Background Accurate molecular diagnostic tests are necessary for confirming a diagnosis of coronavirus disease 2019 (COVID-19) Direct detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) nucleic acids in respiratory tract specimens informs patient, healthcare institution and public health level decision-making The numbers of available SARS-CoV-2 nucleic acid detection tests are rapidly increasing, as is the COVID-19 diagnostic literature Thus, the Infectious Diseases Society of America (IDSA) recognized a significant need for frequently updated systematic reviews of the literature to inform evidence-based best practice guidance Objective The IDSA's goal was to develop an evidence-based diagnostic guideline to assists clinicians, clinical laboratorians, patients and policymakers in decisions related to the optimal use of SARS-CoV-2 nucleic acid amplification tests In addition, we provide a conceptual framework for understanding molecular diagnostic test performance, discuss the nuance of test result interpretation in a variety of practice settings, and highlight important unmet research needs in the COVID-19 diagnostic testing space Methods IDSA convened a multidisciplinary panel of infectious diseases clinicians, clinical microbiologists, and experts in systematic literature review to identify and prioritize clinical questions and outcomes related to the use of SARS-CoV-2 molecular diagnostics Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was used to assess the certainty of evidence and make testing recommendations Results The panel agreed on 15 diagnostic recommendations Conclusions Universal access to accurate SARS-CoV-2 nucleic acid testing is critical for patient care, hospital infection prevention and the public response to the COVID-19 pandemic Information on the clinical performance of available tests is rapidly emerging, but the quality of evidence of the current literature is considered low to very low Recognizing these limitations, the IDSA panel weighed available diagnostic evidence and recommends nucleic acid testing for all symptomatic individuals suspected of having COVID-19 In addition, testing is recommended for asymptomatic individuals with known or suspected contact with a COVID-19 case Testing asymptomatic individuals without known exposure is suggested when the results will impact isolation/quarantine/personal protective equipment (PPE) usage decisions, dictate eligibility for surgery, or inform administration of immunosuppressive therapy Ultimately, prioritization of testing will depend on institutional-specific resources and the needs of different patient populations

Infectious Diseases Society of America Guidelines on the Diagnosis of COVID-19.

The Pediatric Task Force reviewed all questions submitted by the International Liaison Committee on Resuscitation (ILCOR) member councils in 2010, reviewed all council training materials and resuscitation guidelines and algorithms, and conferred on recent areas of interest and controversy. We identified a few areas where there were key differences in council-specific guidelines based on historical recommendations, such as the A-B-C (Airway, Breathing, Circulation) versus C-A-B (Circulation, Airway, Breathing) sequence of provision of cardiopulmonary resuscitation (CPR), initial back blows versus abdominal thrusts for foreign-body airway obstruction, an upper limit for recommended chest compression rate, and initial defibrillation dose for shockable rhythms (2 versus 4 J/kg). We produced a working list of prioritized questions and topics, which was adjusted with the advent of new research evidence. This led to a prioritized palate of 21 PICO (population, intervention, comparator, outcome) questions for ILCOR task force focus.

The 2015 process was supported by information specialists who performed in-depth systematic searches, liaising with pediatric content experts so that the most appropriate terms and outcomes and the most relevant publications were identified. Relevant adult literature was considered (extrapolated) in those PICO questions that overlapped with other task forces, or when there were insufficient pediatric data. In rare circumstances (in the absence of sufficient human data), appropriate animal studies were incorporated into reviews of the literature. However, these data were considered only when higher levels of evidence were not available and the topic was deemed critical.

When formulating the PICO questions, the task force felt it important to evaluate patient outcomes that extend beyond return of spontaneous circulation (ROSC) or discharge from the pediatric intensive care unit (PICU). In recognition that the measures must have meaning, not only to clinicians but also to parents and caregivers, longer-term outcomes at 30 …

https://www.ahajournals.org/doi/pdf/10.1161/CIR.0000000000000275

Part 6: Pediatric basic life support and pediatric advanced life support: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations☆☆☆

Guideline panels should not GRADE good practice statements.

Background The availability of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) serologic testing has rapidly increased. Current assays use a variety of technologies, measure different classes of immunoglobulin or immunoglobulin combinations and detect antibodies directed against different portions of the virus. The overall accuracy of these tests, however, has not been well-defined. The Infectious Diseases Society of America (IDSA) convened an expert panel to perform a systematic review of the coronavirus disease 2019 (COVID-19) serology literature and construct best practice guidance related to SARS-CoV-2 serologic testing. This guideline is the fourth in a series of rapid, frequently updated COVID-19 guidelines developed by IDSA. Objective IDSA's goal was to develop evidence-based recommendations that assist clinicians, clinical laboratories, patients and policymakers in decisions related to the optimal use of SARS-CoV-2 serologic tests in a variety of settings. We also highlight important unmet research needs pertaining to the use of anti-SARS-CoV-2 antibody tests for diagnosis, public health surveillance, vaccine development and the selection of convalescent plasma donors. Methods A multidisciplinary panel of infectious diseases clinicians, clinical microbiologists and experts in systematic literature review identified and prioritized clinical questions related to the use of SARS-CoV-2 serologic tests. Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was used to assess the certainty of evidence and make testing recommendations. Results The panel agreed on eight diagnostic recommendations. Conclusions Information on the clinical performance and utility of SARS-CoV-2 serologic tests are rapidly emerging. Based on available evidence, detection of anti-SARS-CoV-2 antibodies may be useful for confirming the presence of current or past infection in selected situations. The panel identified three potential indications for serologic testing including: 1) evaluation of patients with a high clinical suspicion for COVID-19 when molecular diagnostic testing is negative and at least two weeks have passed since symptom onset; 2) assessment of multisystem inflammatory syndrome in children; and 3) for conducting serosurveillance studies. The certainty of available evidence supporting the use of serology for either diagnosis or epidemiology was, however, graded as very low to moderate.

/pdf/infectious-diseases-society-of-america-guidelines-on-the-23rwudtdp7.pdf

Infectious Diseases Society of America Guidelines on the Diagnosis of COVID-19:Serologic Testing.

Avian influenza viruses of the H9N2 subtype have seriously affected the poultry industry of the Far and Middle East since the mid-1990s and are considered one of the most likely candidates to cause a new influenza pandemic in humans. To understand the genesis and epidemiology of these viruses, we investigated the spatial and evolutionary dynamics of complete genome sequences of H9N2 viruses circulating in nine Middle Eastern and Central Asian countries from 1998 to 2010. We identified four distinct and cocirculating groups (A, B, C, and D), each of which has undergone widespread inter- and intrasubtype reassortments, leading to the generation of viruses with unknown biological properties. Our analysis also suggested that eastern Asia served as the major source for H9N2 gene segments in the Middle East and Central Asia and that in this geographic region within-country evolution played a more important role in shaping viral genetic diversity than migration between countries. The genetic variability identified among the H9N2 viruses was associated with specific amino acid substitutions that are believed to result in increased transmissibility in mammals, as well as resistance to antiviral drugs. Our study highlights the need to constantly monitor the evolution of H9N2 viruses in poultry to better understand the potential risk to human health posed by these viruses.

Phylogeography and evolutionary history of reassortant H9N2 viruses with potential human health implications

https://www.agricolae.eu/wp-content/uploads/2015/10/JOURNAL-OF-CLINICAL-EPIDEMIOLOGY.pdf

World Health Organization recommendations are often strong based on low confidence in effect estimates

To the Editor:

H1N1 and H3N2 influenza virus subtypes continue to cause human disease (1,2), while avian influenza A H5 and H7 subtypes spread globally among birds with limited an inefficient transmission to humans (3,4). Results from recent ferret research on the H9N2 subtype has demonstrated an increased theoretical threat to humans from the potential emergence of novel subtypes of avian influenza.

In North America, there is no evidence of fixed lineages of the H9N2 avian influenza virus in land-based poultry; it is found in wild ducks and shore birds (5). In contrast, H9N2 remains endemic across Asia, mainly limited to outbreaks in domestic land-based poultry, but overshadowed as a pandemic threat by H5N1 bird flu, which has spread from Asia into Africa and Europe (6–9). However, there is evidence of interspecies transmission of H9N2 from land-based poultry to mammals, such as pigs and swine (10–13). Further evidence of an expanded mammalian host range includes efficient replication of H9N2 in mice without adaptation (14). H9N2 has already caused mild respiratory disease in humans in Hong Kong and mainland China in 1999 and 2003 (10,13,15,16). The six genes encoding the internal components of the H9N2 virus are similar to those found in a previous 1997 outbreak of H5N1 that caused several human deaths in Hong Kong (15). Furthermore, circulating H9N2 strains show human-like receptor specificity with amino acid leucine at position 226 at the receptor-binding site of human airway epithelial cells cultured in vitro (17). H9N2 isolated from live bird markets in Hong Kong possessed receptor specificity similar to human H3N2 viruses (18) and mutations similar to human H2N2 and H3N2 viruses, so the glycoproteins of the Hong Kong H9N2 viruses may potentially promote human infection.

In a ferret model of transmission (9), the H9N2 avian reassortment subtype appears to be evolving. The H9N2 virus replicates in the respiratory tract of ferrets and can spread to noninfected ferrets (9). The amino acid leucine residue located at position 226 in the hemagglutinin receptor-binding site (instead of glutamine), plays a key role in human virus-like receptor specificity, and promotes transmission of the H9N2 virus in ferrets. Airborne transmission has not been detected. Mixing the H9N2 viral genes containing the surface glycoprotein and the six internal genes of a human H3N2 virus resulted in increased transmissibility. The model and reassortment mixing results raises concern about viral evolution as well as efficient pandemic transmission, and suggests that the H9N2 avian virus could be of pandemic importance (19). To conclude that H9N2 is the next human pandemic strain is premature at this time given the unfolding evidence. Yet, the possibility for competent nonavian intermediate reassorters generating novel and virulent pandemic strains of H9N2 (or other avain influenza strains) has increased given the recent raccoon influenza transmission findings (20). Additional study and timely surveillance of H9N2 is needed to identify any increments in viral adaptation to human beings. Studies should consider the widespread prevalence of the H9N2 virus in poultry, and co-circulation and mixing of avian H9N2 with human H3N2, H5, H7 and other avian and mammalian viruses.

/pdf/is-h9n2-avian-influenza-virus-a-pandemic-potential-k5xyzqftho.pdf

Supriya Rave

Papers

World Health Organization recommendations are often strong based on low confidence in effect estimates

Is H9N2 avian influenza virus a pandemic potential