Altered COVID-19 immunity in children with asthma by atopic status

Background

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection causes a spectrum of clinical outcomes that may be complicated by severe asthma. Antiviral immunity is often compromised in patients with asthma; however, whether this is true for SARS-CoV-2 immunity and children is unknown.

Objective

We aimed to evaluate SARS-CoV-2 immunity in children with asthma on the basis of infection or vaccination history and compared to respiratory syncytial viral or allergen (eg, cockroach, dust mite)-specific immunity.

Methods

Fifty-three children from an urban asthma study were evaluated for medical history, lung function, and virus- or allergen-specific immunity using antibody or T-cell assays.

Results

Polyclonal antibody responses to spike were observed in most children from infection and/or vaccination history. Children with atopic asthma or high allergen-specific IgE, particularly to dust mites, exhibited reduced seroconversion, antibody magnitude, and SARS-CoV-2 virus neutralization after SARS-CoV-2 infection or vaccination. TH1 responses to SARS-CoV-2 and respiratory syncytial virus correlated with antigen-respective IgG. Cockroach-specific T-cell activation as well as IL-17A and IL-21 cytokines negatively correlated with SARS-CoV-2 antibodies and effector functions, distinct from total and dust mite IgE. Allergen-specific IgE and lack of vaccination were associated with recent health care utilization. Reduced lung function (forced expiratory volume in 1 second ≤ 80%) was independently associated with (SARS-CoV-2) peptide-induced cytokines, including IL-31, whereas poor asthma control was associated with cockroach-specific cytokine responses.

Conclusion

Mechanisms underpinning atopic and nonatopic asthma may complicate the development of memory to SARS-CoV-2 infection or vaccination and lead to a higher risk of repeated infection in these children.

Persistence of antibody responses to COVID-19 vaccines among participants in the COVID-19 Community Research Partnership

Introduction

High levels of immunity to SARS-CoV-2 in the community correlate with protection from COVID-19 illness. Measuring COVID-19 antibody seroprevalence and persistence may elucidate the level and length of protection afforded by vaccination and infection within a population.

Methods

We measured the duration of detectable anti-spike antibodies following COVID-19 vaccination in a multistate, longitudinal cohort study of almost 13,000 adults who completed daily surveys and submitted monthly dried blood spots collected at home.

Results

Overall, anti-spike antibodies persisted up to 284 days of follow-up with seroreversion occurring in only 2.4% of the study population. In adjusted analyses, risk of seroreversion increased with age (adults aged 55-64: adjusted hazard ratio [aHR] 2.19 [95% confidence interval (CI): 1.22, 3.92] and adults aged > 65: aHR 3.59 [95% CI: 2.07, 6.20] compared to adults aged 18-39). Adults with diabetes had a higher risk of seroreversion versus nondiabetics (aHR 1.77 [95% CI: 1.29, 2.44]). Decreased risk of seroreversion was shown for non-Hispanic Black versus non-Hispanic White (aHR 0.32 [95% CI: 0.13, 0.79]); college degree earners versus no college degree (aHR 0.61 [95% CI: 0.46, 0.81]); and those who received Moderna mRNA-1273 vaccine versus Pfizer-BioNTech BNT162b2 (aHR 0.35 [95% CI: 0.26, 0.47]). An interaction between healthcare worker occupation and sex was detected, with seroreversion increased among male, non-healthcare workers.

Conclusion

We established that a remote, longitudinal, multi-site study can reliably detect antibody durability following COVID-19 vaccination. The survey platform and measurement of antibody response using at-home collection at convenient intervals allowed us to explore sociodemographic factors and comorbidities and identify predictors of antibody persistence, which has been demonstrated to correlate with protection against disease. Our findings may help inform public health interventions and policies to protect those at highest risk for severe illness and assist in determining the optimal timing of booster doses.Clinical trials registry: NCT04342884.

Post-Ebola Symptoms 7 Years After Infection: The Natural History of Long Ebola

BACKGROUND

Lingering symptoms have been reported by survivors of Ebola virus disease (EVD). There are few data describing the persistence and severity of these symptoms over time.

METHODS

Symptoms of headache, fatigue, joint pain, muscle pain, hearing loss, visual loss, numbness of hands or feet were longitudinally assessed among participants in the Liberian Ebola Survivors Cohort study. Generalized linear mixed effects models, adjusted for sex and age, were used to calculate the odds of reporting a symptom and it being rated as highly interfering with life.

RESULTS

From June 2015 to June 2016, 326 survivors were enrolled a median of 389 days (range 51-614) from acute EVD. At baseline 75.2% reported at least 1 symptom; 85.8% were highly interfering with life. Over a median follow-up of 5.9 years, reporting of any symptom declined (odds ratio for each 90 days of follow-up = 0.96, 95% confidence interval [CI]: .95, .97; P < .0001) with all symptoms declining except for numbness of hands or feet. Rating of any symptom as highly interfering decreased over time. Among 311 with 5 years of follow-up, 52% (n = 161) reported a symptom and 29% (n = 47) of these as highly interfering with their lives.

CONCLUSIONS

Major post-EVD symptoms are common early during convalescence and decline over time along with severity. However, even 5 years after acute infection, a majority continue to have symptoms and, for many, these continue to greatly impact their lives. These findings call for investigations to identify the mechanisms of post-EVD sequelae and therapeutic interventions to benefit the thousands of effected EVD survivors.

COVID-19 Symptoms by Variant Period in the North Carolina COVID-19 Community Research Partnership, North Carolina, USA

In North Carolina, USA, the SARS-CoV-2 Omicron variant was associated with changing symptomology in daily surveys, including increasing rates of self-reported cough and sore throat and decreased rates of loss of taste and smell. Compared with the pre-Delta period, Delta and Omicron (pre-BA.4/BA.5) variant periods were associated with shorter symptom duration.

1868. Characterization of COVID-19 Symptoms and Outcomes by Variant Period in the North Carolina COVID-19 Community Research Partnership (NC-CCRP)

Background

We characterize the evolution of symptoms in those with self-reported SARS-CoV-2 infections and the likelihood of seeking treatment or medical care during different waves of the pandemic.

Methods

The NC-CCRP is a longitudinal observational study of 37,820 participants who completed a daily symptom log from April 2020 through February 2022, during which there were 5,167 self-reported COVID-19 infections. Three variant periods were defined as pre-delta, delta, and omicron, based on the predominant variant in North Carolina. Quasi-Poisson and logistic regression models adjusted for demographics and vaccination were used to assess COVID-19 symptoms and their duration and seeking treatment or hospitalization.

Results

Cough was the most reported symptom in all waves and increased from 77% pre-delta to 85% during omicron (p=0.001). Sore throat was more common during self-reported infections during omicron (71%), compared with 62% during delta and 54% pre-delta (p&lt; 0.001). The largest change in proportion reporting a symptom was loss of taste or smell which decreased from 55% during pre-delta to 17% during omicron (p&lt; 0.001). Compared with the pre-delta period, delta (incidence risk reduction, IRR 0.86; 95% CI 0.79-0.93) and omicron (IRR 0.67; 95% CI 0.61-0.73) were associated with lower symptom duration. Participants infected during the delta wave were more likely to seek treatment compared with either pre-delta (odds ratio, OR 1.32 95% CI 1.06-1.64) or omicron (OR 1.42; 95% CI 1.21-1.67). Omicron period infections were associated with a lower likelihood of self-reported hospitalization compared with pre-delta (OR 0.26; 95% CI 0.10-0.59) or delta (OR 0.26; 95% CI 0.11-0.60). Vaccination was associated with a reduced likelihood of hospitalization (OR 0.35; 95% CI 0.18-0.70).

Proportion and Duration of Symptoms by Variant Wave; Unadjusted by Vaccination Status.

Conclusion

Our study indicates evolution in symptom presentation and duration by variant period. The omicron wave was associated with shorter duration and lower severity of illness. Longitudinal tracking of symptomology and severity of a novel pathogen provide insights into the evolution of the pathogen in the community and is vital for public health and clinical response.

Disclosures

All Authors: No reported disclosures.

1049. Breakthrough SARS-CoV-2 Infections after Vaccination in the North Carolina COVID-19 Community Research Partnership (NC-CCRP)

Background

We characterize the incidence and risk factors of SARS-CoV-2 breakthrough infections in the NC-CCRP.

Cumulative Incidence of Breakthrough infections after Self-reported Symptomatic SARS-CoV-2 Test

Cumulative incidence curves (1 minus the unadjusted Kaplan–Meier risk), number at risk at each time point for the first self-reported symptomatic positive SARS-CoV-2 test, starting from full vaccination among participants who reported full vaccination.

Methods

The NC-CCRP is an observational cohort study assessing COVID-19 symptoms, test results, vaccination status, and risk behavior via daily email or text surveys. Cox models were used to estimate hazard rates. Fixed covariates were age at enrollment, race/ethnicity, sex, county of residence classification, vaccine product, and healthcare worker status. Time varying covariates were vaccination rate in county of residence, mask usage in the week prior, the Delta time frame, the Omicron time frame, and receipt of a vaccine booster.

Results

Among 15,808 eligible adult participants, 638 (4.0%) reported a positive SARS-CoV-2 test after vaccination from 01/15/2021 to 01/03/2022. The breakthrough rate increased with time from vaccination (Figure), with a cumulative incidence of 6.95% over 45 weeks of follow-up. Factors associated with a lower risk of breakthrough infection (p&lt; 0.05) included older age (HR 0.7 for participants 45-64 years and 0.41 for those &gt; 65 years compared to those 18-44 years), prior SARS-CoV-2 infection (HR 0.58), higher rates of mask use (HR 0.66), and receipt of a booster vaccination (HR 0.33). Higher rates of breakthrough infection were reported by participants vaccinated with BNT162b2 (HR 1.35) or Ad26.COV2.S (1.74) compared to mRNA-1273, those residing in suburban (HR 1.33) or rural (1.24) counties compared to urban counties, and during circulation of the Delta (3.54) and Omicron (16.68) variants compared to earlier time periods. There was no association of breakthrough infection with sex, race/ethnicity, healthcare worker status, or vaccination rate in the county of residence.

Conclusion

In this real-world analysis, risk of breakthrough infections increased with time since vaccination, with some variability among the specific vaccine products. Risk increased dramatically during the Omicron surge. Higher rates among younger individuals may reflect more frequent, or higher risk exposures, including those related to childcare. Significantly lower rates of breakthrough associated with mask wearing and receipt of a booster highlight specific measures that individuals can take to minimize the risk for COVID-19.

Disclosures

Michael S. Runyon, MD, MPH, Abbott Laboratories: Grant/Research Support|Roche Diagnostics Operations, Inc: Grant/Research Support.

The COVID-19 Community Research Partnership: a multistate surveillance platform for characterizing the epidemiology of the SARS-CoV-2 pandemic

The COVID-19 Community Research Partnership (CCRP) is a multisite surveillance platform designed to characterize the epidemiology of the Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-COV-2) pandemic. This article describes the CCRP study design and methodology. The CCRP includes two prospective cohorts, one with six health systems in the mid-Atlantic and southern USA, and the other with six health systems in North Carolina. With enrollment beginning in April 2020, sites invited persons within their healthcare systems as well as community members to participate in daily surveillance for symptoms of COVID-like illnesses, testing, and risk behaviors. Participants with electronic health records (EHRs) were also asked to volunteer data access. Subsets of participants, representative of the general population and including oversampling of populations of interest, were selected for repeated at-home serology testing. By October 2021, 65 739 participants (62 261 adult and 3478 pediatric) were enrolled, with 89% providing syndromic data, 74% providing EHR data, and 70% participating in one of the two serology sub-studies. An average of 62% of the participants completed a daily survey at least once a week, and 55% of the serology kits were returned. The CCRP provides rich regional epidemiologic data and the opportunity to more fully characterize the risks and sequelae of SARS-CoV-2 infection.

Breakthrough SARS-CoV-2 Infections after Vaccination in North Carolina

We characterize the overall incidence and risk factors for breakthrough infection among fully vaccinated participants in the North Carolina COVID-19 Community Research Partnership cohort. Among 15,808 eligible participants, 638 reported a positive SARS-CoV-2 test after vaccination. Factors associated with a lower risk of breakthrough in the time-to-event analysis included older age, prior SARS-CovV-2 infection, higher rates of face mask use, and receipt of a booster vaccination. Higher rates of breakthrough were reported by participants vaccinated with BNT162b2 or Ad26.COV2.S compared to mRNA-1273, in suburban or rural counties compared to urban counties, and during circulation of the Delta and Omicron variants.

Mission, Organization and Future Direction of the Serological Sciences Network for COVID-19 (SeroNet) Epidemiologic Cohort Studies

Global efforts are needed to elucidate the epidemiology of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), the underlying cause of coronavirus disease 2019 (COVID-19) including seroprevalence, risk factors and long-term sequelae, as well as immune responses following vaccination across populations and the social dimensions of prevention and treatment strategies. In the U.S., the National Cancer Institute in partnership with the National Institute of Allergy and Infectious Diseases, established the SARS-CoV-2 Serological Sciences Network (SeroNet) as the nation’s largest coordinated effort to study COVID-19. The network is comprised of multidisciplinary researchers bridging gaps and fostering collaborations between immunologists, epidemiologists, virologists, clinicians and clinical laboratories, social and behavioral scientists, policy makers, data scientists, and community members. In total, 49 institutions form the SeroNet consortium to study individuals with cancer, autoimmune disease, inflammatory bowel diseases, cardiovascular diseases, HIV, transplant recipients, as well as otherwise healthy pregnant women, children, college students, and high-risk occupational workers (including health care workers and first responders). Several studies focus on underrepresented populations, including ethnic minorities and rural communities. To support integrative data analyses across SeroNet studies, efforts are underway to define common data elements for standardized serology measurements, cellular and molecular assays, self-reported data, treatment, and clinical outcomes. In this paper, we discuss the overarching framework for SeroNet epidemiology studies, critical research questions under investigation, and data accessibility for the worldwide scientific community. Lessons learned will help inform preparedness and responsiveness to future emerging diseases.

729. Lassa Fever Associated Hearing Loss

Background

Hearing loss (HL) is the second leading cause of disability affecting approximately 19% of the world’s population. Despite well known social, economic, and neurologic consequences this condition receives little attention. Lassa Fever (LF) was noted to be associated with HL shortly after its discovery in the 1970’s. However, the true burden of this sequelae is likely underestimated due to a lack of standardized measurement and reporting.

Methods

We performed a cross-sectional study of LF survivors and household controls in Kenema, Sierra Leone. Upon recruitment, survivors and controls were screened for HL by determining Pure Tone Averages (PTA) of air conduction thresholds using an AMBCO audiometer, according to WHO standards. Individuals found to have elevated PTAs were referred to confirmatory testing measuring both air and bone thresholds using a SHOEBOX audiometer to differentiate sensorineural and conductive HL. All subjects completed symptom questionnaires and physical exams to understand the full spectrum of viral sequelae.

Results

94 LF survivors and 281 controls were recruited. The average age of LF survivors was higher than controls (32.9 vs 28.7, p=0.008). Of these 94 LF survivors, 40 (43%) were found to have HL in comparison to 40 (14%) of controls (p&lt; 0.001). Lassa fever survivors were also found to have significantly worse HL with 16 (40%) found to have profound HL compared to only 2 (5%) of controls (p&lt; 0.001). Logistic regression of this cohort found that LF infection (OR = 1.30, p&lt; 0.001), any inner or middle ear symptoms (OR = 1.20, p=0.041), or pharyngeal symptoms (OR = 1.23, p=0.012) were significant risk factors of developing HL (p&lt; 0.001). Interestingly the development of any pulmonary symptoms was protective of HL (OR = 0.86, p=0.039). Animal model studies suggested that LF infection may result in the development of an ANCA vasculitis which may be causative of LF sequelae. A subset of LF survivors (n=80) and IgG negative controls (n=9) were tested for ANCA proteins, of these 20 (25%) survivors vs 5 (55%) tested positive with mean concentrations of 202.4 µg/ml and 135.7 µg/ml (p=0.449), respectively.

Conclusion

This data further characterizes the sequelae of LF and suggests mechanisms of pathogenesis of symptoms.

Disclosures

All Authors: No reported disclosures

New-onset atrial arrhythmias associated with mortality in black and white patients hospitalized with COVID-19

BACKGROUND

Specific details about cardiovascular complications, especially arrhythmias, related to the coronavirus disease of 2019 (COVID-19) are not well described.

OBJECTIVE

We sought to evaluate the incidence and predictive factors of cardiovascular complications and new-onset arrhythmias in Black and White hospitalized COVID-19 patients and determine the impact of new-onset arrhythmia on outcomes.

METHODS

We collected and analyzed baseline demographic and clinical data from COVID-19 patients hospitalized at the Tulane Medical Center in New Orleans, Louisiana, between March 1 and May 1, 2020.

RESULTS

Among 310 hospitalized COVID-19 patients, the mean age was 61.4 ± 16.5 years, with 58,7% females, and 67% Black patients. Black patients were more likely to be younger, have diabetes and obesity. The incidence of cardiac complications was 20%, with 9% of patients having new-onset arrhythmia. There was no significant difference in cardiovascular outcomes between Black and White patients. A multivariate analysis determined age ≥60 years to be a predictor of new-onset arrhythmia (OR = 7.36, 95% CI [1.95;27.76], p = .003). D-dimer levels positively correlated with cardiac and new-onset arrhythmic event. New onset atrial arrhythmias predicted in-hospital mortality (OR = 2.99 95% CI [1.35;6.63], p = .007), a longer intensive care unit length of stay (mean of 6.14 days, 95% CI [2.51;9.77], p = .001) and mechanical ventilation duration(mean of 9.08 days, 95% CI [3.75;14.40], p = .001).

CONCLUSION

Our results indicate that new onset atrial arrhythmias are commonly encountered in COVID-19 patients and can predict in-hospital mortality. Early elevation in D-dimer in COVID-19 patients is a significant predictor of new onset arrhythmias. Our finding suggest continuous rhythm monitoring should be adopted in this patient population during hospitalization to better risk stratify hospitalized patients and prompt earlier intervention.

Long-term Complications of Ebola Virus Disease: Prevalence and Predictors of Major Symptoms and the Role of Inflammation

BACKGROUND

Cohort studies have reported a high prevalence of musculoskeletal, neurologic, auditory, and visual complications among Ebola virus disease (EVD) survivors. However, little is known about the host- and disease-related predictors of these symptoms and their etiological mechanisms.

METHODS

The presence and patterns of 8 cardinal symptoms that are most commonly reported following EVD survival were assessed in the 326 EVD survivors who participated in the ongoing longitudinal Liberian EVD Survivor Study. At quarterly study visits, symptoms that developed since acute EVD were recorded and blood was collected for biomarkers of inflammation and immune activation.

RESULTS

At baseline (mean 408 days from acute EVD), 75.5% of survivors reported at least 1 new cardinal symptom since surviving EVD, which in 85.8% was rated as highly interfering with life. Two or more incident symptoms were reported by 61.0% of survivors, with pairings of joint pain, headache, or fatigue the most frequent. Women were significantly more likely than men to report headache, while older age was significantly associated with musculoskeletal and visual symptoms. In analyses adjusted for multiple comparisons, no statistically significant association was found between any symptom and 26 markers of inflammation and immune activation. Symptom frequency remained largely unchanged during study follow-up.

CONCLUSIONS

Post-EVD complications occur in a majority of survivors and remain present more than 4 years after acute infection. An association between markers of inflammation and immune activation and individual symptoms was not found, suggesting an alternative etiology for persistent post-EVD symptomatology.

Boosting understanding of Lassa Fever virus epidemiology: Field testing a novel assay to identify past Lassa Fever virus infection in blood and oral fluids of survivors and unexposed controls in Sierra Leone

BACKGROUND

Despite identification 50 years ago, the true burden of Lassa Fever (LF) across Africa remains undefined for reasons including research focus on hospitalised patients, lack of validated field-feasible tools which reliably identify past infection, and the fact that all assays require blood samples making large-scale surveys difficult. Designated a priority pathogen of epidemic potential requiring urgent research by the World Health Organisation, a better understanding of LF sero-epidemiology is essential to developing and evaluating new interventions including vaccines. We describe the first field testing of a novel species-neutral Double Antigen Binding Assay (DABA) designed to detect antibodies to LF in plasma and oral fluid.

METHODOLOGY/PRINCIPAL FINDINGS

Paired plasma and oral fluid were collected in Sierra Leone from survivors discharged from Kenema Government Hospital Lassa Fever Unit between 1980 and 2018, and from controls recruited in Freetown in 2019. Epidemiological sensitivity and specificity of the DABA measured against historical diagnosis in survivors and self-declared non-exposed controls was 81.7% (95% CI 70.7%- 89.9%) and 83.3% (72.7%- 91.1%) respectively in plasma, and 71.8% (60.0%- 81.9%) and 83.3% (72.7%- 91.1%) respectively in oral fluid. Antibodies were identified in people infected up to 15 years and, in one case, 40 years previously. Participants found oral fluid collection easy and painless with 80% happy to give an oral fluid sample regularly.

CONCLUSIONS/SIGNIFICANCE

Given the difficulties of assay validation in a resource-limited setting, including unexpected exposures and diagnostics of varying accuracy, the new assay performed well in both plasma and oral fluid. Sensitivity and specificity are expected to be higher when case/control ascertainment is more definitive and further work is planned to investigate this. Even at the performance levels achieved, the species-neutral DABA has the potential to facilitate the large-scale seroprevalence surveys needed to underpin essential developments in LF control, as well as support zoonotic investigations.

31. Post-ebola Syndrome Presents with Multiple Overlapping Symptom Clusters: Evidence from an Ongoing Cohort Study in Eastern Sierra Leone

Background

Since the outbreak of Ebola Virus Disease (EVD) in West Africa from 2013–2016, a large cohort of survivors with persistent health complaints has emerged. This constellation of issues is termed post-Ebola syndrome. Here we characterize the symptoms and physical exam findings of this syndrome in a cohort of survivors from Sierra Leone 2.6 years after resolution of disease.

Ebola survivors present with clusters of symptoms that represent sub phenotypes of post-Ebola syndrome

Methods

Potential survivor participants in Eastern Sierra Leone were identified and recruited through the Sierra Leone Association of Ebola Survivors. Household contacts of survivors were identified by enrolled survivors. Both groups were administered a questionnaire assessing self-reported symptoms. A physical exam was performed by a limited number of trained providers. Symptoms were then compared using hierarchical clustering. Statistical analysis of the correlations between clusters was conducted using conditional logistic regression. Both SPICE and principal component (PCA) analyses were performed to explore the relationships between symptom clusters.

Results

Between March 2016 and January 2019, 375 Ebola survivors and 1040 contacts were enrolled. At enrollment, Ebola survivors of all age groups reported significantly more symptoms than their contacts in all categories. Six symptom clusters were identified representing distinct organ systems. SPICE revealed 2 general phenotypes: with or without rheumatologic symptoms. Clusters including rheumatologic symptoms were correlated with one another (r = 0.63) but not with other clusters (r < 0.35). Ophthalmologic/auditory symptoms were moderately correlated with the non-rheumatologic clusters (r > 0.5). Interestingly, psychologic/neurologic, cardiac/GI and constitutional clusters correlated with one another (r > 0.6) p < 0.0001 in all cases. The symptom clusters were then mapped onto a PCA. Each symptom cluster separated from the remainder along PC1, particularly the phenotypes with rheumatologic symptoms.

Conclusion

This study presents an in-depth characterization of post-Ebola syndrome in Sierra Leonean survivors. The interrelationship between symptom clusters indicates that post-Ebola syndrome is a heterogeneous disease. The phenotypes identified may have unique mechanisms of pathogenesis, and require distinct therapies.

Disclosures

John Schieffelin, MD, MSPH, Wolters-Kluwer (Independent Contractor)

Ophthalmic manifestations and vision impairment in Lassa fever survivors

The purpose of this study was to describe the ocular findings, structural ocular complications, and vision impairment in a cohort of Lassa fever survivors in Kenema, Sierra Leone. A retrospective, uncontrolled, cross-sectional study of 31 Lassa fever survivors (62 eyes) who underwent an ophthalmic evaluation in January 2018 at the Kenema Government Hospital in Kenema, Sierra Leone was performed. Data collection included demographic information, ocular/systemic symptoms, visual acuity (VA), and ophthalmic examination findings. Main outcome measures included anterior and posterior segment ophthalmic manifestations and level of VA impairment in Lassa fever survivors. Anterior segment findings included cataract (18%) and pterygium (2%), while posterior segment manifestations consisted of glaucoma (6%), preretinal hemorrhage (2%), and lattice degeneration (2%). Findings suggestive of prior sequelae of uveitis included chorioretinal scarring (5%), retinal fibrosis (3%), and vitreous opacity (2%). Visual acuity was normal/mildly impaired in 53 eyes (85%), moderately impaired in 6 eyes (10%), and 3 eyes (5%) were considered blind by the World Health Organization (WHO) criteria. Median VA was worse in Lassa fever survivors with ophthalmic disease findings (p<0.0001) for both anterior segment (p<0.0001) and posterior segment disease (p<0.013). Untreated cataract was a significant cause of visual acuity impairment (p<0.0001). Lassa fever survivors in this cohort were found to have cataract and posterior segment findings that potentially represent sequelae of uveitis associated with visual impairment. Future studies are warranted to improve our understanding of the spectrum of ocular disease in this emerging infectious disease of public health consequence.

Fatal Eosinophilic Myocarditis in a Healthy 17-Year-Old Male with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2c)

Background: Cardiac damage is frequently referred to in patients with SARS-CoV-2, is usually diagnosed by enzyme elevations, and is generally thought to be due to underlying coronary artery disease. There are references to cardiomyopathies accompanying coronavirus, but there has been no histologic confirmation.Case report: A previously healthy 17 year male old presented in full cardiac arrest to the emergency department after a 2 day history of headache, dizziness, nausea and vomiting. Autopsy demonstrated an enlarged flabby heart with eosinophilic myocarditis. There was no interstitial pneumonia or diffuse alveolar damage. Postmortem nasopharyngeal swabs detected severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) known to cause coronavirus disease 2019 (COVID-19). No other cause for the eosinophilic myocarditis was elucidated.Conclusion: Like other viruses, SARS-CoV-2 may be associated with fulminant myocarditis.

Dengue and chikungunya seroprevalence among Qatari nationals and immigrants residing in Qatar

The objective of this study is to characterize the seroprevalence of anti-dengue (DENV) and anti-chikungunya (CHIKV) antibodies among blood donors residing in Qatar who are Middle East and North Africa (MENA) nationals and non-nationals. Sera were collected from adult blood donors in Qatar from 2013 to 2016 and tested for anti-DENV and anti-CHIKV IgG using commercial microplate enzyme-linked immunosorbent assays. Age-specific seroprevalence was summarized by region/nationality: Asia (India, Philippines), Middle East (Iran, Jordan, Lebanon, Pakistan, Palestine, Syria, Yemen), North Africa (Egypt, Sudan), Qatar. The adjusted odds of anti-DENV and anti-CHIKV IgG seropositivity was estimated by logistic regression. Among 1,992 serum samples tested, Asian nationals had higher adjusted odds of being seropositive for anti-DENV antibodies compared to nationals of the Middle East (aOR 0.05, 95% CI 0.04-0.07), North Africa (aOR 0.14, 95% CI 0.10-0.20), and Qatar (aOR 0.01, 95% CI 0.01-0.03). Asian nationals also had higher adjusted odds of being seropositive for anti-CHIKV antibodies compared to those from the Middle East (aOR 0.14, 95% CI 0.07-0.27), North Africa (aOR 0.50, 95% CI 0.26-0.96), and Qatar (aOR 0.38, 95% CI 0.15-0.96). The adjusted odds of being anti-DENV seropositive was higher among anti-CHIKV seropositive adults, and vice versa (aOR 1.94, 95% CI 1.09-3.44), suggesting co-circulation of these viruses. DENV and CHIKV exposure is lower in Qatar and MENA nationals compared to Asian nationals suggesting a lower burden of DENV and CHIKV disease in the MENA. Antibodies to both viruses were detected in nationals from most MENA countries, supporting the need to better understand the regional epidemiology of these viruses.

965. Applying Clinical Prediction Tools to Patients with Lassa Fever

Background

Clinical prediction tools such as the Quick Sequential Organ Failure Assessment (qSOFA) and the Modified Early Warning Score (MEWS) have been used to predict mortality from sepsis in high-income countries, but their application to low- and middle-income countries have been limited. Lassa fever is a viral hemorrhagic fever endemic to West Africa with a case fatality ratio for hospitalized patients of up to 69%. The purpose of this study was to evaluate existing clinical prediction tools for critical illness in predicting adverse outcomes in patients with Lassa fever.

Methods

We conducted a retrospective cohort study of patients admitted to the Kenema Government Hospital Lassa ward in Sierra Leone between 2012 and 2017. Patients were required to meet the World Health Organization case definition for suspected Lassa Fever to be admitted to the ward. We included patients who had laboratory-confirmed Lassa fever via ELISA tests for Lassa Ag or IgM. Control samples were included with negative ELISA tests for Lassa Ag and IgM. We compared criteria for qSOFA, MEWS, Systemic Inflammatory Response Syndrome (SIRS), and Universal Vital Assessment (UVA) among the Lassa Ag+ (patients with acute viremia), Ag-/IgM+ (patients who cleared the virus and developed an immune response), and Ag−/IgM− (control) groups.

Results

There were 157 patients included in this preliminary analysis. Of patients in the Ag+ group, the mean age was 20.2 years and 40.8% were female. Patient demographics were similar among all groups. Clinical outcomes significantly differed among the groups, with the highest in-hospital mortality at 62.5% in the Ag+ group. For each clinical prediction tool, mean scores significantly differed among groups (P < 0.05; see table). The highest scores were consistently seen in the Ag+ group.

Conclusion

Patients with acute viremia for Lassa fever had higher scores for clinical prediction tools compared with controls, which imply a higher risk of mortality. Additional research is needed on the sensitivity and specificity of these tools for mortality due to Lassa fever.

Disclosures

All authors: No reported disclosures.

Derivation and validation of a universal vital assessment (UVA) score: a tool for predicting mortality in adult hospitalised patients in sub-Saharan Africa

Background

Critical illness is a leading cause of morbidity and mortality in sub-Saharan Africa (SSA). Identifying patients with the highest risk of death could help with resource allocation and clinical decision making. Accordingly, we derived and validated a universal vital assessment (UVA) score for use in SSA.

Methods

We pooled data from hospital-based cohort studies conducted in six countries in SSA spanning the years 2009–2015. We derived and internally validated a UVA score using decision trees and linear regression and compared its performance with the modified early warning score (MEWS) and the quick sepsis-related organ failure assessment (qSOFA) score.

Results

Of 5573 patients included in the analysis, 2829 (50.8%) were female, the median (IQR) age was 36 (27–49) years, 2122 (38.1%) were HIV-infected and 996 (17.3%) died in-hospital. The UVA score included points for temperature, heart and respiratory rates, systolic blood pressure, oxygen saturation, Glasgow Coma Scale score and HIV serostatus, and had an area under the receiver operating characteristic curve (AUC) of 0.77 (95% CI 0.75 to 0.79), which outperformed MEWS (AUC 0.70 (95% CI 0.67 to 0.71)) and qSOFA (AUC 0.69 (95% CI 0.67 to 0.72)).

Conclusion

We identified predictors of in-hospital mortality irrespective of the underlying condition(s) in a large population of hospitalised patients in SSA and derived and internally validated a UVA score to assist clinicians in risk-stratifying patients for in-hospital mortality. The UVA score could help improve patient triage in resource-limited environments and serve as a standard for mortality risk in future studies.

Clinical validation trial of a diagnostic for Ebola Zaire antigen detection: Design rationale and challenges to implementation

The current Ebola outbreak in West Africa has affected more people than all previous outbreaks combined. The current diagnostic method of choice, quantitative polymerase chain reaction, requires specialized conditions as well as specially trained technicians. Insufficient testing capacity has extended the time from sample collection to results. These delays have led to further delays in the transfer and treatment to Ebola Treatment Units. A sensitive and specific point-of-care device that could be used reliably in low-resource settings by healthcare workers with minimal training would increase the efficiency of triage and appropriate transfer of care. This article describes a study designed to validate the sensitivity and specificity of the ReEBOVTM Rapid Diagnostic Test using venous whole blood and capillary blood obtained via fingerprick. We present the scientific and clinical rationale for the decisions made in the design of a diagnostic validation study to be conducted in an outbreak setting. The multi-site strategy greatly complicated implementation. In addition, a decrease in cases in one geographic area along with a concomitant increase in other areas made site selection challenging. Initiation of clinical trials during rapidly evolving outbreaks requires significant cooperation on a national level between research teams implementing studies and clinical care providers. Coordination and streamlining of approval process are essential if trials are to be implemented in a timely fashion.

Caring for critically ill patients with ebola virus disease. Perspectives from West Africa

The largest ever Ebola virus disease outbreak is ravaging West Africa. The constellation of little public health infrastructure, low levels of health literacy, limited acute care and infection prevention and control resources, densely populated areas, and a highly transmissible and lethal viral infection have led to thousands of confirmed, probable, or suspected cases thus far. Ebola virus disease is characterized by a febrile severe illness with profound gastrointestinal manifestations and is complicated by intravascular volume depletion, shock, profound electrolyte abnormalities, and organ dysfunction. Despite no proven Ebola virus-specific medical therapies, the potential effect of supportive care is great for a condition with high baseline mortality and one usually occurring in resource-constrained settings. With more personnel, basic monitoring, and supportive treatment, many of the sickest patients with Ebola virus disease do not need to die. Ebola virus disease represents an illness ready for a paradigm shift in care delivery and outcomes, and the profession of critical care medicine can and should be instrumental in helping this happen.

Factors associated with mortality in febrile patients in a government referral hospital in the Kenema district of Sierra Leone

There is a paucity of data on the etiologies and outcomes of febrile illness in rural Sierra Leone, especially in the Lassa-endemic district of Kenema. We conducted a retrospective study of patients with subjective or documented fever (T ≥ 38.0°C) who were admitted to a rural tertiary care hospital in Kenema between November 1, 2011 and October 31, 2012. Of 854 patients admitted during the study period, 429 (50.2%) patients had fever on admission. The most common diagnoses were malaria (27.3%), pneumonia (5.1%), and Lassa fever (4.9%). However, 53.4% of febrile patients had no diagnosis at discharge. The in-hospital mortality rate was 18.9% and associated with documented temperature ≥ 38.0°C (adjusted odds ratio [AOR] = 2.89, P = 0.001) and lack of diagnosis at discharge (AOR = 2.04, P = 0.03). Failure to diagnose the majority of febrile adults and its association with increased mortality highlight the need for improved diagnostic capacity to improve patient outcomes.

The effect of antibodies on endothelial cells during Dengue virus infection (P6138)

Profound vascular leakage in conjunction with elevated viremia is the hallmark of Dengue Hemorrhagic Fever/Dengue Shock Syndrome (DHF/DSS). Antibody (Ab)-dependent enhancement (ADE), in which pre-existing, cross-reactive Ab enhance virus infectivity, is thought to be responsible for increased viremia, while loss of endothelial cell (EC) barrier integrity is the precursor to plasma leakage. However, the relationship between increased viremia and vascular leak has not been established. We hypothesize that DV-Ab immune complexes enhance infection of FcγR-bearing cells causing increased virus production and release of mediators contributing to enhanced EC infection and increased vascular permeability seen in DHF/DSS. Anti-DV human monoclonal Abs (HMAb) were generated by molecular cloning to study ADE. Human dermal microvascular EC (HMEC-1) were infected directly with DV or indirectly using media from K562 cells infected with DV+/-HMAb. HMEC-1 infection and infectious virion production were quantified by qRT-PCR and plaque assay, respectively. HMEC-1 monolayers were assessed by microscopy. Indirect HMEC-1 infection under ADE conditions caused enhancement compared to infection media without Ab, and resulted in aberrant changes in HMEC-1 cell morphology, indicating that under ADE conditions, K562 cells enhance DV infection of ECs by increasing the infectious viral load and potentially releasing soluble mediators that cause EC barrier dysfunction.