus, and to aid in developing effective treatment regimens, therapeutics, and vaccines. This review focuses on the recent advancements in the rapidly evolving areas of clinical care and management of COVID-19. The emerging strategies for the diagnosis and treatment of this disease are explored, and the development of effective vaccines is reviewed.

Immunopathological similarities between COVID-19 and influenza: Investigating the consequences of Co-infection

Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been a global public health emergency since December 2019, and so far, more than 980,000 people (until September 24, 2020) around the world have died. SARS-CoV-2 mimics the influenza virus regarding methods and modes of transmission, clinical features, related immune responses, and seasonal coincidence. Accordingly, co-infection by these viruses is imaginable because some studies have reported several cases with SARS-CoV-2 and influenza virus co-infection. Given the importance of the mentioned co-infection and the coming influenza season, it is essential to recognize the similarities and differences between the symptoms, immunopathogenesis and treatment of SARS-CoV-2 and influenza virus. Therefore, we reviewed the virology, clinical features, and immunopathogenesis of both influenza virus and SARS-CoV-2 and evaluated outcomes in cases with SARS-CoV-2 and influenza virus co-infection.

COVID-19: Diagnostics, Therapeutic Advances, and Vaccine Development

PURPOSE OF REVIEW

Human race is currently facing the wrath of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a highly transmittable and pathogenic RNA virus, causing coronavirus disease 2019 (COVID-19), the worst ever global pandemic. Coronaviruses (CoVs) have emerged as a major public health concern. Urgent global response to COVID-19 outbreak has been to limit spread of SARS-CoV-2 via extensive monitoring and containment. Various treatment regimens have been adopted to manage COVID-19, with known drugs and drug combinations used to decrease the morbidity and mortality associated with COVID-19. Intensive research on various fronts including studying molecular and structural aspects of these viruses and unraveling the pathophysiology and mechanistic basis of COVID-19 aimed at developing effective prophylactic, therapeutic agents and vaccines has been carried out globally.

RECENT FINDINGS

No approved antiviral treatment except remdesivir exists for SARS-CoV-2 till date though novel drug targets have been identified. However, worldwide frantic and competitive vaccine development pharmaceutical race has borne fruit in the form of a number of promising candidate vaccines, out of which few have already received emergency use authorization by regulatory bodies in record time.

SUMMARY

This review highlights the painstaking efforts of healthcare workers and scientific community to successfully address the COVID-19 pandemic-though damage in the form of severe illness, loss of lives, and livelihood has left a serious mark. Focusing on extensive research on various therapeutic options and antiviral strategies including neutralizing antibodies, potential drugs, and drug targets, light has been shed on various diagnostic options and the amazing vaccine development process as well.

Clinical Assessment and Validation of a Rapid and Sensitive SARS-CoV-2 Test Using Reverse Transcription Loop-Mediated Isothermal Amplification Without the Need for RNA Extraction

BACKGROUND

Amid the enduring pandemic, there is an urgent need for expanded access to rapid, sensitive, and inexpensive coronavirus disease 2019 (COVID-19) testing worldwide without specialized equipment. We developed a simple test that uses colorimetric reverse transcription loop-mediated isothermal amplification (RT-LAMP) to detect severe acute resrpiratory syndrome coronavirus 2 (SARS-CoV-2) in 40 minutes from sample collection to result.

METHODS

We tested 135 nasopharyngeal specimens from patients evaluated for COVID-19 infection at Massachusetts General Hospital. Specimens were either added directly to RT-LAMP reactions, inactivated by a combined chemical and heat treatment step, or inactivated then purified with a silica particle-based concentration method. Amplification was performed with 2 SARS-CoV-2-specific primer sets and an internal specimen control; the resulting color change was visually interpreted.

RESULTS

Direct RT-LAMP testing of unprocessed specimens could only reliably detect samples with abundant SARS-CoV-2 (>3 000 000 copies/mL), with sensitivities of 50% (95% CI, 28%-72%) and 59% (95% CI, 43%-73%) in samples collected in universal transport medium and saline, respectively, compared with quantitative polymerase chain reaction (qPCR). Adding an upfront RNase inactivation step markedly improved the limit of detection to at least 25 000 copies/mL, with 87.5% (95% CI, 72%-95%) sensitivity and 100% specificity (95% CI, 87%-100%). Using both inactivation and purification increased the assay sensitivity by 10-fold, achieving a limit of detection comparable to commercial real-time PCR-based diagnostics.

CONCLUSIONS

By incorporating a fast and inexpensive sample preparation step, RT-LAMP accurately detects SARS-CoV-2 with limited equipment for about US$6 per sample, making this a potentially ideal assay to increase testing capacity, especially in resource-limited settings.

Comparison of the Quidel Sofia SARS FIA Test to the Hologic Aptima SARS-CoV-2 TMA Test for Diagnosis of COVID-19 in Symptomatic Outpatients

The Quidel Sofia severe acute respiratory syndrome (SARS) fluorescent immunoassay (FIA) test (SOFIA) is a rapid antigen immunoassay for the detection of SARS coronavirus 2 (SARS-CoV-2) proteins from nasal or nasopharyngeal swab specimens. The purpose of this study was to compare the results of the SOFIA test to those of the Hologic Aptima SARS-CoV-2 TMA test (APTIMA TMA), a high-throughput molecular diagnostic test that uses transcription-mediated amplification (TMA) for the detection of SARS-CoV-2 nucleic acid from upper respiratory tract specimens. Three hundred forty-seven symptomatic patients from an urgent care center in an area with a high prevalence of SARS-CoV-2 infections were tested in parallel using nasal swabs for the SOFIA test and nasopharyngeal swabs for the APTIMA TMA test. The SOFIA test demonstrated a positive percent agreement (PPA) of 82.0% with the APTIMA TMA test for symptomatic patients tested ≤5 days from symptom onset and a PPA of 54.5% for symptomatic patients >5 days from symptom onset. The Cepheid Xpert Xpress SARS-CoV-2 reverse transcription-PCR (RT-PCR) test was used to determine the cycle threshold (CT ) value for any specimens that were discrepant between the SOFIA and APTIMA TMA tests. Using a CT value of ≤35 as a surrogate for SARS-CoV-2 culture positivity, we estimate that the SOFIA test detected 87.2% of symptomatic patients tested ≤5 days from symptom onset who were likely to be culture positive.

SARS-CoV-2 pandemic: a review of molecular diagnostic tools including sample collection and commercial response with associated advantages and limitations

The unprecedented global pandemic known as SARS-CoV-2 has exercised to its limits nearly all aspects of modern viral diagnostics. In doing so, it has illuminated both the advantages and limitations of current technologies. Tremendous effort has been put forth to expand our capacity to diagnose this deadly virus. In this work, we put forth key observations in the functionality of current methods for SARS-CoV-2 diagnostic testing. These methods include nucleic acid amplification-, CRISPR-, sequencing-, antigen-, and antibody-based detection methods. Additionally, we include analysis of equally critical aspects of COVID-19 diagnostics, including sample collection and preparation, testing models, and commercial response. We emphasize the integrated nature of assays, wherein issues in sample collection and preparation could impact the overall performance in a clinical setting.

Typical RSV cough: myth or reality? A diagnostic accuracy study

Respiratory syncytial virus (RSV) is well known for causing a potentially severe course of bronchiolitis in infants. Many paediatric healthcare workers claim to be able to diagnose RSV based on cough sound, which was evaluated in this study. Parents of children < 1 year old admitted to the paediatric ward because of airway complaints were asked to record cough sounds of their child. In all children, MLPA analysis-a variation of PCR analysis-on nasopharyngeal swab was performed (golden standard). Sixteen cough fragments representing 4 different viral pathogens were selected and presented to paediatric healthcare workers. Thirty-two paediatric nurses, 16 residents and 16 senior staff members were asked to classify the audio files and state whether the cough was due to RSV infection or not. Senior staff, nurses and residents correctly identified RSV with a sensitivity of 76.2%, 73.1% and 51.3% respectively. Correct exclusion of RSV cases was performed with a specificity of 60.8%, 60.2% and 65.3% respectively. Sensitivity ranged from 0 to 100% between colleagues; no one correctly identified all negatives. Residents had significantly lower rates of sensitivity than senior staff and nurses. This was strongly related to work experience, in which more than 3.5 years of work experience was related to the best result.Conclusion: Senior staff and nurses were better in making a cough-based diagnosis of RSV compared to residents. Both groups were able to detect the same proportion of true RSV patients based on cough sounds compared to bedside tests but could not validly distinguish RSV from other pathogens based on cough sounds. What is Known: • Many paediatric healthcare workers claim to be capable of diagnosing RSV in infants based on cough sound • Up to now, no studies investigating the recognisability of RSV based on cough sound are published What is New: • Senior staff and paediatric nurses performed better than various other bedside tests in diagnosing RSV but could not replace MLPA analysis • Residents need at least 3.5 years of work experience to be able to make a RSV diagnosis based on cough sound.

Point of Care Diagnostics in the Age of COVID-19

The recent outbreak of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and its associated serious respiratory disease, coronavirus disease 2019 (COVID-19), poses a major threat to global public health. Owing to the lack of vaccine and effective treatments, many countries have been overwhelmed with an exponential spread of the virus and surge in the number of confirmed COVID-19 cases. Current standard diagnostic methods are inadequate for widespread testing as they suffer from prolonged turn-around times (>12 h) and mostly rely on high-biosafety-level laboratories and well-trained technicians. Point-of-care (POC) tests have the potential to vastly improve healthcare in several ways, ranging from enabling earlier detection and easier monitoring of disease to reaching remote populations. In recent years, the field of POC diagnostics has improved markedly with the advent of micro- and nanotechnologies. Due to the COVID-19 pandemic, POC technologies have been rapidly innovated to address key limitations faced in existing standard diagnostic methods. This review summarizes and compares the latest available POC immunoassay, nucleic acid-based and clustered regularly interspaced short palindromic repeats- (CRISPR)-mediated tests for SARS-CoV-2 detection that we anticipate aiding healthcare facilities to control virus infection and prevent subsequent spread.

Review and Analysis of Massively Registered Clinical Trials of COVID-19 using the Text Mining Approach

OBJECTIVE

Immediately after the outbreak of nCoV, many clinical trials are registered for COVID-19. The numbers of registrations are now raising inordinately. It is challenging to understand which research areas are explored in this massive pool of clinical studies. If such information can be compiled, then it is easy to explore new research studies for possible contributions in COVID-19 research.

METHODS

In the present work, a text-mining technique of artificial intelligence is utilized to map the research domains explored through the clinical trials of COVID-19. With the help of the open-- source and graphical user interface-based tool, 3007 clinical trials are analyzed here. The dataset is acquired from the international clinical trial registry platform of WHO. With the help of hierarchical cluster analysis, the clinical trials were grouped according to their common research studies. These clusters are analyzed manually using their word clouds for understanding the scientific area of a particular cluster. The scientific fields of clinical studies are comprehensively reviewed and discussed based on this analysis.

RESULTS

More than three-thousand clinical trials are grouped in 212 clusters by hierarchical cluster analysis. Manual intervention of these clusters using their individual word-cloud helped to identify various scientific areas which are explored in COVID19 related clinical studies.

CONCLUSION

The text-mining is an easy and fastest way to explore many registered clinical trials. In our study, thirteen major clusters or research areas were identified in which the majority of clinical trials were registered. Many other uncategorized clinical studies were also identified as "miscellaneous studies". The clinical trials within the individual cluster were studied, and their research purposes are compiled comprehensively in the present work.

CRISPR-based assays for rapid detection of SARS-CoV-2

COVID-19 pandemic posed an unprecedented threat to global public health and economies. There is no effective treatment of the disease, hence, scaling up testing for rapid diagnosis of SARS-CoV-2 infected patients and quarantine them from healthy individuals is one the best strategies to curb the pandemic. Establishing globally accepted easy-to-access diagnostic tests is extremely important to understanding the epidemiology of the present pandemic. While nucleic acid based tests are considered to be more sensitive with respect to serological tests but present gold standard qRT-PCR-based assays possess limitations such as low sample throughput, requirement for sophisticated reagents and instrumentation. To overcome these shortcomings, recent efforts of incorporating LAMP-based isothermal detection, and minimizing the number of reagents required are on rise. CRISPR based novel techniques, when merge with isothermal and allied technologies, promises to provide sensitive and rapid detection of SARS-CoV-2 nucleic acids. Here, we discuss and present compilation of state-of-the-art detection techniques for COVID-19 using CRISPR technology which has tremendous potential to transform diagnostics and epidemiology.

SARS-CoV-2: Pathogenesis, and Advancements in Diagnostics and Treatment

The emergence and rapid spread of SARS-CoV-2 in December 2019 has brought the world to a standstill. While less pathogenic than the 2002-2003 SARS-CoV, this novel betacoronavirus presents a global threat due to its high transmission rate, ability to invade multiple tissues, and ability to trigger immunological hyperactivation. The identification of the animal reservoir and intermediate host were important steps toward slowing the spread of disease, and its genetic similarity to SARS-CoV has helped to determine pathogenesis and direct treatment strategies. The exponential increase in cases has necessitated fast and reliable testing procedures. Although RT-PCR remains the gold standard, it is a time-consuming procedure, paving the way for newer techniques such as serologic tests and enzyme immunoassays. Various clinical trials using broad antiviral agents in addition to novel medications have produced controversial results; however, the advancement of immunotherapy, particularly monoclonal antibodies and immune modulators is showing great promise in clinical trials. Non-orthodox medications such as anti-malarials have been tested in multiple institutions but definitive conclusions are yet to be made. Adjuvant therapies have also proven to be effective in decreasing mortality in the disease course. While no formal guidelines have been established, the multitude of ongoing clinical trials as a result of unprecedented access to research data brings us closer to halting the SARS-CoV-2 pandemic.

Low Detection Rate of Pulmonary Embolism in Patients Presenting to the Emergency Department With Suspected Coronavirus Disease 2019 (COVID-19): A Single-Centre UK Study

Purpose

Critically ill patients with coronavirus disease 2019 (COVID-19) are at increased risk of thrombosis. There are limited data on PE rates in COVID-19 patients at presentation to the emergency department (ED). In this study, we evaluated the detection rates of PE in patients presenting to the ED with suspected and proven COVID-19.

Methods

A single-centre retrospective study was undertaken of 285 consecutive patients undergoing CT pulmonary angiogram (CTPA) in the Emergency Department at Nottingham University Hospitals NHS Trust in the United Kingdom between 25 March and 30 April 2020. At our institution, CTPA is performed in all patients undergoing CT for triage. The study group consisted of patients considered COVID-19 positive based on polymerase chain reaction (PCR) results and CTPA findings. The detection rate of PE in COVID-19 patients was compared to patients undergoing CTPA for suspected PE only and for suspected COVID-19 with no COVID CT findings and negative PCR (control group 1); and CTPAs prior to the coronavirus pandemic (control group 2).

Results

One of 48 patients in the study group had a PE (2%) compared to 25/215 (12%) in control group 1 and 10/50 (20%) in control group 2. Prevalence of PE in the study group was lower than in control group 1 (P = 0.058) and compared to control group 2 (P = 0.005). Eleven patients undergoing CTPA had negative PCR but positive CT for COVID-19.

Conclusion

Detection rate of pulmonary embolus is low in patients with COVID-19 undergoing CTPA on a triage pathway.

Recent biotechnological tools for diagnosis of corona virus disease: A review

Recently, a corona virus disease (COVID-19) caused by a novel corona virus (sevier acute respiratory syndrome corona virus 2; SARS-CoV-2), rapidly spread throughout the world. It has been resulted an unprecedented public health crisis and has become a global threat. WHO declared it as a pandemic due to rapid transmission and severity of the disease. According to WHO, as of 22nd of August 2020, the disease spread over 213 countries of the world having 22,812,491 confirmed cases and 795,132 deaths recorded worldwide. In the absence of suitable antiviral drugs and vaccines, the current pandemic has created an urgent need for accurate diagnostic tools that would be helpful for early detection of the patients. Many tests including classical and high-throughput techniques have developed and obtained U.S. Food and drug administration (FDA) approval. However, efforts are being made to develop new diagnostic tools for detection of the disease. Several molecular diagnostic tests such as real-time-polymerase chain reaction, real-time isothermal loop-mediated amplification (RT-LAMP), full genome analysis by next-generation sequencing, clustered regularly interspaced short palindromic repeats technique and microarray-based assays along with other techniques such as computed tomography scan, biomarkers, biosensor, nanotechnology, serological test, enzyme-linked immunosorbent assay (ELISA), isolation of viral strain in cell culture are currently available for diagnosis of COVID-19 infection. This review provides a brief overview of promising high-throughput techniques currently used for detection of SARS-CoV-2, along with their scope and limitations that may be used for effective control of the disease.

A rapid and sensitive method to detect SARS-CoV-2 virus using targeted-mass spectrometry

In the last few months, there has been a global catastrophic outbreak of severe acute respiratory syndrome disease caused by the novel coronavirus SARS-CoV-2 affecting millions of people worldwide. Early diagnosis and isolation are key to contain the rapid spread of the virus. Towards this goal, we report a simple, sensitive and rapid method to detect the virus using a targeted mass spectrometric approach, which can directly detect the presence of virus from naso-oropharyngeal swabs. Using a multiple reaction monitoring we can detect the presence of two peptides specific to SARS-CoV-2 in a 2.3 min gradient run with 100% specificity and 90.5% sensitivity when compared to RT-PCR. Importantly, we further show that these peptides could be detected even in the patients who have recovered from the symptoms and have tested negative for the virus by RT-PCR highlighting the sensitivity of the technique. This method has the translational potential of in terms of the rapid diagnostics of symptomatic and asymptomatic COVID-19 and can augment current methods available for diagnosis of SARS-CoV-2.

Molecular and Immunological Diagnostic Tests of COVID-19: Current Status and Challenges

Rapid spread of coronavirus disease 2019 (COVID-19) is ravaging the globe. Since its first report in December 2019, COVID-19 cases have exploded to over 14 million as of July 2020, claiming more than 600,000 lives. Implementing fast and widespread diagnostic tests is paramount to contain COVID-19, given the current lack of an effective therapeutic or vaccine. This review focuses on a broad description of currently available diagnostic tests to detect either the virus (SARS-CoV-2) or virus-induced immune responses. We specifically explain the working mechanisms of these tests and compare their analytical performance. These analyses will assist in selecting most effective tests for a given application, for example, epidemiology or global pandemic research, population screening, hospital-based testing, home-based and point-of-care testing, and therapeutic trials. Finally, we lay out the shortcomings of certain tests and future needs.

Clinical evaluation of fully automated molecular diagnostic system "Simprova" for influenza virus, respiratory syncytial virus, and human metapneumovirus

Influenza virus, respiratory syncytial virus, and human metapneumovirus commonly cause acute upper and lower respiratory tract infections, especially in children and the elderly. Although rapid antigen detection tests for detecting these infections have been introduced recently, these are less sensitive than nucleic acid amplification tests. More recently, highly sensitive point-of-care testings (POCTs) have been developed based on nucleic acid amplification tests, which are easy to use in clinical settings. In this study, loop-mediated isothermal amplification (LAMP)-based POCT “Simprova” to detect influenza A and B viruses, respiratory syncytial virus, and human metapneumovirus was developed. Simprova system is fully automated and does not require skilled personnel. In addition, positive results can be achieved faster than with PCR. In this study, the accuracy of the POCT was retrospectively analyzed using 241 frozen stocked specimens. Additionally, the usability of the Simprova at clinical sites was assessed in a prospective clinical study using 380 clinical specimens and compared to those of real-time PCR and rapid antigen detection test. The novel LAMP-based POCT demonstrated high sensitivity and specificity in characterizing clinical specimens from patients with influenza-like illnesses. The Simprova is a powerful tool for early diagnosis of respiratory viral infections in point-of-care settings.

Laboratory diagnosis of SARS-CoV-2: available approaches and limitations

The ongoing pandemic of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is one of the most devastating outbreaks witnessed in the last 100 years. The outbreak started in China and spread rapidly to almost every country, culminating in woefully overwhelmed health-care systems in most countries. The only approved diagnostic test to accompany radiographic evaluation is reverse transcription PCR. However, the applicability of this test in diagnosis and surveillance is challenged by a global shortage of reagents and the lack of well-equipped laboratories with specialized staff in several low- and middle-income countries. Loop-mediated isothermal amplification and CRISPR-based diagnostic assays have developed and expected to play a role however, their accuracy is still inferior to the recommended PCR approach. The need for the development of accurate and rapid diagnostic assays became apparent. Immunodiagnostic tests and other molecular approaches were developed and tested. Other recently developed point-of-care molecular tests are expected to be helpful in pandemic management as no particular skills are required from the operator. Fortunately, a number of serological tests have been granted authorization for use under the emergency situation by the US FDA for the diagnosis of SARS-CoV-2. The majority of recently authorized serological tests detect IgG and IgM in blood of infected individuals by on ELISA, chemiluminescence platforms or lateral flow cassettes.

Clinical-Forensic Autopsy Findings to Defeat COVID-19 Disease: A Literature Review

The severe acute respiratory syndrome (SARS)-CoV-2 was identified for the first time in China, in December 2019. Confirmed cases of COVID-19 have been reported around the world; indeed, this infection has been declared a pandemic. Consequently, the scientific community is working hard to gain useful information about the history of this virus, its transmission, diagnosis, clinical features, radiological findings, research and development of candidate therapeutics as well as vaccines. This review aims to analyze the diagnostic techniques used to ascertain the COVID-19 infection, critically reviewing positive points and criticism for forensic implications, obviously including autopsy. Finally, this review proposes a practical workflow to be applied in the management of corpses during this outbreak of the COVID-19 infection, which could be useful in cases of future infectious disease emergencies. Analyzing the diagnostic methods, to date, virus nucleic acid RT-PCR represents the standard method used to ascertain the COVID-19 infection in living subjects and corpses, even if this technique has several criticisms: mainly, the staff should be highly specialized, working in high-throughput settings, able to handle high workloads and aware of health risks and the importance of the results. Thus, IgG/IgM serological tests have been developed, overcoming RT-qPCR duration, costs, and management, not requiring highly trained personnel. Nevertheless, serological tests present problems; the WHO recommends the use of these new point-of-care immunodiagnostic tests only in research settings. Furthermore, nothing has yet been published regarding the possibility of applying these methods during post-mortem investigations. In light of this scenario, in this review, we suggest a flow chart for the pathologist called on to ascertain the cause of death of a subject with historical and clinical findings of COVID-19 status or without any anamnestic, diagnostic, or exposure information. Indeed, the literature data confirmed the analytical vulnerabilities of the kits used for laboratory diagnosis of COVID-19, particularly during postmortem examinations. For these reasons, autopsy remains the gold standard method to ascertain the exact cause of death (from or with COVID-19 infection, or other causes), to consequently provide real data for statistical evaluations and to take necessary measures to contain the risks of the infection. Moreover, performing autopsies could provide information on the pathogenesis of the COVID-19 infection with obvious therapeutic implications.

Dermatological procedures amidst COVID-19: When and how to resume

The pandemic of COVID‐19 has captivated more than 3 million people across the globe affecting the dermatology practice as well. Due to the novel nature of the virus and concomitant lack of research, standard guidelines have not been set in place regarding the procedures. Currently, due to fear and spread of coronavirus aesthetic practice has taken a seat back. Dermatologic surgeon/aesthetician have to be prepared for the forthcoming alterations in the practice and adjust to the necessary precautionary methods. This articles aims to prepare dermatologist for the upcoming difficulties and precautions to be taken for conducting procedures in amidst of coronavirus.

An Overview of Novel Coronavirus SARS-Cov-2 Spanning around the Past, Present and Future Perspectives

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), a new enveloped RNA virus known as Coronavirus (COVID-19) are most prevalent in humans and wild animals. All four species that is alpha, beta, delta and theta have been identified till date and are responsible for human disease; causing influenza like illness (ILI). This virus has similar lineage of Middle East Respiratory Syndrome coronavirus (MERS-CoV) and related Coronavirus (SARS-CoV). This outbreak initially presented as pneumonia-like illness in a group of people in Wuhan, China. The infection was said to be caused by seafood and unusual animals in the wholesale markets of this city. SARS-CoV-2 is highly infectious and has resulted in a rapid pandemic. As of now it has spread to 197 countries with total no of cases in the world being 3.76 million as of early march. The mortality till now is 7.11% .The cases have been increasing since its first discovery in China. In India also the number has been increased. Till now India has total of 39,980 cases and mortality is attributed to be 3.26%. As per data from Ministry of health and family welfare (MoHFW) death is more commonly seen in males with age >60years. Among these most of the deaths were related to other co-morbid conditions. This article will help the readers with an overview of novel Coronavirus spanning around the clinical features, diagnostic modalities, treatment strategies and infection control measures. It will also help in raising awareness among healthcare workers regarding COVID-19 and aid in early recognition of these patients. Moreover, this review will also focus on the most recent information for the effective management, prevention, and treatment of patients worldwide.

Three months of COVID-19: A systematic review and meta-analysis

The pandemic of 2019 novel coronavirus (SARS‐CoV‐2019), reminiscent of the 2002‐SARS‐CoV outbreak, has completely isolated countries, disrupted health systems and partially paralyzed international trade and travel. In order to be better equipped to anticipate transmission of this virus to new regions, it is imperative to track the progress of the virus over time. This review analyses information on progression of the pandemic in the past 3 months and systematically discusses the characteristics of SARS‐CoV‐2019 virus including its epidemiologic, pathophysiologic, and clinical manifestations. Furthermore, the review also encompasses some recently proposed conceptual models that estimate the spread of this disease based on the basic reproductive number for better prevention and control procedures. Finally, we shed light on how the virus has endangered the global economy, impacting it both from the supply and demand side.

Update for Anaesthetists on Clinical Features of COVID-19 Patients and Relevant Management

When preparing for the outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and the coronavirus infection disease (COVID-19) questions arose regarding various aspects concerning the anaesthetist. When reviewing the literature it became obvious that keeping up-to-date with all relevant publications is almost impossible. We searched for and summarised clinically relevant topics that could help making clinical decisions. This is a subjective analysis of literature concerning specific topics raised in our daily practice (e.g., clinical features of COVID-19 patients; ventilation of the critically ill COVID-19 patient; diagnostic of infection with SARS-CoV-2; stability of the virus; Covid-19 in specific patient populations, e.g., paediatrics, immunosuppressed patients, patients with hypertension, diabetes mellitus, kidney or liver disease; co-medication with non-steroidal anti-inflammatory drugs (NSAIDs); antiviral treatment) and we believe that these answers help colleagues in clinical decision-making. With ongoing treatment of severely ill COVID-19 patients other questions will come up. While respective guidelines on these topics will serve clinicians in clinical practice, regularly updating all guidelines concerning COVID-19 will be a necessary, although challenging task in the upcoming weeks and months. All recommendations during the current extremely rapid development of knowledge must be evaluated on a daily basis, as suggestions made today may be out-dated with the new evidence available tomorrow.

Very high sensitivity of a rapid influenza diagnostic test in adults and elderly individuals within 48 hours of the onset of illness

During influenza epidemics, Japanese clinicians routinely perform rapid influenza diagnostic tests (RIDTs) in the examination of patients who have an influenza-like illness, and patients with positive test results, including otherwise healthy individuals, are treated with anti-influenza drugs. However, it was recently reported that the sensitivity of RIDTs was extremely low in adult patients. We examined the sensitivity and specificity of an RIDT that is widely used in Japan, ImunoAce Flu (TAUNS, Shizuoka, Japan), in comparison to reverse transcriptase polymerase chain reaction (RT-PCR). The sensitivity and specificity of the ImunoAce Flu test were 97.1% (95%CI: 93.8–98.9) and 89.2% (95%CI: 84.1–93.1), respectively. The ImunoAce Flu test is designed to not only detect influenza A or B, but also to detect H1N1pdm09 with the use of an additional test kit (Linjudge FluA/pdm). Its sensitivity and specificity for A/H1N1pdm09 were 97.6% (95%CI: 87.4–99.9) and 92.6% (95%CI: 82.1–97.9), respectively. Thus, by consecutively testing patients with the ImunoAce Flu test followed by the Linjudge FluA/pdm test, we are able to diagnose whether a patient has A/H1N1pdm09 or A/H3N2 infection within a short time. The reliability of rapid test results seems to be much higher in Japan than in other countries, because approximately 90% of influenza patients are tested and treated within 48 hours after the onset of illness, when the influenza viral load in the upper respiratory tract is high. From the Japanese experience, RIDTs are sufficiently sensitive and highly useful, if patients are tested within 48 hours after the onset of illness.

Epidemiology, Genomic Structure, the Molecular Mechanism of Injury, Diagnosis and Clinical Manifestations of Coronavirus Infection: An Overview

COVID-19 is caused by a novel beta coronavirus (SARS-CoV-2) strain that was first discovered in 2019 in the Wuhan city of China. Based on virus genome sequencing studies, the bat is suspected as the natural host of virus, and infection might be transmitted from bats via unknown intermediate hosts like reptiles and snakes etc., to infect humans. COVID-19 is transmitted from person to person contact, primarily via droplet infection within the incubation period or after clinical manifestations of fever, cough, sneezing, sputum, dyspnea, and pneumonia and through contaminated fomites. COVID-19 enters the respiratory tract through the ACE2 receptor on alveoli through binding of s-protein of the virus and causes injuries though the cytopathic effect, as well as cytokines and other mediators, released after developing sepsis. ACE 2 is almost 100-fold higher in kidneys than lung, and the virus can also involve the kidney in the same manner. Kidney involvement manifests in the form of proteinuria, hematuria, and an acute rise in serum creatinine. Kidney involvement is an independent risk factor for mortality. Diagnosis is primarly made by detecting viral RNA by reverse transcriptase polymerase chain reaction (rtPCR) in nasopharyngeal swab samples. Role of antibodies, both IgM and IgG are still evolving and at best restricted for epidemiological purpose. Though a large number of treatments, including hydroxychloroquine, anti-viral, convalescent plasma etc., are being tried, as of now treatment is symptomatic only.

Real-time surveillance systems: Applicability for the control of influenza in acute care

Background

The high morbidity and mortality caused by influenza viruses translate into a great impact on specialized health care. Apart from the annual vaccination, the relevance of other measures to prevent and control this infection is unknown. The objective of our research was to determine the importance of a real‐time surveillance system to establish early extended transmission precautions.

Methods

Quasi‐experimental before‐and‐after study comparing the influenza cases detected in hospitalized adults during the 2016/2017 season (264 patients) with those detected after the implementation of a real‐time surveillance system in the 2017/2018 season (519 patients). The improvements included early microbiological diagnosis, immediate communication of results, constant updating of patient information, coordination among professionals, periodic surveillance of the adequacy of preventive measures, and greater control of roommates. The effectiveness of the intervention was determined from the nosocomial infection rate in each season.

Results

After the real‐time surveillance system for influenza was implemented, patients with early microbiological diagnosis and immediate isolation increased significantly (13.7% vs 68.2%; P < .001). In addition, nosocomial infections decreased from 17% to 9.2% (P = .001) and overall hospital stay was significantly reduced. Assuming that the entire effect was due to the intervention, the absolute risk reduction was 7.8% and number needed to treat was 12.8.

Conclusion

The results in our study reveal the impact of nosocomial transmission of influenza virus in a tertiary hospital and highlight the need to supplement traditional strategies with novel methodologies such as modern surveillance systems based on early diagnosis, close case monitoring, and coordination among professionals.

Performance and Impact of a CLIA-waived, Point-of-care Respiratory PCR Panel in a Pediatric Clinic

BACKGROUND

Laboratory-based respiratory polymerase chain reaction (PCR) panels are rarely used in outpatient pediatric practice due to prolonged turn-around times and cost of medical equipment. The BioFire FilmArray Respiratory Panel EZ (RP EZ) is a Clinical Laboratory Improvement Amendments-waived respiratory pathogen PCR panel which rapidly tests for 14 common respiratory organisms. The aim of this study was to identify the distribution of organisms seen in pediatric clinics and to determine if utilization of this point-of-care test improved disease management, while exploring impact on clinic workflow.

METHODS

From January 2018 through January 2019, when clinically appropriate, patients were tested by the RP EZ and/or antigen tests (Clinic A) or antigen test only (Clinic B). Residual samples from Clinic B antigen tests were frozen and later tested on the RP EZ for definitive pathogen identification. Patient data and prescription records were extracted from the electronic health record.

RESULTS

A total of 430 patients had RP EZ tests performed, and at least 1 organism was detected in 70.4% of patients. The most common organisms identified were human rhinovirus/enterovirus, influenza, and respiratory syncytial virus. Appropriate treatment occurred for 93.6% of patients when the RP EZ was performed (Clinic A) versus 87.9% of patients who had only antigen tests performed (Clinic B, P = 0.0445). Utilization of RP EZ testing also significantly reduced appointment duration time (48.0 versus 54.9 minutes, P = 0.0009). Three false-positive influenza B results were identified by antigen testing.

CONCLUSIONS

A point-of-care PCR panel improved patient care by providing an accurate diagnosis and shortened appointment duration.

A severe influenza season in Austria and its impact on the paediatric population: mortality and hospital admission rates, november 2017 - march 2018

BACKGROUND

In Austria paediatric influenza-associated hospitalisations and deaths have never been systematically monitored. We examined the influenza season 2017/18 in terms of hospitalisation and mortality in the Austrian paediatric population and put the results into perspective of the available data from the last 15 years.

METHODS

Cases of influenza-associated hospitalisations and deaths for season 2017/18 in children below 18 years were retrospectively collected from 12 and 33 Austrian hospitals, respectively. Hospitalisation and mortality rates for the whole Austrian paediatric population were estimated, adjusting for the population in each catchment area. Two Austrian databases were queried for hospitalisations and deaths associated with influenza during 2002-2016. Rough estimate of the vaccination coverage was calculated from a survey on 100 inpatients.

RESULTS

Influenza-related paediatric hospitalisation rate in season 2017/18 was estimated as 128 (CI: 122-135) per 100,000 children, much higher than the national average of 40 per 100,000 over the years 2002-2016. There were nine reported influenza-associated deaths among children, resulting in mortality rate of 0.67 (CI: 0.32-1.21) per 100,000 children.

CONCLUSIONS

Reported influenza-associated hospitalisations and fatalities demonstrate a high burden of influenza in the Austrian paediatric population corresponding with very low vaccination coverage.

Fine-scale family structure shapes influenza transmission risk in households: Insights from primary schools in Matsumoto city, 2014/15

Households are important settings for the transmission of seasonal influenza. Previous studies found that the per-person risk of within-household transmission decreases with household size. However, more detailed heterogeneities driven by household composition and contact patterns have not been studied. We employed a mathematical model that accounts for infections both from outside and within the household. The model was applied to citywide primary school seasonal influenza surveillance and household surveys from 10,486 students during the 2014/15 season in Matsumoto city, Japan. We compared a range of models to estimate the structure of household transmission and found that familial relationship and household composition strongly influenced the transmission patterns of seasonal influenza in households. Children had a substantially high risk of infection from outside the household (up to 20%) compared with adults (1–3%). Intense transmission was observed within-generation (between children/parents/grandparents) and also between mother and child, with transmission risks typically ranging from 5–20% depending on the transmission route and household composition. Children were identified as the largest source of secondary transmission, with family structure influencing infection risk.

We characterised detailed heterogeneity in household transmission patterns of influenza by applying a mathematical model to citywide primary school influenza survey data from 10,486 students in Matsumoto city, Japan, one of the largest-scale household surveys on seasonal influenza. Children were identified as the largest source of secondary transmission, with family structure influencing infection risk. This suggests that vaccinating children would have stronger secondary effects on transmission than would be assumed without taking into account transmission patterns within the household.

Performance evaluation of the Panther Fusion® respiratory tract panel

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Clinical specificity of Panther Fusion® is between 96 %–100 %, compared to LDT.

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Clinical sensitivity Panther Fusion® is between 71.9 %–100 %, compared to LDT.

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Overall linear regression showed good correlations between LDT and Panther Fusion® for all viruses, except RV and PIV-4.

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The Panther Fusion® provides a random-access system with continuous loading and shorter sample-to-answer times compared to LDT.

Background

Respiratory tract infections are among the most common infections during winter season. Rapid diagnostics is required for clinical decision making regarding isolation of patients and appropriate therapy.

Objectives

The aim of this study was to evaluate the analytical and clinical performance characteristics of the Panther Fusion® respiratory panel using published laboratory-developed real-time PCR assays (LDT).

Study design

Analytical sensitivity of Panther Fusion® Flu A/B/RSV was assessed by testing dilutions of cell culture isolates. Clinical performance assessment included the complete Panther Fusion® respiratory panel (Flu-A/B/RSV, PIV 1-4 and AdV/hMPV/RV) and consisted of a retrospective and a prospective study-arm. The retrospective evaluation included 201, stored (−80 °C) samples collected between February 2006 and January 2017. Prospective evaluation was performed on 1045 unselected pretreated respiratory tract samples from patients presented to our hospital between November 2017 and May 2018.

Results

Analytical sensitivity was generally slightly lower for the Panther Fusion® assays. Clinical specificity and sensitivity was between 96 %–100 % and 71.9 %–100 %, respectively. Discrepant results were found in 146 samples of which 88 samples tested LDT positive / Panther Fusion® negative and 58 samples were LDT negative / Panther Fusion® positive. A total of ten discrepant samples with Ct-values <30 were sequenced to confirm the presence of 7 RV-C not-detected by LDT and 1 RV-A and 2 ADV-2 not detected by Panther Fusion®.

Conclusions

The Panther Fusion® provides a random-access system with continuous loading and much shorter sample-to-answer times compared to LDT, albeit with a slightly less clinical sensitivity compared to the LDT.

Treatment of influenza with neuraminidase inhibitors

PURPOSE OF REVIEW

Seasonal and pandemic influenza are major causes of morbidity and mortality globally. Neuraminidase inhibitors (NAIs) are the only class of antiviral agent recommended for the treatment of currently circulating strains of influenza. There has previously been controversy over the level of evidence for patient benefit with NAIs. We review here the current evidence base for the clinical impact of treatment of influenza with NAIs.

RECENT FINDINGS

Meta-analysis of pharma-sponsored studies (including previously unpublished data) shows that NAIs reduce the duration of illness in influenza-infected patients, and suggest a possible reduction in the rate of complications and hospitalization. Meta-analysis of observational studies examining oseltamivir use during the H1N1 2009 pandemic, suggest a reduction in hospitalization rate in community-dwelling patients and a reduction in mortality in hospitalized adults treated with NAIs. Current NAI use in the community and hospitals varies widely but in general they are underutilized.

SUMMARY

Although there has been controversy over the level of evidence for patient benefit, a growing body of evidence suggests that treatment of influenza with NAIs is associated with improved outcomes for both patients in the community and more severely unwell patients in hospital. Clinical outcomes are optimal with earlier use and strategies to improve early widespread NAI utilization are needed.

Rapid Molecular Tests for Influenza, Respiratory Syncytial Virus, and Other Respiratory Viruses: A Systematic Review of Diagnostic Accuracy and Clinical Impact Studies

We systematically reviewed available evidence from Embase, Medline, and the Cochrane Library on diagnostic accuracy and clinical impact of commercially available rapid (results <3 hours) molecular diagnostics for respiratory viruses as compared to conventional molecular tests. Quality of included studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies criteria for diagnostic test accuracy (DTA) studies, and the Cochrane Risk of Bias Assessment and Risk of Bias in Nonrandomized Studies of Interventions criteria for randomized and observational impact studies, respectively. Sixty-three DTA reports (56 studies) were meta-analyzed with a pooled sensitivity of 90.9% (95% confidence interval [CI], 88.7%-93.1%) and specificity of 96.1% (95% CI, 94.2%-97.9%) for the detection of either influenza virus (n = 29), respiratory syncytial virus (RSV) (n = 1), influenza virus and RSV (n = 19), or a viral panel including influenza virus and RSV (n = 14). The 15 included impact studies (5 randomized) were very heterogeneous and results were therefore inconclusive. However, we suggest that implementation of rapid diagnostics in hospital care settings should be considered.

Development of a multiplex real-time RT-PCR assay for simultaneous detection and differentiation of influenza A, B, C, and D viruses

Influenza is a common and contagious respiratory disease caused by influenza A, B, C, and D viruses (IAV, IBV, ICV, and IDV). A multiplex real-time RT-PCR assay was developed for simultaneous detection of IAV, IBV, ICV, and IDV. The assay was designed to target unique sequences in the matrix gene of IBV and ICV, the RNA polymerase subunit PB1 of IDV, and combined with USDA and CDC IAV assays, both target the matrix gene. The host 18S rRNA gene was included as an internal control. In silico analyses indicated high strain coverages: 97.9% for IBV, 99.5% for ICV, and 100% for IDV. Transcribed RNA, viral isolates and clinical samples were used for validation. The assay specifically detected target viruses without cross-reactivity, nor detection of other common pathogens. The limit of detection was approximately 30 copies for each viral RNA template, which was equivalent to a threshold cycle value of ~37.

Cost-Effective Respiratory Virus Testing

The timely and accurate diagnosis of respiratory virus infections has the potential to optimize downstream (posttesting) use of limited health care resources, including antibiotics, antivirals, ancillary testing, and inpatient and emergency department beds. Cost-effective algorithms for respiratory virus testing must take into consideration numerous factors, including which patients should be tested, what testing should be performed (for example, antigen testing versus reverse transcription-PCR testing or influenza A/B testing versus testing with a comprehensive respiratory virus panel), and the turnaround time necessary to achieve the desired posttesting outcomes. Despite the clinical impact of respiratory virus infections, the cost-effectiveness of respiratory virus testing is incompletely understood. In this article, we review the literature pertaining to the cost-effectiveness of respiratory virus testing in pediatric and adult patient populations, in emergency department, outpatient, and inpatient clinical settings. Furthermore, we consider the cost-effectiveness of a variety of testing methods, including rapid antigen tests, direct fluorescent antibody assays, and nucleic acid amplification tests.

Analytical performances of the BD Veritor™ System for the detection of respiratory syncytial virus and influenzaviruses A and B when used at bedside in the pediatric emergency department

This study aims to evaluate the analytical performance of the BD Veritor™ rapid diagnostic assays (RDTs) for respiratory syncytial virus (RSV) and influenzaviruses when performed 24/7 at bedside by nurses in the pediatric emergency department (PED). The study was performed between 14/10/2015 and 19/03/2016 on nasopharyngeal aspirates (NPAs) collected from children consulting at the PED of the University Hospital of Saint-Etienne for bronchiolitis (RSV detection) or flu-like syndrome (influenzaviruses A/B detection). NPAs were tested 24/7 at the PED with the RDT and then sent to the Infectious Agents Department for routine analyses, first by immunofluorescence assay (IFA), then by nucleic acid amplification test (NAAT) considered as the gold standard in case of discrepancy between RDT and IFA results. For RSV detection, 205 NPAs was analyzed; the overall concordance between RDT and routine assays was of 97.6% (200/205). The sensitivity (Se), specificity (Sp), negative predictive value (NPV) and positive predictive value (PPV) were of 97.6% (160/164), 97.6% (40/41), 90.9% (40/44) and 99.4% (160/161), respectively. A total of 419 NPA was tested for influenzaviruses. For influenzavirus A, the overall concordance was of 98.8% (414/419); Se, Sp, NPV and PPV were of 100% (41/41), 98.7% (373/378), 100% (373/373) and 89.1% (41/46), respectively. For influenzavirus B, the overall concordance was of 97.9% (410/419); Se, Sp, NPV and PPV were of 96.6% (172/178), 98.8% (238/241), 97.5% (238/244) and 98.3% (172/175), respectively. Due to their excellent performances and their easy handle by non-laboratory personnel, these RDTs can be warmly recommended as point of care assays at the PED.

Cost-Benefit Analysis of Real-Time Influenza Testing for Patients in German Emergency Rooms

Background: Seasonal influenza causes significant morbidity worldwide and has a substantial economic impact on the healthcare system. Objective: To assess the cost–benefit relation of implementing a real-time influenza test in emergency rooms (ER) of German hospitals. Methods: A deterministic decision-analytic model was developed simulating the incremental costs of using the Solana^® Influenza A+B test, compared to those of using conventional clinical judgement alone to confirm or exclude influenza in adult ILI (influenza-like illness) patients, in German ER, prior to hospitalization. Direct costs were evaluated from the hospital perspective, considering resource use directly related to influenza testing and treatment, as well as indirect costs incurred by nosocomial influenza transmission. Results: Through base-case analysis and assuming an influenza prevalence of 42.6%, real-time testing with Solana^® reduced average costs of hospitalized ILI patients by €132.61, per tested patient. Moreover, the Solana^® saved €6.9 per tested patient in favor of the hospital. In probabilistic sensitivity analysis, under all reasonable assumptions, implementing the Solana^® saved on average €144.13 as compared to applying the clinical-judgement-only strategy, thus, it was found to be constantly less expensive. Conclusions: Using highly sensitive and specific real-time influenza tests in ILI patients at German ER might significantly reduce hospital expenditures

The impact of incorporating early rapid influenza diagnosis on hospital occupancy and hospital acquired influenza

OBJECTIVE

To assess the impact of incorporating early rapid influenza diagnosis on antimicrobial usage, nosocomial influenza transmission, length of stay, and occupancy rates among hospitalized patients.

SETTING

A 1,100 bed tertiary-care hospital in southern Israel.

METHODS

We implemented early rapid detection of influenza with immediate communication of results. Using Orion methods, we compared the 2017-2018 influenza season to the prior season in our hospital and to the 2017-2018 occupancy rates at other Israeli hospitals.

RESULTS

During the intervention season, 5,006 patients were admitted; 1,824 were tested for influenza, of whom 437 (23.9%) were positive. In the previous season, 4,825 patients were admitted; 1,225 were tested and 288 (23.5%) were positive. Time from admission to test report decreased from 35.5 to 18.4 hours (P &lt; .001). Early discharge rates significantly increased, from 21.5% to 41.6% at 36 hours, from 37.2% to 54.5% at 48 hours, and from 66% to 73.2% at 72 hours. No increase in repeat ER visits, readmission, or mortality rates was observed. Hospital occupancy decreased by 10% compared to the previous year and was 26% lower than the national rate. Hospital-acquired influenza cases were reduced from 37 (11.4%) to 12 (2.7%) (P &lt; .001). Antibiotic usage was reduced both before and after notification of test results by 16% and 12%, respectively.

CONCLUSIONS

Implementing this intervention led to earlier discharge of patients, lower occupancy in medical wards, reduced antibiotic administration, and fewer hospital-acquired influenza events. This strategy is useful for optimizing hospital resources, and its implementation should be considered for upcoming influenza seasons.

What is the role of rapid molecular testing for seniors and other at-risk adults with respiratory syncytial virus infections?

Lower respiratory tract infections are a leading cause of hospitalization and viruses are important causal pathogens, especially in the elderly, immunocompromised patients and those with respiratory or cardiovascular comorbidities. Respiratory syncytial virus (RSV) is recognized as comprising a substantial burden of morbidity and mortality in older and at-risk adults, and the emergence of rapid point-of-care molecular testing has made it possible to confirm an RSV diagnosis accurately, in a clinically actionable timeframe. RSV patients have significantly higher healthcare resource use (including hospital stays and emergency room/urgent care visits) than non-RSV matched controls, especially if aged ≥65 years, a longer length of hospitalization than those with influenza, and associated costs nearly three times higher. We found no direct clinical outcome data specific to rapid molecular testing for RSV in adults and very little in children. There is very limited evidence that prompt diagnosis may reduce hospital length of stay but this and other outcome parameters need confirmation in larger, prospective clinical trials. Regarding reducing inappropriate antibiotic prescribing, the picture is mixed and testing alone is unlikely to change entrenched habits. There is little incentive for clinicians to order routine RSV tests in adults given the absence of a specific antiviral therapy. However, with numerous vaccine and antiviral candidates in clinical development, we believe it is good practice to plan and start establishing standardized testing protocols - perhaps as part of outcome studies. For especially vulnerable patients, e.g., immunocompromised and transplant patients, prompt accurate RSV diagnosis may prevent disease spread and save lives.

Rapid Point-of-Care Influenza Testing for Patients in German Emergency Rooms - A Cost-Benefit Analysis

BACKGROUND

Each year, influenza causes significant morbidity and death worldwide and produces significant economic losses at the expense of the healthcare system.

OBJECTIVE

To assess the cost-benefit relationship of implementing a rapid point-of-care (POC) influenza test in emergency rooms (ERs) of German hospitals.

METHODS

A deterministic decision-analytic model simulated the incremental costs of using the Sofia^® Influenza A+B test compared to those of using clinical judgement alone to confirm or exclude influenza in adult ILI (influenza-like illness) patients in German ERs prior to hospitalization. Direct costs, with and without subsequent oseltamivir treatment, were evaluated from the hospital perspective as well as indirect costs incurred by nosocomial influenza transmission to hospital employees.

RESULTS

In base-case analysis, taking the influenza prevalence of 25.9% in the season 2018/2019 and assuming a hospitalization rate among influenza suspects of 21.9%, rapid testing with the Sofia^® followed by administering oseltamivir to patients testing positive reduced average costs of hospitalized ILI patients by €52.16 per tested patient. If oseltamivir was not offered, testing with the Sofia^® reduced costs by €42.28 in favor of the hospital.In probabilistic sensitivity analysis, under all reasonable assumptions, implementing the Sofia^® saved on average €119.89 as compared to applying the clinical-judgement-only strategy. The major part of the cost savings, €113.17 or 94.4%, was due to the POC test's high specificity, which led to 91% reduction in needless bed-blocking on the first day of hospitalization. However, as the sensitivity of 75.3% was only slightly higher than that of conventional clinical judgement, improved classification of patients with true influenza and a correspondingly lower rate of illness in hospital employees could not be achieved.

CONCLUSIONS

Using highly specific rapid POC influenza tests in ILI patients at German ER, despite their sub-optimal sensitivity, may significantly reduce hospital expenditures.

Respiratory syncytial virus: diagnosis, prevention and management

Respiratory syncytial virus (RSV) is responsible for a large burden of disease globally and can present as a variety of clinical syndromes in children of all ages. Bronchiolitis in infants under 1 year of age is the most common clinical presentation hospitalizing 24.2 per 1000 infants each year in the United Kingdom. RSV has been shown to account for 22% of all episodes of acute lower respiratory tract infection in children globally. RSV hospitalization, that is, RSV severe disease, has also been associated with subsequent chronic respiratory morbidity. Routine viral testing in all children is not currently recommended by the United Kingdom National Institute for Health and Care Excellence (NICE) or the American Academy of Pediatrics (AAP) guidance and management is largely supportive. There is some evidence for the use of ribavirin in severely immunocompromised children. Emphasis is placed on prevention of RSV infection through infection control measures both in hospital and in the community, and the use of the RSV-specific monoclonal antibody, palivizumab, for certain high-risk groups of infants. New RSV antivirals and vaccines are currently in development. Ongoing work is needed to improve the prevention of RSV infection, not only because of the acute morbidity and mortality, but also to reduce the associated chronic respiratory morbidity after severe infection.

Analysis of delays in the prescription of oseltamivir in hospitals and potential for improvement

OBJECTIVES

Patients hospitalized for influenza should receive early treatment with a neuraminidase inhibitor.

PATIENTS AND METHODS

We conducted a retrospective study of the prescription of oseltamivir during the 2016-2017 influenza epidemic among patients hospitalized for influenza confirmed by RT-PCR in the infectious disease department.

RESULTS

Treatment with oseltamivir was initiated as recommended in 96% of hospitalized patients presenting with influenza. However, a delay in prescription was observed with only 18% of prescriptions made on the first day. The prescriptions were exclusively initiated in the infectious disease department.

CONCLUSION

To improve the early prescription of oseltamivir during the influenza season, two recommendations are essential: oseltamivir availability in the emergency department pharmacy, awareness of physicians of the need to prescribe to any patient hospitalized for a lower respiratory tract infection treatment with a neuraminidase inhibitor upon admission to the emergency department.