Feeding Low-Income Children during the Covid-19 Pandemic

March 30, 2020. DOI: 10.1056/NEJMp200563

USDA National food programs serve nearly 35 million children daily and continuing these programs during COVID-19 responses is essential. The effects of missing school-provided meals include fatigue, reduced immune response, nutritional deficits, increased financial burden on low-income families, and impact to psychological and physical wellness. The USDA is encouraging schools to meet the needs but has not mandated that schools offer food service during closures. Waivers for food distribution have been provided to local education authorities to adopt innovative approaches to providing meals and to practice appropriate social distancing. The Families First Coronavirus Response Act, signed into law on March 18, supports nutrition assistance and increased emergency benefits under the Supplemental Nutrition Assistance Program (SNAP) to those already enrolled in the program. The Coronavirus Aid, Relief, and Economic Security (CARES) Act was signed into law to appropriate over $23 billion for SNAP and child nutrition programs to accommodate surges in administrative and benefit costs due to increased unemployment. Policy-based solutions that ensure food security for millions of American children are critical during national emergencies like the COVID-19 pandemic. The nutritional needs of vulnerable children are exacerbating disparities in health and educational attainment and the following approaches are suggested:

• Centralize and distribute information about meal provisions during school closure
• Provide multiple days' worth of meals, drive-through meal pickup, and meal delivery
• Extend emergency benefits and authorize use beyond emergencies into summer months
• Codify efforts to expand SNAP access and benefits during future pandemics or national emergencies
• Examine and amend policies that reduce or deter participation in the nutrition safety net (e.g., the public charge rule)

Supporting Equitable Food Access During National Emergencies—The Promise of Online Grocery Shopping and Food Delivery Services

March 27, 2020

National emergencies like the COVID19 pandemic reveal innovative and strategic opportunities to ensure food access for vulnerable groups. For many reasons, some groups may find it difficult to have a sufficient supply of food for even two weeks—those on fixed incomes, those who live in a food desert, or those who lack transportation. There are public and private sector solutions that could develop future policy actions during a national emergency, including SNAP online grocery purchasing pilot with delivery service, grab-and-go meal pick-up, enforce price gouging laws, waive fees for ordering online for customers over 60 years or older, food delivery time slots for shift workers, expanded delivery in rural areas, online ordering at food pantries or implement a mobile food pantry program, and promote healthy food items through discounts and incentives with double dollars. Placing these solutions in areas where food insecurity is high, people can refocus priorities to other needs during the crisis period.

Safety of Extended Use and Reuse of N95 Respirators

March 2020. Clinical Evidence Assessment.

A review of 21 laboratory students on N95 reuse and extended use was conducted. Key conclusions were:

• Up to 18% of viral and bacterial particles were found on respirator filters after 4 to 6 days of use
• Autoclaves, steaming, moist heat, bleach, benzalkonium chloride, and ultraviolet-C achieved a >10,000-fold reduction in H5N1
• 7-8% of N95 masks failed fitting after two uses and >20% failed after 5 fittings
• Reduced filtration (<95%) caused by bleach, ethanol, steaming and autoclaving after several cleanings
• Covering respirators with surgical masks had no clinically significantly effect on breathing effort and gas exchange, and no toxic residue from decontamination from bleach or hydrogen peroxide

COVID-19 epidemic: disentangling the re-emerging controversy about medical facemasks from an epidemiological perspective

March 31, 2020. https://doi.org/10.1093/ije/dyaa044

Surgical facemasks and N95 respirators are in short supply while the demand continues to grow. There are many views and perspectives on the use of medical facemask, which results in inconsistency and confusion in a time when communications should be strategic and clear. Respirators are meant to filter the user's exposure to airborne particles, while surgical masks prevent droplet transmission from health care workers to patients and are generally considered ineffective against airborne infection. This study answers three main questions:

1. Can infected individuals reduce the risk of spreading the virus to others by wearing facemasks? Yes. Facemasks with an appropriate fit are a passive barrier to stop infected persons from spreading a virus through droplets or aerosol and reduce fomite transmission from less touching of their nose and mouth. This is important to consider for exposed, asymptomatic patients.
2. Can uninfected people reduce the risk of infection by wearing facemasks? Maybe. One study found that frequent use of facemasks in public spaces was associated with a >60% lower odds (not risk) of contracting SARS in 2003 compared with infrequent use. Proper use of a facemasks has been show effective among health care workers in randomized control trials, reducing actual risk of SARS by 40-60%.
3. Can widespread use of facemasks in a population facilitate the control of an epidemic? Maybe. More research is needed to confirm observations from populations with widespread use of facemasks. Facemasks are highly visible and may elevate the public's perception on risk awareness.

The benefit of the facemask outweighs the cost to the society. Facemasks have great value to infection control in specific environments and must be worn properly. Stockpiling medical supplies should be discouraged. Facemasks are important in high-risk regions to mitigate the COVID-19 epidemic but may not be cost-effective in low-risk areas. More research could help to clarify the controversy.

March 26, 2020. doi:10.1001/jama.2020.4621

Transmission of SARS-CoV-2 in utero from an infected mother to infant before birth is explored in this single case study. Clinical information was obtained about a mother in Wuhan, China, who developed COVID-19 at 34 weeks, 2 days of gestation on January 31, 2020 and was hospitalized on February 2, 2020. The mother delivered by cesarean on February 22, 2020, wore an N95 mask and did not hold the infant, who was subsequently quarantined in the neonatal intensive care unit. The neonate had elevated IgM (possible IgG antibodies transmitted through the placenta) antibodies to SARS-CoV-2, including cytokines and white blood cell count increases. Additional testing on fluid samples like amniotic fluid and breast milk should be performed to confirm this observation.

March 26, 2020. doi:10.1001/jama.2020.4861

Early studies found no maternal-infant transmission of SARS-CoV-2 based on viral testing for the disease, but presence of elevated antibodies at delivery has been an observation. This study used serologic (i.e., antibodies indicating exposure) criteria to determine if infection was evidenced in newborns among six pregnant women confirmed with COVID19 in China. All had cesarean deliveries and newborns were isolated immediately after delivery. All six infants had detectable antibodies, but SARS-CoV-2 was not confirmed in any of them. This study lacks confirmation of serological characteristics of other fluids like cord blood, amniotic fluid, and breast milk. More study is necessary on understanding if antibodies are transferring from the mother to the infant.

March 26, 2020. doi:10.1001/jamapediatrics.2020.0878

This cohort study reviewed 33 infants born to mothers with confirmed COVID-19, including three neonates with confirmed COVID-19. Infant 1 was born at 40 weeks gestation, had swabs positive for SARS-CoV-2 on days 2 and 4 and negative on day 6. Infant 2 was born at 40 weeks and 4 days gestation, had swabs positive on days 2 and 4 and negative on day 6. Infant 3 was born at 31 weeks and 2 days gestation, had swabs positive on days 2 and 4 and negative on day 7. Recent studies have not indicated any clinical findings that vertical maternal-fetal transmission occurs, but cannot be ruled out.

Protecting the psychological health of children through effective communication about COVID-19

March 31, 2020. DOI: https://doi.org/10.1016/S2352-4642(20)30097-3

Children are being exposed to large amounts of information about COVID-19 as well as the added stress from parents or caregivers. Changing and challenging events require sensitive and effective communication with children in a way they can understand. Honest information prevents children from making sense of the pandemic on their own. Parents are encouraged to be mindful of their children's cues or distress, especially in response to having to quarantine and be physically distant from friends and loved ones. Adults may not think it is important to set the example by sharing some of their feelings, but it is because children may avoid sharing their own concerns to protect others. Authenticity during times of uncertainty is protective and responsible for children and young people.

March 27, 2020. doi:10.1001/jama.2020.4783

Treatment of critically ill patients with COVID-19 is an urgent need. This small study of 5 patients were on ventilation due to the acute respiratory distress syndrome (ARDS) and received transfusion with convalescent plasma with a SARS-CoV-2 specific antibody (IgG) binding titer greater than 1:1000 (end point dilution titer, by enzyme-linked immunosorbent assay [ELISA]) and a neutralization titer greater than 40 (end point dilution titer) that was collected from 5 patients who have recovered from COVID-19. The plasma was given between 10 to 22 days after admission. ARDS resolved in 4 patients at 12 days after transfusion, and 3 patients were weaned from ventilation within 2 weeks of treatment; 3 were discharged from the hospital (at 51-55 days) and 2 were in stable condition at 37 days after transfusion.

Treatment of 5 Critically Ill Patients With COVID-19 With Convalescent Plasma

March 27, 2020. doi:10.1001/jama.2020.4783

Treatment of critically ill patients with COVID-19 is an urgent need. This small study of 5 patients were on ventilation due to the acute respiratory distress syndrome (ARDS) and received transfusion with convalescent plasma with a SARS-CoV-2 specific antibody (IgG) binding titer greater than 1:1000 (end point dilution titer, by enzyme-linked immunosorbent assay [ELISA]) and a neutralization titer greater than 40 (end point dilution titer) that was collected from 5 patients who have recovered from COVID-19. The plasma was given between 10 to 22 days after admission. ARDS resolved in 4 patients at 12 days after transfusion, and 3 patients were weaned from ventilation within 2 weeks of treatment; 3 were discharged from the hospital (at 51-55 days) and 2 were in stable condition at 37 days after transfusion.