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To: cwilson@smithfamilycarpets.com
From: "Charlotte" <joshepaleax@gmail.com>
Date: Tue, 04 May 2021 12:35:13 +0530
Subject:    Safe to Covid-19: stay homes save lives.

Stay home.Save lives. As COVID-19 continues to impact communities around th=
e world, help stop the spread by following these steps,=E2=80=9D reads the =
description of the doodle. The doodle redirects to a page of prevention met=
hods in this battle against COVID-19. =

The public service announcement by Google lists five steps that can help st=
op coronavirus.

=E2=80=A2 STAY home
=E2=80=A2 =


=E2=80=A2 KEEP a safe distance
=E2=80=A2

=E2=80=A2 WASH hands often
=E2=80=A2

=E2=80=A2 COVER your cough
=E2=80=A2

=E2=80=A2 SICK? Call the helpline =

Elaborated tips as recommended by the World Health Organization (WHO) are s=
hared next.


=E2=80=A2 Protect yourself and others around you by knowing the facts and t=
aking appropriate precautions. =



=E2=80=A2 Follow the advice provided by your local public health agency, re=
ads the banner.


=E2=80=A2 Advises of cleaning hands with soap and water for at least 20 sec=
onds.

=E2=80=A2 maintaining safe distance. =


Introduction
An outbreak of pneumonia of unknown origin was first reported in Wuhan, Chi=
na, on Dec 31, 2019. After a week, the cause had been identified as severe =
acute respiratory syndrome coronavirus 2 (SARS-CoV-2).1
With a persistently increasing number of cases of COVID-19 worldwide, WHO d=
eclared a pandemic on March 11, 2020.2
Spain has been one of the most affected countries worldwide with 203?715 co=
nfirmed cases as of April 30, 2020.3
Particularly, the Community of Madrid has documented the highest number of =
cases within the country.4
HIV-infected individuals might be at an increased risk of SARS-CoV-2 infect=
ion or severe disease, especially individuals with comorbidities, lower CD4=
 cell counts, or unsuppressed HIV RNA viral load.5
,  6
Conversely, immunosuppression or regular use of antiretrovirals such as pro=
tease inhibitors, nucleoside reverse transfer inhibitors, or non-nucleoside=
 reverse transfer inhibitors (NNRTI) might modify the risk of infection wit=
h SARS-CoV-2 and clinical presentation in this population.7
,  8
,  9
,  10
,  11
Here, we describe the SARS-CoV-2 infection rate and clinical characteristic=
s of COVID-19 among adults living with HIV.
Methods
 Study design and participants
This was an observational prospective study at the Hospital Universitario R=
am=C3=B3n y Cajal (Madrid, Spain), a tertiary university hospital with 1100=
 beds with 2873 adult patients with HIV on regular follow-up at the monogra=
phic HIV clinics. We included consecutive HIV-infected individuals aged 18 =
years or older with a diagnosis of suspected or confirmed COVID-19 as of Ap=
ril 30, 2020. All research was done according to the Declaration of Helsink=
i and local legislation. The study protocol was approved by our institution=
al review board (EC 110/20) and patients provided oral informed consent to =
minimise physical contact with study staff.
Research in context
Evidence before this study
We searched PubMed using the terms =E2=80=9CCOVID-19=E2=80=9D, =E2=80=9Ccor=
onavirus disease 2019=E2=80=9D, and =E2=80=9CHIV=E2=80=9D for studies publi=
shed from Nov 1, 2019, to April 14, 2020, in any language. We found 13 arti=
cles about COVID-19 in HIV-infected individuals. These studies included one=
 related to the rate of infection, one case series, two case reports, one a=
bout CT features in an HIV-infected individual with COVID-19, and eight epi=
demiological perspectives regarding HIV response or health care. Controvers=
ies exist regarding the role of some antiretrovirals on preventing or treat=
ing severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection,=
 as well as the influence of immune dysfunction on clinical presentation.
Added value of this study
To our knowledge, this is the first study to comprehensively describe the i=
nfection rate of COVID-19 in people living with HIV compared with the gener=
al population in the same region and the clinical characteristics and outco=
mes of COVID-19 in a prospective cohort of HIV-infected individuals. As of =
April 30, 2020, 51 COVID-19 cases were diagnosed among a cohort of 2873 HIV=
-infected individuals (incidence 1=C2=B78% [95% CI 1=C2=B73=E2=80=932=C2=B7=
3]). COVID-19 presented similar clinical, laboratory, and radiographical fe=
atures in HIV-infected individuals compared with reports of the general pop=
ulation. Among HIV-infected individuals, those with COVID-19 had a signific=
antly higher prevalence of comorbidities. Lower CD4 cell counts affected di=
sease severity and viral kinetics. Age-adjusted mortality was higher in our=
 cohort than that described in the general population in the same region.
Implications of all the available evidence
HIV-infected individuals should not be considered protected from SARS-CoV-2=
 infection or as having lower risk of severe disease. Indeed, those with lo=
w CD4 cell counts might have worse outcomes than individuals with restored =
immunity. Globally, they should receive the same treatment approach as that=
 applied to the general population.
 Data collection
Since the beginning of the epidemic, all new suspected or confirmed COVID-1=
9 cases diagnosed at the hospital were marked with a specific alert signal =
in electronic health records. We detected co-infection with HIV and SARS-Co=
V-2 by crossing the HIV clinic database and the dataset of individuals with=
 the alert signal of COVID-19. Additionally, physicians who run HIV clinics=
 in the hospital were notified of all COVID-19 diagnoses in their clinic at=
tendees. Furthermore, incident cases diagnosed in other health centres were=
 notified by the patients themselves or their families to their usual treat=
ing physician, as is standard practice when any event occurs to patients wi=
th HIV who regularly attend the clinic. Data were extracted from electronic=
 health records daily by staff of the Department of Infectious Diseases by =
use of a standardised data collection form. Recorded variables were age, ge=
nder, comorbidities, HIV-specific variables (year of HIV infection diagnosi=
s, nadir and recent [ie, most recent within previous 6 months] CD4 cell cou=
nts, recent CD4/CD8 ratio, recent RNA-HIV plasma viral load, and current an=
tiretroviral therapy [ART]), clinical characteristics of COVID-19, baseline=
 blood tests, radiological results, treatment, and outcomes. We used epidem=
iological reports from the health authorities of the Community of Madrid to=
 compare infection rates between HIV-infected individuals and the general p=
opulation.4
 Laboratory procedures
Laboratory confirmation of SARS-CoV-2 infection was done by qualitative rea=
l-time RT-PCR assay of nasopharyngeal swabs, sputum, or lower respiratory t=
ract aspirates only in individuals who were admitted to hospital, health-ca=
re workers, other essential services, or on a case-by-case basis in high-ri=
sk or individuals who reside in closed institutions such as nursing homes, =
detention centres, mental health facilities, and children's homes.12
Public health authorities' regulations in Spain did not recommend confirmat=
ory tests in individuals presenting with mild acute respiratory infection.12
Blood tests and chest x-rays were done at the emergency room according to t=
he clinical needs of each patient, as decided by emergency room physicians.=
 All radiological assessments were done by radiologists.
 Definitions
Confirmed COVID-19 was defined by positive RT-PCR for SARS-CoV-2 in respira=
tory samples. Suspected cases were those in individuals with compatible cli=
nical or radiological findings who were diagnosed with COVID-19, but who di=
d not have RT-PCR testing, or whose results were inconclusive. Fever was de=
fined as an axillary temperature of 37=C2=B73=C2=B0C or higher.13
Lymphocytopenia was defined as a lymphocyte count of less than 1=C2=B70 cel=
ls?=C3=97?109 per L, thrombocytopenia was defined as a platelet count of le=
ss than 150?=C3=97?109 per L, and increased alanine aminotransferase was de=
fined as 40 units per L or higher; defined according to laboratory referenc=
e levels at the Hospital Universitario Ram=C3=B3n y Cajal. Estimated glomer=
ular filtration rate was calculated with the Chronic Kidney Disease Epidemi=
ology Collaboration formula.14
Severe disease was defined as fever or suspected respiratory infection plus=
 respiratory rate greater than 30 breaths per min, oxygen saturation of 93%=
 or less on room air, or acute severe respiratory distress (acute lung infi=
ltrate in chest imaging and ratio of partial pressure of arterial oxygen to=
 fractional concentration of oxygen in inspired air [PaO2/FiO2] of =3D300).=
15
Critically ill individuals were those with rapid disease progression and re=
spiratory failure with need for mechanical ventilation or organ failure tha=
t needs monitoring in an intensive care unit (ICU).16
 Statistical analysis
No sample size was calculated given that all individuals with a diagnosis o=
f COVID-19 were included. Comparisons were assessed by using the Mann-Whitn=
ey U test for continuous variables, whereas categorical variables were asse=
ssed by ?2 test or Fisher's exact test where appropriate. Correlations were=
 assessed by Spearman correlation coefficients. To establish the factors as=
sociated with a diagnosis of COVID-19 in patients living with HIV, we compa=
red baseline characteristics of HIV-infected individuals with a diagnosis o=
f COVID-19 with those of HIV-infected individuals who had a visit in the pa=
st 6 months of 2019, before the beginning of the epidemic, extracting data =
from an anonymised database with updated information about age, nadir CD4 c=
ell count, ART, and comorbidities. We used multivariate logistic regression=
 models to explore the factors associated with COVID-19 diagnosis in the co=
hort, adjusted for age, gender, nadir CD4 cell counts, and years of HIV inf=
ection. Statistical significance was defined as a two-sided p value of less=
 than 0=C2=B705. All statistics were done with IBM SPSS Statistics, version=
 25.0.
 Role of the funding source
This study had no funder. The corresponding author had full access to all t=
he data in the study and had final responsibility for the decision to submi=
t for publication.
Results
Of 2873 HIV-infected individuals regularly followed up in our clinics, 51 w=
ere diagnosed with COVID-19 as of April 30, 2020, resulting in a rate of in=
fection of 1=C2=B78% (95% CI 1=C2=B73=E2=80=932=C2=B73; figure 1). 35 (69%)=
 had a laboratory-confirmed SARS-CoV-2 infection, establishing a confirmed =
COVID-19 rate of 1=C2=B72% (95% CI 0=C2=B78=E2=80=931=C2=B77), whereas 16 (=
31%) were suspected cases. As of the same date, 269?417 cases (61?577 labor=
atory confirmed and 207?840 suspected) were reported in the Community of Ma=
drid general population, resulting in an overall COVID-19 rate of 4=C2=B702=
% (95% CI 4=C2=B701=E2=80=934=C2=B704), and 0=C2=B792% (95% CI 0=C2=B791=E2=
=80=930=C2=B793) for confirmed cases. The mean age of HIV-infected individu=
als with confirmed COVID-19 was slightly lower than the general population =
(53=C2=B76 years [SD 10=C2=B70] vs 59=C2=B77 years [19=C2=B73]) and most (2=
6 [51%]) cases occurred at ages 50=E2=80=9359 years, whereas in the general=
 population, the distribution of COVID-19 was more uniform across age group=
s (figure 2).



=E2=80=A2 refraining from touching eyes, nose or mouth; covering one=E2=80=
=99s nose and mouth while coughing or sneezing; staying home if sick; seeki=
ng medical attention if one =

has fever. and following directions of the public health authority were giv=
en. =