The Mould Show

COVID Toes, loss of smell and preview of our survey results on COVID-safe workplaces

May 08, 2020 Dr Cameron Jones Episode 46
The Mould Show
COVID Toes, loss of smell and preview of our survey results on COVID-safe workplaces
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The Mould Show
COVID Toes, loss of smell and preview of our survey results on COVID-safe workplaces
May 08, 2020 Episode 46
Dr Cameron Jones

The way humans behave is central to the ways in which SARS-CoV-2 can be transmitted. Whether it’s a cough or a sneeze or touching something that’s then handled by someone else, we need to change behaviour (and quickly) to minimize transmission in the absence of pharmaceutical interventions. In Australia, as coronavirus restrictions are relaxed and businesses are being encouraged to prepare for reopening, the risks once again loom for fresh wave/s of infection. So, what does COVID-safe awareness look like? Overarchingly, it’s using scientifically and medically valid information to make choices that minimize harm and in the first place, accessing this information and using it for self-education and then applying it for your own and others' benefit.

This week, I want to focus some attention on 2 interesting papers. Both of them are about non-fever warning signs that the exposed and then infected individual may go on to develop into COVID-19. Think of today’s Livestream as a symptom-checker that relies on 2 recently published papers that I’ll summarise briefly. The first, looks at how the loss of smell is correlated with a positive diagnosis of COVID-19. The second paper reviews an interesting case of discoloured lesions affecting the feet that pre-date fever symptoms and have become known as “COVID Toes”. Whilst there is still much to learn about the transmission and diverse epidemiology seen with this coronavirus, the literature offers us these 2 easy-to-remember considerations that might be useful. With the race to re-open Schools, it might be prudent to be on the lookout for funny feet or a non-smelly fragrance!

The last part of this Livestream will briefly summarise 2 key points from a recent survey into the knowledge and perceptions of direct contact transmission pathways in Australia. We administered this survey to a cohort of Australians, and I’ll give you a very sneak peek since the paper is now at the peer-review stage. I’ll cover the full results in the next few weeks especially as this relates to the creation and maintenance of COVID-safe workplaces.

REFERENCES:

Predictive value of sudden olfactory loss in the diagnosis of COVID-19
Antje Haehner, Julia Draf, Sarah Draeger, Katja de With, Thomas Hummel
medRxiv 2020.04.27.20081356; doi: https://doi.org/10.1101/2020.04.27.20081356
Posted May 03, 2020.

Mazzotta F, Troccoli T. Acute acro-ischemia in the child at the time of COVID-19. International Federation of Podiatrists. Available at: https://www.fip-ifp.org/wp-content/uploads/2020/04/acroischemia-ENG.pdf. Accessed April 27, 2020.

Dietz L, Horve PF, Coil DA, Fretz M, Eisen JA, Van Den Wymelenberg K. 2020. 2019 novel coronavirus (COVID-19) pandemic: built environment considerations to reduce transmission. mSystems 5:e00245-20. https://doi.org/10.1128/mSystems.00245-20.

Xing YH, Ni W, Wu Q, et al. Prolonged viral shedding in feces of pediatric patients with coronavirus disease 2019 [published online ahead of print, 2020 Mar 28]. J Microbiol Immunol Infect. 2020;S1684-1182(20)30081-5. doi:10.1016/j.jmii.2020.03.021

Show Notes Transcript

The way humans behave is central to the ways in which SARS-CoV-2 can be transmitted. Whether it’s a cough or a sneeze or touching something that’s then handled by someone else, we need to change behaviour (and quickly) to minimize transmission in the absence of pharmaceutical interventions. In Australia, as coronavirus restrictions are relaxed and businesses are being encouraged to prepare for reopening, the risks once again loom for fresh wave/s of infection. So, what does COVID-safe awareness look like? Overarchingly, it’s using scientifically and medically valid information to make choices that minimize harm and in the first place, accessing this information and using it for self-education and then applying it for your own and others' benefit.

This week, I want to focus some attention on 2 interesting papers. Both of them are about non-fever warning signs that the exposed and then infected individual may go on to develop into COVID-19. Think of today’s Livestream as a symptom-checker that relies on 2 recently published papers that I’ll summarise briefly. The first, looks at how the loss of smell is correlated with a positive diagnosis of COVID-19. The second paper reviews an interesting case of discoloured lesions affecting the feet that pre-date fever symptoms and have become known as “COVID Toes”. Whilst there is still much to learn about the transmission and diverse epidemiology seen with this coronavirus, the literature offers us these 2 easy-to-remember considerations that might be useful. With the race to re-open Schools, it might be prudent to be on the lookout for funny feet or a non-smelly fragrance!

The last part of this Livestream will briefly summarise 2 key points from a recent survey into the knowledge and perceptions of direct contact transmission pathways in Australia. We administered this survey to a cohort of Australians, and I’ll give you a very sneak peek since the paper is now at the peer-review stage. I’ll cover the full results in the next few weeks especially as this relates to the creation and maintenance of COVID-safe workplaces.

REFERENCES:

Predictive value of sudden olfactory loss in the diagnosis of COVID-19
Antje Haehner, Julia Draf, Sarah Draeger, Katja de With, Thomas Hummel
medRxiv 2020.04.27.20081356; doi: https://doi.org/10.1101/2020.04.27.20081356
Posted May 03, 2020.

Mazzotta F, Troccoli T. Acute acro-ischemia in the child at the time of COVID-19. International Federation of Podiatrists. Available at: https://www.fip-ifp.org/wp-content/uploads/2020/04/acroischemia-ENG.pdf. Accessed April 27, 2020.

Dietz L, Horve PF, Coil DA, Fretz M, Eisen JA, Van Den Wymelenberg K. 2020. 2019 novel coronavirus (COVID-19) pandemic: built environment considerations to reduce transmission. mSystems 5:e00245-20. https://doi.org/10.1128/mSystems.00245-20.

Xing YH, Ni W, Wu Q, et al. Prolonged viral shedding in feces of pediatric patients with coronavirus disease 2019 [published online ahead of print, 2020 Mar 28]. J Microbiol Immunol Infect. 2020;S1684-1182(20)30081-5. doi:10.1016/j.jmii.2020.03.021

Hello, my name is Dr. Cameron Jones and thank you for tuning in to this week's live stream. I'm doing it from the lab. This is where I spend a lot of my time for a couple of reasons. Most of you who are following this live stream or turn on your TV or radio, probably are aware that at least in Australia the coronavirus restrictions are going to be relaxed to some extent. That means that sectors of the economy are going to be going back to work and we're incredibly busy working on various different aspects of this to support public health.

Therefore, my normal, quite lengthy live streams each week are going to be a little bit shorter and we're kicking off with this one which is also unfortunately a little bit late. In any case, what I want to bring to you today is really an overview of some of the key papers which have come out in the last week or so which impact on our understanding of COVID-19 or, most specifically, the acquisition of this particular virus.

I'm going to be talking a little bit about that but I'm also going to be previewing some of the results from a survey which we have just done on the Australian population or a sector of the Australian population. I talked about this a little bit in last week's live stream. Essentially, this is focusing on what is called direct and indirect coming into contact with the virus.

There are two ways that you can become sick with the virus. That is obviously coming in contact with infected or asymptomatic persons and the most usual route is a droplet spread. The other one is this indirect contact or picking it up from surfaces, and we've spent quite a lot of time focusing on indirect or fomite transmission.

I'm going to extend a discussion of that into this week's livestream and show, simply because we've done a survey on what people's perceptions and existing knowledge is around SARS-CoV-2 and how this impacts on our thinking and also this information is very useful. We're currently putting out a paper which is undergoing peer review at this point in time, and this is going to focus exclusively on this second type of transmission pathway which is the surface contaminants.

In any case, what I want to do now is I want to get up what we're going to be talking about today. I've put this quite provocative title up, COVID Toes, Loss of Smell, and a Preview of our Survey Results on a COVID Safe Workplace. The reason I have done this is that I was quite interested when I saw this paper appear on the pre-print server on the med archive. This particular paper was talking about something called the loss of smell.

Many people who go on to contract the illness, COVID-19, after exposure to the virus have amazingly lost their sense of smell. I want to review what this paper actually said because I think that this is a really good marker, this is a really good example of something which is very easy to use. Certainly as our schools re-open and child care and kindergartens re-open, a lot of these very significant symptoms which individuals might experience are just the type of thing that you want to be on the lookout for and certainly want to discuss this with your healthcare provider and medical practitioner.

In any case, I've put the paper title and the earl up on the screen. Basically, what the paper was doing is that they looked at 500 patients who had a mean age of around about 41-years-old and they ranged in age from 18 to 86 years. They presented with the following symptoms, essentially just of the common cold, and these symptoms included cough at 77% nearly. The individuals experienced sore throat at nearly 65% rhinorrhea.

Now, this is a common symptom of allergies and it's typically mucus with fluid. 55% of individuals had this, and myalgia so a common cold symptom as well as dyspnea and fever. Again, we're all on the lookout for fevers because this is what we have been told is the number one flag fall for going out and probably considering whether or not you have been exposed.

This loss of smell is really, really interesting and in the review of the statistics that the authors put out in their paper they were saying that 13.8% had experienced sudden smell or taste loss, a loss of smell. Now if we drill further into this publication, we can discover a few more interesting facts and figures. From this initial 500 person grouping, 69 of them had some loss of smell or taste. Again, 22 of these tested positive for the SARS-CoV-2 virus, 12 of them also lost their sense of smell and were positive as well, so you can see that the numbers are reducing.

Overall, the frequency of the symptom, sudden smell loss or anosmia. Again, I had to look this up. Basically, COVID-19 patients, the percentage is 64.7%, so that is the medical term for loss of smell. Now, compared to COVID-19 patients without smell loss, the group was significantly younger and much less severely affected to what we have seen when we turn on the news and see some very serious complications including difficulty with breathing.

By excluding patients with just a blocked nose, the symptom sudden smell loss had a very high specificity of 97%, and so what the authors suggest is that this symptom of loss of smell should be added to the WHO symptom list. I thought that this was one of the stand out papers that has come out in the last 10 days.

Now let's move on to something called COVID toes. Again, I'm no podiatrist or medical doctor, I'm a microbiologist, but when I read this paper about COVID toes and saw some of the images I was really intrigued because, firstly, it looks like a severe inflammatory reaction but, secondly, I wonder what the microbiology of these toes would be as well. Again, we don't have enough information regarding COVID-19 in general. This is such a new illness and virus that there are so many publications coming out each week it's very difficult to get across all of these.

We just don't have information about, say, the microbiology of the toes but what we can see, and again, this publication goes into some detail, if we move away from the actual images, again, here's the paper which has appeared in the literature. What happened is that a 13-year-old boy presented with foot lesions and they had a typical colour of violet rounded lesions with blurred limits and it occurred on both feet, not just one.

Again, you can see a pattern here. I'm focusing on symptoms which are affecting young people in general, which are the loss of smell or taste and also these COVID toes or these quite significant and obvious signs. Now again, the academics ensured that the child had not taken any drugs, that this was not a drug reaction. Essentially, after the appearance of the discoloration to the feet, two days later the child began to experience the symptoms of fever followed by muscle pain, headache, intense itching and burning of the feet. Eventually, these lesions self-healed. This is really, really interesting.

However, during the problem period of the high fever, the patient was unable to wear shoes and the symptom appears to be quite localized to the feet and it is characterized by these red to blue colored toes. I think that this is just fascinating because, again, as I said, these are new symptoms and there's a lot to be learned from this. I'm sure a lot of publications are going to come be coming out talking about this localized inflammatory reaction. As I said, it will be very interesting to see whether or not any of these lesions do become co-infected with other microbes, bacteria or fungi, and we'll see what the literature shows in the coming weeks to months.

In any case, I now want to move on to a survey which I touched on very briefly last week. Essentially, this is a publication which I have just submitted and basically this is regarding the implications of environmental surface testing and COVID safe awareness and the implications with regard to restrictions in movement being lifted and what we should be considering about the built environment.

Again, a lovely publication has come out which puts this whole topic into context. Again, I've put the earl up here. Basically, we're talking about moving about our predominantly homes at the moment but when restrictions are lifted we'll be moving back out into the workplaces. Now, we already know that many workers will have their hours staggered and that offices may need to change the way staff are actually managed and might be the end, if we listen to the media, therefore shared open plan offices.

At this point in time, we're all being encouraged to wear masks and use gloves and hand sanitizer. The reason for that is to minimize something called this T, which is on your face you don't want to touch a contaminated object and then touch your eyes, nose or mouth, and that's why it's called a T. This is the hot zone on your body that you definitely don't want to bring your hands into contact with.

The whole point of the problem of fomite contamination is that there are just so many surfaces that could potentially become contaminated with this virus, as we've certainly seen over the months and years in Aero- biology with the distribution of fungal spores, particularly after water damage, which is the prime work that I'm involved with all the time.

More recently, the risk management of workplaces that could be susceptible to a virus settling out onto surfaces is a big component now of what we're actively doing on a day-to-day basis. If we look at this, and this schematic shows very clearly as an individual moves about the built environment, they are going to touch many different areas and materials and objects and then there is a high risk of other individuals coming in contact with that.

Because, as I said, we're still learning about the transmission characteristics of this particular virus, that it is not just all the individuals that came in infected on planes, there's a large percentage of asymptomatic persons which could be shedding virus which is picked up by others, and that's what I really want to focus on. Again, I'm not going to jump the gun because, as I said, my publication is under peer review at this point in time but I'm just cherry picking a couple of the, from the 25 questions that are polled, a test group here in Australia about. We also did some pilots in the US and the UK as well.

One of the questions was regarding how long the virus can remain in the air. Again, part of the survey requirements were that the individuals were not allowed to look up the answers on the internet. What is very interesting and what was actually quite good to see, that the general knowledge of a virus, certainly the SARS-CoV-2 virus, at least for asbestos contamination, was reasonably good.

You can see that the dominant peak here was between the one to three hour. This was the question that I asked about the viability of the virus in droplets when they have been expelled from a symptomatic or an asymptomatic person, how long can they remain suspended in the air? There is a lot of modeling being done in the scientific literature, there are simulations being done in labs, and then there are real world case studies that are coming out of the hospitals and healthcare environments.

My study has picked up the fact that the Australian population is quite accurately determining that the viability of the virus in the air is at least three hours. A lot of people actually just didn't know so that is a very important fact as well. Some people thought that the virus became inactive quite quickly. Again, last week I talked at some length about the potential transmission of virus on other micron and sub-micron debris present in the air and the relationship with PM2.5 particulate matter pollution, and that being a transmission vector for the virus. I'm not going to get into this now at all and I'll turn my phone off as well.

Now, if we move on to the next question, how long can the SARS COVID virus remain viable on surfaces? Now, this is really, really interesting because this is what I wanted to drill into in my survey. I've got some great data which, again as I said, is going to be in the literature and as soon as this is accepted for publication I'll be talking about it here very quickly soon after.

One of the key facts here is that the Australian public were suggesting and certainly suggesting that the virus could remain active for one to five days. Now, that was the dominant, dominant percentage and in a sense that's a little bit wrong because there's lots of evidence in the academic literature that the virus can remain active for a lot longer than these one to five days. Some of the points that I'd like to make in support of that is the fact that a viable virus, that is virus which can cause an infection in another group of cells, have been swabbed from the surface of the external side of a face mask for up to seven days.

Certainly, what we know in the emergent literature of wastewater testing or testing for fecal contamination, that many people shed the virus in their feces. There have been some concerning publications that have come out in the last week or so that have been showing that viruses shed even after people are unable to swab successfully to get a positive result from the nasopharyngeal swab, that out of the feces that the SARS-CoV-2 virus remains detectable up to 30 days.

There are some other publications that are suggesting that it's a bit less and some a little bit more, and so this is a really interesting fact which I wanted to highlight and I will go into much greater detail in print when this comes out. In any case, why am I doing this? Well, the reason why I am doing this is that we are about to head into the next phase. This is, in a sense, termed various different things but it is the post-COVID re-opening.

The initial government response was to isolate and quarantine. Now we're slowly going to relax those conditions and we need to be thinking about what to expect when this all occurs. Hence, why I chose to focus on, not so much microbiology this week but I wanted to talk about these really, really interesting and memorable symptoms such as COVID toes or loss of smell and how that can potentially be used.

I wanted to focus on young people because schools are eminently probably about to re-open and this issue as we know, that the virus is transmitted by close contact but definitely fomite and surface contamination is a risk. That because the schools are going back, we really need to be well aware of these things and be very careful of the T-zone and be mindful of the fact that the virus can remain extractable and swabbable, if you like, to show a positive result using molecular testing techniques from the feces, certainly for 20 to 30 days after people have shown a negative result.

Now, persistent shedding of the SARS-CoV-2 in stools in infected children and even when they're asymptomatic means that there is great potential, I hope not, but there is significant potential for the virus to be spread and cross-contaminate a lot of these high touch items. Again, I want to quote from a paper in here about this issue of viral shedding in asymptomatic individuals in children. The author stated that massive efforts should be made at all levels to prevent spreading of the infection among children after re-opening of kindergartens and schools.

That's all I wanted to say as part of this week's live stream. Really it is a risk awareness episode today and the key take home messages are the T-zone. Be mindful, that's why you're using hand sanitizer and perhaps face masks still. Be aware that the things that you touch you don't know whether they're sanitary and if there is this big potential for fecal cross-contamination of everyday items. Certainly the literature in swabbing of the healthcare environment has shown that patient rooms with people who have been diagnosed with COVID, there's very high percentage of high touch areas that end up having persistent viral levels which are detectable with swab testing.

In any case, once our paper undergoes a successful peer review, I will post all the details from the survey here because it's some very useful information. In any case, I am going to get back to work and I will talk to you next week. Bye for now.