The COVID-19 pandemic has been the worst global health crisis of our time, infecting an estimated 600 million people and causing 6 million deaths, and it continues to be a lingering threat worldwide [1]. What made this pandemic different fromany other that humanity has faced in the past was not just about how potent and virulent the SARS-CoV-2 virus was, but also that it had an ally that waseven more virulent and potent: the infodemic of misinformation. Despite glaringly clear evidence of vaccine and mask efficiency, and the global scientific effort that resulted in making an effective vaccine accessibleall over the world in record time, misinformation related to masks and vaccines has made their global adaption a challenge. With the emergence of effective antivirals, people continued to get affected in large numbers largely due to the misinformation virus playing a crucial role in the pandemic. While there is controversy on whether the COVID-19 pandemic is becoming endemic or not, it is quite clear that the misinformation pandemic is well entrenched in our society even before the COVID-19 pandemic and has just exploded in the past few years, both regarding the spreading of COVID-19 misinformation as well as political issues. It is going to require a sustained global effort to mitigate its ongoing onslaught [1].
Misinformation is defined as "publicly available information that is misleading or deceptive relative to the best available scientific evidence, and that runs contrary to statements by actors or institutions who adhere to scientific principles" [2]. The term disinformation is used to refer to "deliberate, engineered falsehoods circulated with malicious intent or to serve a personal, political, or economic agenda." "Infodemic" is another term defined by the WHO as referring to "false and misleading information that causes confusion, risk-taking behaviors and mistrust of health officials" [2]. The problem becomes compounded since the majority of people now turn to online resources and social media for information about COVID. One study reported that 72% of Americans turned to online news and social media sources for COVID-19 information, with 47% reporting that the source was social media [3]. Cinelli et al., employing epidemic modeling for the dissemination of information, showed high measures of the transmissibility of posts on various social media platforms [4]. This misinformation pandemic led to an erosion of trust in science, and scientifically based expert guidelines, as well as in governmental interventions, and public health responses to COVID-19 [5].
While misinformation has been impactful on a multitude of aspects related to COVID-19, including mask-wearing, use of chloroquine, and ivermectin, among others, the single biggest area where there has been a sustained and relentless misinformation campaign has been on the issue of vaccination; both in terms of efficacy and, much more so, in terms of its safety.Concerns about potential safety aspects particularly the side effects and the rapid pace at which these vaccines were developed are some of the primary reasons for COVID-19 vaccine hesitancy. The WHO has defined vaccine hesitancy as "the reluctance or refusal to vaccinate although the availability of vaccines" [6-7]. Vaccine hesitancy has been the primary culprit in derailing public health vaccination strategies globally and one of the primary drivers of misinformation on social media. The US Surgeon General identified misinformation as the greatest threat to COVID-19 vaccination efforts [8]. Table 1 illustrates common topics of COVID-19 misinformation.
Muric et al. analyzed antivaccine-related tweets from Twitters application programming interface (API) and found that misinformation originated from websites with low and dubious credibility and that many accounts with antivaccination content were right-leaning politically [9]. Bots, short for software robots, are typically automated spam accounts and likely play a critical role in orchestrating the misinformation spread. One study found that up to 66% of bots are discussing COVID-19 [10]. Another potent source of misinformation is "trolls". This term is used for individuals who deliberately misrepresent their identity with the purpose of promoting discord. Amplification is a term used to describe a commonly used misinformation strategy by employing multiple bots and trolls to create impressions of false equivalence or consensus [11]. Similarly, another study [12] by Ferrara et al., found that automated bots tweeted significantly more COVID-19-related content as compared to non-bot accounts, and a content analysis of these tweets revealed that they significantly promoted political conspiracies and divisive content. Figure 1 illustrates the targeted misinformation.
Hughes et al. [13] employed qualitative coding methodology to analyze and identify specific patterns of content that were commonly employed by anti-vaccine media. A framework called "the 5C model of the drivers of vaccine hesitancy" provides five main individual-level determinants for vaccine hesitancy: confidence, complacency, convenience (or constraints), risk calculation, and collective responsibility [14]. A study from the United Kingdom (UK) found that demographic variables associated with COVID vaccine hesitancy included youth, female gender, and low income or education. These subjects also tended to rely heavily on social media for information and lacked trust in science [15]. Wilson et al. were able to demonstrate a significant relationship between social media use to organize offline action and concerns about vaccine safety, and they also found an influence from foreign disinformation campaigns [16].
Social media may help promote disinformation by making use of vivid imagery and content [17]. Betsch et al., describe that based on the fuzz-trace theory, where individuals process new information through verbatim memories which incorporate many precise details and gist memories that only contain a summarized bottom line meaning, they make decisions usually based on the gist memories rather than detail memories [18]. Content on social media that isvagueand anecdotal tendsto be shared more readily and is more likelytogo viral, as opposed to evidence-based information that tends to be duller and more theoretical.
Machine learning-based models have been shown to be effective in detecting misinformation regarding COVID-19 vaccines on social media platforms. Bots and trolls are programmed to spread misinformation. Machine learning can help in detecting and mitigating this misinformation.Artificial intelligence can also utilize several machine learning models to classify fake news and tweets[19].At least two studies have attempted to create datasets of tweets to annotate misinformation about covid vaccines - Covid Lies and Covax Lies [20,21]. As these detection systems are improvised and additional targets of misinformation are added, these efforts may result in developing misinformation inoculation interventions on social media platforms relevant to COVID-19 vaccination.
There is an urgent need for interventions to mitigate the effects of this infodemic, but thus far, the best way to achieve effective solutions has been elusive.
Promoting Accuracy in Information
As the understanding of COVID evolves, separating valid information from misinformation becomes a moving target and hence challenging to actualize. The availability of abundant and unreliable sources of information poses additional challenges. The information chain needs structure, wherein information production needs to be limited and mainly resourced to standardized public health portals (e.g. World Health Organization, Center for Disease Prevention) as reliable sources of information [22]. Artificial intelligence and machine learning models can help in recognizing and mitigating the fake and false information either spread via the algorithm or the trend and help in flagging and mitigating it [19]. This available information should be relayed or promoted by leveraging mass media platforms like social media, television, newspapers, and radio. Implementing this structural differentiation between information source and relay of information is vital to minimize the spread of wrong content and ensure accurate data is available to end users [22].Pennycook et al., in one study, showed that a simple accuracy reminder could help participants in truth discernment and influence their subsequent sharing behavior [23].
Clarifying Misinterpreted Ideas
Eradicating health-related misconceptions is the first key to promoting community health [24]. This can be established by individuals that can best present facts in non-scientific jargon, which for most populations is their trusted community health leaders, which includes physicians, researchers, mental health workers, community health workers, or social workers [25]. Bautista et al. proposed a two-phased conceptual model. An authentication phase as well as a correction phase, which healthcare professionals can use to approach correcting health misinformation on social media (e.g., Twitter and Facebook) [26]. Special campaigns that provide opportunities for them to interact with their patients to clarify doubts and misconceptions through emotive language and imagery can be helpful. This process can be accelerated by health agencies by fostering an increased social media presence that can be utilized in promoting such health events, such as legal consequences and financial penalties for spreading intentional false information either by an act of commission or omission.
Social Media Self-Regulation
Social media plays a big role in influencing the community. Healthcare providers can effectively disseminate useful information through social media platforms. Social media channels can play a proactive role in the continued propagation of pro-health ideas and/or curtailing anti-health ideas. All the major social media companies issued a joint statement on their efforts to minimize misinformation about COVID-19 on their platforms [26]. Pinterest redirected vaccine search results on their site to credible information sources such as the CDC. Facebook or Instagram reduced the ranking and rejected ads of groups and pages that promoted vaccine misinformation [27,28]. Social media can also act as barricades to identify potentially harmful misinformation preachers. Various social media platforms have partnered with government health agencies to link health-related information to official websites to help relay accurate information.
Inoculation
As misinformation may prove resistant to correction, an alternative approach derived from inoculation theory is to proactively prepare people for potential misinformation by explaining the logical inconsistencies and pitfalls inherent in misleading communications beforehand. The rationale for this theory is that "inoculating" people in this manner will enable them to better perceive flaws in the arguments and information presented to them and thereby be able to identify them as being deceptive [29]. Just as how vaccines work, "inoculation" messages introduce counterarguments in peoples minds that can help generate resistance to future misinformation.
Law Enforcement and Community Movement
While social media companies in the United States are subject to US Federal Trade Commission regulations as any other US-based business, they are free of any oversight by the US Federal Communications Commission. More specifically, Section 230 of the Communications Act of 1934 absolves social media companies of an obligation to audit or censor user-generated content on their platforms by not considering them as publishers of information as other media entities. Hence the onus of curbing disinformation is largely a result of internal self-monitoring on the part of these companies, although there is evidence to show that social media platforms may, in many instances, be complicit in disseminating identifiable misinformation [30]. Health misinformation needs to be viewed as a public health crisis, and there is hence an urgent need for federal oversight and regulation of social media companies in the same manner as any other media source. Currently, Congress is actively looking into the security system and details for major companies as Facebook and Twitter. The company has stated that they have become more vigilant in recognizing the fake news and even blocking the accounts of users spreading the fake news [31-32].
The United Nation International Children's Emergency Fund (UNICEF) has created a field guide to target vaccine misinformation which provides a comprehensive structure organized into three phases: Listen, Understand, and Engage [33-36]. The phase listen refers to the creation of an active and dynamic social listening system that includes appropriate monitoring tools, including the use of virality scores and rumor logs. The understand phase proposes a Five Pillars of Verification system: provenance, source, date, location, and motivation for responding to information and creating a "risk evaluation matrix." The phase "engage" explores promoting social media health literacy and inoculation strategies.
The infodemicis here to stay and has potentially more lethal ramifications than even the COVID-19 pandemic. Unlike the hugely successful vaccination development program for COVID-19, inoculation strategies for this infodemic are not as easy to resolve and involve a complex interplay between social media companies, medical professionals, researchers, implementation scientists, and federal agencies.
Read the original:
COVID-19 Misinformation: A Potent Co-Factor in the COVID-19 Pandemic - Cureus
Overview
00:00:27
MH Hello, everybody. This is Margaret Harris in WHO Headquarters, Geneva, welcoming you today, October 5, to a media briefing on the many major global health issues that WHO is currently responding to. As always, well open with remarks by our WHO Director-General Dr Tedros Adhanom Ghebreyesus, after which we will open the floor to questions from media representatives.
Joining Dr Tedros in the room are, Ill go from left to right, Dr Maria Van Kerkhove, Technical Lead on COVID-19 and on Dr Tedros right is Dr Sylvie Briand, Director, Epidemic and Pandemic Preparedness and Prevention, Dr Abdi Mahamud, Acting Director, Alert and Response, and Dr Soumya Swaminathan, our WHO Chief Scientist.
00:01:17
Online, we also have many experts, including Dr Mike Ryan, our Executive Director, World Health Emergencies, Dr Rick Brenna, our Regional Emergency Director for the Eastern Mediterranean Region, Dr Palitha Mahipala, our WHO Representative in Pakistan, and we have even more, a big range of subject-matter experts whom I will introduce to you as they answer your questions.
I have to apologise in advance. We do not have simultaneous translation today, as we have a number of major global meetings going on at the same time as this press conference and so it was not possible to arrange the simultaneous translation. I apologise for that. But now, without further ado, I will hand over to Dr Tedros. Dr Tedros, you have the floor.
TAG Thank you. Thank you, Margaret. Good morning, good afternoon and good evening. First to Uganda, where WHO is continuing to support the government to respond to an outbreak of Ebola disease in four districts. So far, 63 confirmed and probable cases have been reported, including 29 deaths. Ten health workers have been infected, and four have died. Four people have recovered and are receiving follow-up care.
WHO has released US$2 million from our Contingency Fund for Emergencies, and were working with our partners to support the Ministry of Health by sending additional specialists, supplies and resources. When there is a delay in detecting an Ebola outbreak it is normal for cases to increase steadily at the beginning and then decrease as life-saving interventions and outbreak control measures are implemented.
00:03:19
The vaccines used successfully to curb recent Ebola outbreaks in the Democratic Republic of the Congo are not effective against the type of Ebola virus that is responsible for this outbreak in Uganda. However, several vaccines are in various stages of development against this virus, two of which could begin clinical trials in Uganda in the coming weeks, pending regulatory and ethics approvals from the Ugandan government.
Now to Pakistan. Although the waters have stopped rising, the danger is only increasing. More than 1,500 lives were lost in the floods but many more could be lost to disease in the coming weeks without a massive and urgent international response. WHOs Executive Director for Health Emergencies, Dr Mike Ryan, has just led a team to Pakistan to assess the needs.
Approximately 10% of all of Pakistans health facilities have been damaged, leaving millions without access to health care. Stocks of essential medicines and medical supplies are limited or have been washed away, damaged roads and bridges are impeding access to services and supplies, and disease surveillance and referral mechanisms have been severely disrupted. There are now outbreaks of malaria, cholera and dengue, an increase in skin infections, and we estimate that more than 2,000 women are giving birth every day, most of them in unsafe conditions.
WHOs focus is on supporting people in four groups, those in camps, who we access easily but are a small percentage of the total need, those who are living along the roadside for hundreds of kilometres, those in areas cut off by flood waters, who are very difficult to access, and those in areas where the water is receding, and are returning home to destroyed villages and homes.
00:05:47
In August, WHO released US$10 million from our Contingency Fund for Emergencies but this massive and unprecedented disaster needs a massive and unprecedented response. Today, we have issued an appeal for US$81.5 million to support WHOs work to support the delivery of immunisation and other life-saving health services, to address severe acute malnutrition, to enhance disease surveillance and to strengthen water and sanitation, and we urge our donors and partners to support this effort. In the words of the United Nations Secretary-General Antonio Guterres, this is not about generosity, this is about justice.
Now, to COVID-19. Several countries in Europe are now reporting an increase in COVID-19 cases, hospitalisations and deaths. This is to be expected as the weather cools and people spend more time together inside and most countries no longer have measures in place to limit the spread of the virus. We expect reported cases of COVID-19 to increase but the deaths dont have to, given we have vaccines and therapeutics that can save lives.
Omicron remains the dominant variant globally, and WHO and our partners are tracking more than 300 subvariants but surveillance, testing and sequencing remain weak globally, which makes tracking this virus like chasing shadows. So, we continue to call on all countries to increase surveillance, testing and sequencing, and to ensure the most at-risk groups are vaccinated.
At the same time, the Northern hemisphere influenza season is starting. Measures introduced to curb the spread of COVID-19 during the pandemic also helped to reduce the burden of flu but, with most of those measures lifted, flu is back and should not be taken lightly. Flu vaccines are safe and effective in reducing severe disease and death, especially among the most at-risk groups, so please get your flu vaccine.
00:08:33
Another disease making an unwelcome comeback is cholera. After years of declining cases globally, we have seen a worrying upsurge of cholera outbreaks around the globe over the past year. In the first nine months of this year alone, 27 countries have reported cholera outbreaks. Not only are we seeing more outbreaks but more deadly outbreaks. The data we have, which are limited, show the average case fatality rate so far this year is almost three times the rate of the past five years. In Syria, more than 10,000 suspected cases of cholera have been reported just in the past six weeks.
And in Haiti, after more than three years with no cases of cholera, two cases have been officially reported this week in the capital Port-au-Prince, with 20 suspected cases and seven deaths under investigation in other areas. Its likely the actual number of cases is significantly higher. This outbreak is a particular setback as Haiti was preparing to be certified as cholera-free later this year.
Although cholera can kill within hours, it can be prevented with vaccines and access to safe water and sanitation, and can be treated easily with oral rehydration or antibiotics for more severe cases but the reality is that many people dont have access to these simple interventions.
00:10:33
In 2013, WHO and our partners created an international stockpile of cholera vaccines which last year shipped 27 million doses but, with an increasing number of outbreaks, supply cannot keep up with demand. We urge the worlds leading vaccine manufacturers to talk to us about how we can increase production.
Cholera thrives on poverty and conflict but is now being turbocharged by climate change. Extreme climate events like floods, cyclones and droughts further reduce access to clean water and create the ideal environment for cholera to spread. Cholera is deadly but its also preventable and treatable. With the right planning and action, we can reverse this trend.
Finally, WHO has today issued a medical product alert for four contaminated medicines identified in The Gambia that have been potentially linked with acute kidney injuries and 66 deaths among children. The loss of these young lives is beyond heartbreaking for their families.
The four medicines are cough and cold syrups produced by Maiden Pharmaceuticals Limited, in India. WHO is conducting further investigation with the company and regulatory authorities in India. While the contaminated products have so far only been detected in The Gambia, they may have been distributed to other countries. WHO recommends all countries detect and remove these products from circulation to prevent further harm to patients.
Ebola in Uganda, multiple outbreaks in Pakistan, cholera around the world, the ongoing COVID-19 pandemic, the global monkeypox outbreak, the annual threat of influenza, and contaminated medicines all illustrate why its so urgent that all countries, individually and as a global community, invest in strengthening their defences against outbreaks that can devastate families and communities, and cripple societies and economies.
00:13:37
In particular, it shows why cost-effective investments in disease surveillance and primary health care are so important. Emergencies are an unfortunate fact of life. We might be able to prevent some but we cant prevent them all. But by investing in strong health systems at the local level, we can mitigate the impact emergencies have and save many lives. Margaret, back to you.
MH Thank you very much, Dr Tedros. Now, well open questions to the media. As you know, we need you to raise your hand on the Zoom. We also need you to indicate what your outlet is on the Zoom. We cant take a question from you unless we are very confident you are actually media. Having said that, weve got several questions already and the first goes to Belisa Godinho, from W Magazine, Portugal. Belisa, I know youve submitted two questions but please stick to one question, and I ask that of all journalists, one question at a time. So, Belisa, please go ahead.
BG Thank you. Thank you very much. The W Magazine media issue is about global health and climate. First, I would like to know specifically if and how will the virtual marathon for the design of vaccines on sustainability and the environment be implemented. Thank you.
00:15:25
MH Thank you, Belisa. Thats a very important question. Dr Soumya Swaminathan, our Chief Scientist, will answer.
SS Thank you for that question and, if I understand it correctly, youre asking about how do we prepare in the future for potential outbreaks that will arise, that we expect will come because of the close links between wild animals and the destruction of our forests and environmental hazards.
Weve seen the risk of pandemics continue to increase and spillover events as well. One of the things that we should be doing and we are doing is trying to anticipate where these risks can come from and identify mainly the viral families where we think that a spillover from animals to humans can happen and that can potentially result in epidemics or pandemics.
There are about 25 or so viral families where such a thing could happen. In the past, weve had the R&D Blueprint for Epidemics identify priority pathogens, one of which was a disease X, which SARS-CoV-2 turned out to be, and that was very helpful. The work that the R&D Blueprint has done over the last five years, since it was set up, helped us to prepare very quickly when we had the beginning of the SARS-CoV-2 and then we could move rapidly into developing the countermeasures.
Similar work now needs to be done and the other organisation thats involved in this is CEPI, which is the Coalition for Epidemic Preparedness Innovations, which is investing in platform technologies, mRNA but also other platforms, viral vectors and all the other new platforms that we have in order to prepare what are called prototype vaccines.
00:17:24
So, you pick one virus from a particular viral family and in fact this helped us because there were prototype vaccine candidates that had been developed for SARS-1 and for MERS and these could be quickly repurposed to SARS-2. Potentially, if you had these type or prototype vaccines that had been developed for different virus families you could, as soon as you had the new genetic sequence of the outbreak pathogen, could use that platform and switch over very quickly to a very specific vaccine.
That is the plan and WHOs role here is to develop this list of priority viral families, as I said, about 25, but also to identify priority pathogens or prototype pathogens against which vaccines can be developed. And Im sure that not just CEPI but many agencies and government agencies that have been set up now, like HERA in Europe, and BARDA and DARPA and the NIH in the US, and many others around the world will be investing in this and the whole idea is to be as prepared as possible against potential threats.
Were also seeing now, the DG just mentioned the number of outbreaks and the fact that we do not have tools against diseases like this Sudan Ebola virus even though weve had outbreaks in the past where we dont have enough stocks of cholera vaccines and so on. So, I think that this whole area of R&D, which is directed towards public health, is going to be increasingly important. Thank you.
00:19:02
MH Thank you very much, Dr Swaminathan. The next question goes to Carmen Paun, of Politico. Carmen, could you unmute yourself and ask your question.
CP Thank you so much for giving me the floor. Just on monkeypox, to my knowledge the countries that have been reporting monkeypox outbreaks for a long time still havent secured access to the vaccine and the therapeutic that is used against it. But I was wondering if you see any positive impact of this global outbreak on the countries that have been reporting cases for a long time. Is it increased awareness of the virus, is it more investment in research or so far there are only negative consequences? Thank you.
MH Thank you very much, Carmen. Dr Rosamund Lewis has joined us in the room just in time. Over to you, Dr Lewis. No, its not for you? Oh, sorry, Carmen, Dr Lewis was just coming in. Could you kindly repeat the question?
CP Sure. Very briefly, I was wondering whether she sees any potential positive impact of the global monkeypox outbreaks on the countries that have been reporting outbreaks for a long time. Does she see any increased investment in research? Obviously, theres more awareness. I was wondering if potentially, on the long-term, that could have any positive impact on the countries that have had to deal with the virus for a long time.
RL Thank you very much for that question. The countries in the African region are very much a part of the global response here, so we are working together with them, along with all other countries and all other regions. They are engaged in improving their surveillance. Theyre in engaged in improving detection. They have access to 38,000 test kits that have been provided to the countries for enhancing PCR and they are also engaged in trainings for clinical care and studies, studies on vaccines and studies on therapeutics.
00:21:14
So, we are very hopeful that this will increase the capacity throughout the region and also youve heard that the Strategic Preparedness and Response Plan is being released along with an appeal that we have, so that we can engage even further with the most affected countries. Thank you.
MH Thank you. Dr Briand will add some more on this issue.
SB Thanks a lot for this question. You highlighted this issue of access, inequitable access, and indeed this has been one of our main concerns at the start of this outbreak because there were products available but not everywhere in the world. So, WHO has been working very closely, first with countries who have already access to vaccines and will receive some donation of those vaccines.
We are working out a plan for allocating those vaccines but, of course, this is not an issue that can be dealt from one day to another because there are a number of things that we need to sort out, such as the regulatory aspect and the distribution of doses. We have also received donations from manufacturers and in particular for treatment, and so once those donation agreements are finalised we will be also in a position to allocate those life-saving interventions to countries with more difficulties to access those things.
00:22:50
So, its work in progress. Its not as fast as we would like it to be but its good lessons learned as well for everybody to see that when we have a disease that we didnt anticipate really enough in advance, that we may face outbreaks in multiple counties, we need to have in place a more global mechanism to ensure better access to life-saving intervention. Thank you.
MH Thank you very much, Dr Briand. I now have a written question from Helen Branswell, STAT magazine. Shes on a plane right now so cant actually ask her question on person. But her question is shes looking for an update on the vaccine studies, trials, where we are with assessing the vaccines for Ebola Sudan virus in Uganda. I understand Dr Abdi will answer this question first and then Dr Soumya will add as well.
AM Let me turn first to Soumya. I think weve been working very closely with Ana Maria and Soumya. Please.
SS I think, again, our R&D Blueprint team, led by Ana Maria Henao, has been working very, very closely with the Ugandan Ministry of Health but also with other partners, including CEPI and with the manufacturers. There are about six vaccine candidates available for the Sudan Ebola virus, which are mostly in very early stages of development, but three of them have some human data, some immunogenicity and safety data, and so they can actually proceed to be used in the field in a ring vaccination campaign, similar to what was done in the Ebola outbreak in DRC a couple of years ago.
00:24:55
Its a chimpanzee adenovirus. There are two different candidates, one from the University of Oxford and one from the Sabin Vaccine Institute. There are very limited doses available, unfortunately, of both of them. There is raw material, so there has to be some fill and finish to make the product ready and at the same time, of course, a protocol has already been developed, submitted to the Ethics Review Committee. The principal investigator has been identified, funding is being mobilised, and so all the preparations are ongoing.
Now, which vaccine, which of these two will actually go into the trial may depend on which one actually has doses to deployer sooner. It would be good, of course, to test as many vaccines as possible but at least start with one and then there may need to be a rolling intake. We are hoping that we could get this off the ground as quickly as possible but realistically it may take another four to six weeks and at the same time theres also a plan being made for testing of therapeutics.
As you know, there were several therapeutics tested again at the DRC during the last Ebola outbreak, one monoclonal antibody and remdesivir likely to be in a clinical trial that would test each one of them individually against a combination, but the protocol is still being developed and again were working with partners to do that. Thanks. Abdi, you wanted to add anything to that?
00:26:24
AM Just appreciation of the excellent work and collaboration with the R&D and here, in terms of the collaboration, we have a SAGE meeting on Thursday that will also discuss some of the plenary, and then the approval and the logistic support. Thanks.
MH Thank you both for those answers. Now, we have a question from Christiane Oelrich, from dpw. Christiane, please ask your question. dpa, I apologise.
CO Thank you, Margaret. My question is on corona. There has been some concern raised in Germany and other European countries about the sublineage BQ.1.1. I wonder what your take on this is. Thats basically it.
MH Thank you. I think Dr Maria Van Kerkhove is ready to answer that one.
MK Thanks very much for the question. As the DG said in his speech today, there are more than 300 sublineages of Omicron that were tracking right now and there are several that are on our radar. It sounds a little bit like an alphabet soup with all of these subvariants that were tracking but the bottom line is that this virus continues to evolve.
It's circulating at an incredibly intense level around the world right now. Among the Omicron sublineages, BA.5 is dominant. About 80% of the sequences that are available are BA.5 and its subvariant but surveillance has changed drastically in the last several months and the numbers of sequences that the world and our expert networks are evaluating has dropped by more than 90% since the start of the year.
That limits our ability to really track each of these and exactly the one that youve mentioned today. We have a number of subvariants of Omicron that are on our radar because what were looking at is we will continue to see waves of infection. This is for sure going into the future because we will be living with this virus but we have a lot of tools that can mitigate their impact.
00:28:25
We have diagnostics that can get patients into the clinical care pathway using antivirals and using different therapeutics to prevent severe disease, to prevent death. We have vaccines that continue to be effective against preventing severe disease and death. So, it is absolutely critical that we use these tools.
If we look at all countries and particularly in the Northern Hemisphere right now, we are starting to see an increase in case detection and in some countries were starting to see increases in hospitalisation, increases in admission to ICU and increases in deaths and this is really due to incomplete vaccination coverage, inappropriate or ineffective use of available tools like antivirals. Theyre being used among the populations that need access to them.
Were concerned and in the Northern Hemisphere were entering autumn and the winter months, so we will see co-circulation of other viruses like influenza, also mentioned by the DG today. So, we need health systems to be prepared. We need surveillance systems to be able to detect the known variants and subvariants that are circulating and we need to be able to detect new ones that are out there. But we need strong health systems to be able to deal with patients and provide appropriate clinical care regardless of where they show up within the health care system.
00:29:41
And if you hear anything, please ensure that you get vaccinated. In all countries we are missing people who are at high risk and the highest risk of developing severe disease, either because they have not received a single dose of vaccine or they havent received the full course of dosings that are recommended for them. So, please look at your national guidance, follow national guidance and receive the recommended doses in your area.
But the virus is circulating and theres much more that we need to do to reduce transmission while living our lives safely. Public health measures play a key role, wearing a mask when youre around others, when youre indoor improving ventilation, making sure we have good surveillance and we use the appropriate therapeutics, diagnostics and vaccines to save lives now.
MH Thank you very much, Dr Van Kerkhove. The next question goes to Megha, from Health Policy Watch. Megha, please unmute yourself and ask your question.
ME Thank you so much. My question is just could you please provide an update on what the status of work is at the mRNA hub in Africa? Thank you.
MH Dr Soumya Swaminathan will answer that question.
SS Thank you. Thank you very much for that question. Ill try to provide a brief update. As you know, the mRNA hub in South Africa is based at this company called Afrigen but there are a number of partners supporting, including the Ministry of Science and Innovation, as well as the Medical Research Council and then Biovac is the other company to which the transfer will take place.
00:31:19
At this point we actually have an mRNA vaccine candidate that has been developed by scientists in South Africa using publicly available information. Now this, because its a newly-developed vaccine, needs to go through all the phases of testing that a vaccine normally would.
Right now it is going to go into animal studies, hopefully this month, in October, for all the toxicity studies and so on, and then the technology transfer has to happen and then the GMP doses have to be produced so that it could then go into human clinical trials, which will likely start perhaps towards the end of 2023. And then theres a timeline for going into Phase 2 and 3 trials.
Meanwhile, of course, there is the technology transfer, which has also started happening since the basic methodology and the SOPs for how to develop a vaccine have already been done, even though its yet to be proven efficacious and safe. The spokes, and as you know, we have 15 spokes around the world in different regions of the world. Teams from those companies have already started coming to South Africa for training, for the technology transfer.
00:32:37
Theyre now taking that technology back into their own companies and their countries and beginning work, sometimes to use the technology for other products, for other vaccines. And different spokes are now having discussions about which other diseases they could target and theyre thinking about diseases like tuberculosis and malaria but also about chikungunya and dengue and other infectious diseases.
At the same time, there are two other workstreams which have started. One is the Biomanufacturing Training Initiative with the hub in South Korea. So, well have the second batch of trainees going there in October and were working closely with the WHO Academy team to really build a curriculum for manufacturing training in biologics.
Then, the other workstream is led by our regulatory colleagues, Dr Simo, Dr Rogrio Gaspar, and they are actually now building the regulatory capacity of countries because for countries to be successful producers and exporters of vaccines and health products you need a strong regulatory system. That work is also proceeding. So, all of these parallel activities.
We did start this with a longer-term view really, beyond COVID. So, the idea was not to come up necessarily with a vaccine for COVID, though that would be the proof of principle but its going to take time. So, the idea is to build this network, build the capacity, put the technology in the hands of scientists in these companies who will then make products that are needed for their own populations. Thanks. I hope that answered the question.
MH Thank you, Dr Swaminathan. Dr Maringela Simo would like to add a few points, as you mentioned, about the regulatory aspects. Dr Simo, please. Over to you.
00:34:27
MS Thank you. Thank you for the question. Actually, I want to share good news because this week we finalised the formal assessment of the South African Regulatory Authority, which is now considered by WHO as a functional Maturity Level 3 regulatory authority.
Let me say that the Government of South Africa has invested a lot of effort and training of personnel to be able to achieve WHO standards for a functional regulatory authority. Why is it important? Because South Africa hosting the hub, it needs a strong regulatory authority to oversee the production of vaccines in the country. So, I just wanted to share this news. Thank you.
MH Thank you, Dr Simo and Dr Swaminathan. The next question goes to somebody who has been waiting up very late at night, Mary Ann Benitez, in Hong Kong, from the Hong Kong Standard. Mary Ann, please unmute yourself and ask your question.
MB I would like to ask, because doctors and also the CHP Can you hear me?
MH Very well, Mary Ann. Please, go ahead.
MB Theyve been urging people to get COVID-19 and flu jabs in one go, warning of a possible seasonal, a double whammy of COVID and flu because there have been milder flu winter peaks in the past three years amid the pandemic. So, whats the WHO decision also? Is there a crystal ball that people should be overly worried of, as I said, a double whammy of flu and COVID at the same time? Thank you.
00:36:16
View original post here:
A Merck pill used to combat Covid-19 failed to demonstrate it can lower the risk of hospitalization compared with a placebo among adults at a higher risk from the disease, according to the results of a large study conducted in the U.K.
The preliminary results of the randomized trial, which involved more than 25,000 participants, showed that taking molnupiravir did speed time to recovery by about six days, which means that patients did get some relief. Otherwise, though, the study failed to reach an outcome that had been used late last year by regulators such as those in the U.S. and U.K. to authorize the medicine to thwart the pandemic.
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Merck's Covid pill no better than placebo in lowering risk of hospitalization - STAT
There was a moment during the COVID-19 pandemic when it became clear how essential child care is to a thriving economy.
This truth long known by working parents came only after a deadly global pandemic, women dropping out of the workforce en masse and parents sequestered at home with their children.
Suddenly, politicians were paying attention and even echoing concerns advocates have raised for years: child care workers are underpaid, yet it remains crushingly expensive for parents.
The government invested billions of dollars in helping parents during the pandemic, but that money is set to expire soon. And there was talk at the federal level of including paid family leave, free preschool and expanded public child care in the Inflation Reduction Act, but the final package was stripped of all three.
In Oregon, although work to build child care capacity is underway, the issue has received relatively little attention from the three women Republican Christine Drazan, Democrat Tina Kotek and Betsy Johnson, an unaffiliated candidate running to be the states next top executive.
(Kotek is traveling to Medford this week to visit a preschool and to talk about expanding access to child care.)
The three major candidates for Oregon governor. From left to right: Tina Kotek, Betsy Johnson and Christine Drazan.
OPB Staff / OPB
Kali Thorne Ladd, the chief executive officer of the Portland-based Childrens Institute, an advocacy group focused on public policies affecting children, said shes been dismayed by how little the three candidates for governor have focused on the earliest years of a childs life.
The next governor has the potential to change the trajectory for early learning in Oregon and by doing so, they have the power to change the trajectory of the state, Thorne Ladd said. The success or failure of our children will determine the success or failure of Oregon.
The next woman to be elected governor will also be charged with overseeing a new state agency: the Department of Early Learning and Care, tasked with focusing on children from birth through the age of 5 starting in July of 2023.
Rep. Karin Power, D-Milwaukie, one of the few working parents in the Legislature with small children, helped spearhead an effort to funnel more money into early childhood care and create the dedicated agency during the 2022 legislative session. Power, who is also a lawyer and a mom to a toddler and a first grader, said she deeply, deeply understands that child care is essential infrastructure.
Oregon remains one of the more expensive states in the country for infant care. And its also difficult to secure care in Oregon; every county in Oregon, for example, is considered a child-care desert, for children 2 and younger, meaning there are not enough affordable and accessible spots for the youngest children who need them.
And since neither the state nor the federal government guarantee paid family leave for workers, many parents are stuck trying to patch together care from friends and family or must quit their jobs to care for their kids.
File photo of preschooler.
Rob Manning/OPB
Although the issue of child care hasnt taken center stage with the three gubernatorial candidates, OPB asked each candidate two specific questions on the issue to gain a better understanding of their thinking. Their answers have not been edited.
PAID FAMILY LEAVE
In 2019, Oregon lawmakers passed House Bill 2005, establishing a paid Family and Medical Leave Insurance program.
The program would allow employees to take up to 12 weeks off to care for a new child, seek medical treatment, address domestic violence issues or deal with illness. While on leave, the program would pay a percentage of the persons wages. The amount would depend on how much the employee earns. The persons job would also be protected if they have been with the company for more than 90 days.
The program has gotten off to a rocky start, delayed by the pandemic and myriad other problems, such as turnover and unhappy employees, highlighted in an investigation by the Oregonian.
Employers and employees are scheduled, however, to start paying into the program beginning January 1, 2023, and the program is scheduled to start paying benefits in September 2023.
Here is what we asked the candidates:
Paid family leave is meant to start in Oregon in 2023, but there are many families it wont cover. What is your stance on state-subsidized leave that would cover people working for very small companies fewer than 25 employees or the self-employed?
Editors note: OPBs question to the candidates contained an error that does not affect the candidates answers. Employees at companies with fewer than 25 employees will pay into and be covered by Oregons paid leave program. Self employed people are not required to contribute, but can opt in. Federal employees and tribal government employees will not be covered.
Christine Drazan, the Republican candidate for governor, wrote:
I crossed party lines to support paid family leave in part because constituents supported provisions which helped victims of domestic violence and because responsibility was shared between employees and employers while not burdening our smallest small businesses with an unaffordable program. In the intervening years businesses across the state have faced workforce shortages which have remained unabated. I have great concern that this program as structured will only exacerbate those challenges. We must provide a balanced program which allows businesses to remain open while providing employees with support when they need it most. I do not support expanding the existing program but believe that the existing program warrants review.
Tina Kotek, the Democratic candidate for governor, wrote:
All Oregon families should have access to paid family leave so they can care for a newborn, themselves, or a loved one. As House Speaker, I led the way to pass one of the nations strongest paid family leave programs. As part of the negotiations to pass the bill, Republicans and the business community pushed for an exemption from the employer contribution for companies with 25 or fewer employees. A broad bipartisan coalition ended up supporting that compromise. As Governor, I will focus first on implementing the current law successfully and would then support expanding it.
Betsy Johnson, the unaffiliated candidate for governor, wrote:
Paid family leave is a great policy that politicians should have left to businesses to implement or not based on their market and employee situation. As it is, politicians in Salem have passed heavy handed mandates that will disparately impact small and growing businesses and ironically keep them from being able to maintain their workforces.
This law desperately needs what the initial proposal needed, which is to work closely with business owners by size and sector to figure out how we get around the absurd one-size-fits-all mandate. I deeply believe our government needs to change its perspective from doing things to business to working with business. The idea that its employers are wrong to try to maintain and grow their businesses does real damage to both jobs and job creators.
UNIVERSAL PRESCHOOL
OPB also asked all the candidates about universal preschool. In 2020, voters in Multnomah County approved a measure that will offer free preschool to all children ages 3 and 4 by 2030. The program which will pay lead preschool teachers in line with kindergarten teachers and provide subsidies for programs offering infant and toddler care was expected to start this month, but understaffing in the Early Learning Division has caused delays. A shortage of child care workers and a backlog of background checks is also causing issues with the rollout.
Here is what we asked the candidates:
Voters in Multnomah County approved a universal preschool measure during the pandemic. Do you feel that the private-public partnership model they plan to use could be a fit for families statewide? As governor, would you support legislation to expand free preschool access in the state?
Christine Drazan, the Republican candidate for governor, wrote:
No. During this time of extraordinary tax burden, the last thing we need to do is grow government and expand it.
Tina Kotek, the Democratic candidate for governor, wrote:
I am a strong supporter of making sure every Oregon child can have access to high-quality, affordable early childhood education. Thats why I made sure the Student Success Act included expanded investments in early childhood programs so more children will be ready for school when they enter kindergarten. Oregons path to achieving this big goal will require significant public-private partnership. As Governor, my initial priorities will be on meeting the growing need for suitable physical space for safe child care, expanding our child care workforce by providing capacity-building grants to communities, and expanding the coverage of Oregons Employment Related Daycare Program (ERDC) to meet the needs of more families.
Betsy Johnson, the unaffiliated candidate for governor, wrote:
Im suspicious of the assumptions behind the question. Of course I would be in favor of expanding preschool access and I understand affordability is everything to giving children a head start, but Multnomah Countys program is a disaster from start to finish. It is only a model for failure. It establishes way too high of a tax rate, giving Multnomah County the dubious honor of having the highest individual tax rates of any county in the country and fails to connect early education to the school system as a whole. There is no curriculum, there is no plan, there are no measurables. It is exactly what I would not do.
Here is the original post:
Why the change of heart on COVID vaccines?
Malhotra wrote that he happily received both doses of a COVID-19 vaccine in early 2021. In fact, he said, he was surprised and concerned at the time about the number of vaccine-hesitant patients he encountered on a regular basis.
When his father tragically died after suffering a cardiac arrest in July 2021, however, he says he started to reconsider his perspective. Malhotras father, Prof. Kailash Chand, OBE, was a celebrated figure throughout England and beyondand, yes, he was vaccinated. His death confused Malhotra, both because his father had been taking great care of his body and because there was no evidence of an actual heart attack. Malhotra ultimately concluded that there is a real possibility the COVID-19 vaccines had played a significant role.
Malhotra explained that this is when he started thinking more and more about the vaccines. After reviewing the data in great detail in his editorials, he shared his conclusion that the numbers suggest there is a greater risk of serious adverse events from the vaccines than being hospitalized from COVID-19.
Pharmacovigilance systems and real-world safety data, coupled with plausible mechanisms of harm, are deeply concerning, especially in relation to cardiovascular safety, he added.
The medical and scientific communities have responded to these editorials rather quickly. Both columns were repeatedly shared once they went live, and groups agreeing withMalhotra and disagreeing withMalhotra have both been quite active.
Health Feedback, a group focused on sorting fact from fiction in health and medical media coverage, provided a thorough rebuttalof the editorials on its website.
Scientific evidence from clinical trials and safety monitoring indicate that the COVID-19 vaccines are safe and effective, the group wrote. While severe reactions to the vaccine can occur, they are rare, and the most common side effects of vaccination are mild and go away within a few days. All available evidence indicates that being vaccinated is safer than not being vaccinated.
The Health Feedback response highlighted the fact that multiple organizations supporting Malhotra have been associated with spreading COVID-19 misinformation in the past. This includes the World Council for Health, the host of the previously mentioned press conference, and Health Advisory and Recovery Team.
A recent blog post from Science-Based Medicine, a website owned and operated by the New England Skeptical Society, focused on the second of Malhotras two editorials. David Gorski, MD, PhD, a professor with Wayne State University, wrote the blog post, describing it as projection, pure and simple.
Hes accusing conventional medical authorities, big pharma, and social media companies of spreading medical misinformation about COVID-19 vaccines by using the very techniques of misinformation that he claims to decry, such as cherry-picked studies and conspiracy theories, to do it," Gorski wrote.
Gorski also shared his doubts about the validity of the Journal of Insulin Resistance, saying the publication does not appear to publish many articlesand when it does, it appears to primarily publish the thoughts of its own editors. Both of these facts, he said, raise red flags for this being an ideology journal disguised as a medical journal.
Many have also fully agreed withMalhotra, sharing his story and commenting on it online. The Epoch Times and other outlets already known for being vocal against COVID-19 vaccines, for example, have highlighted the importance of his story. Also,one quick video of Malhotra from Sept. 27 has already hit 1.1 million views on Twitter.
Cardiovascular Business also reached out to both the American College of Cardiology (ACC) and European Society of Cardiology (ESC) about the content of Malhotras editorials. The ACC has repeatedly supported COVID-19 vaccines, emphasizing that the small risks of these vaccines are not nearly as severe as the risks of a COVID-19 infection.
Instead of a full comment, the ACC highlighted its previous publications on this topic, specifically a 2022 document from its Solution Set Oversight Committee.[3] The ESC has not yet responded.
The rest is here:
Background: Studies exploringfactors predicting postoperative ICU requirement in patients with coronavirus disease 2019 (COVID-19)-associated mucormycosis (CAM) were not found in the literature. The aim was to evaluate the demographic profile, comorbidities, pattern of steroid received, airway assessment, and intraoperative hemodynamic perturbations associated with ICU requirement amongst patients scheduled for sinonasal debridement.
Methods: This is a retrospective cohort study. All CAM patients of 18 years were included.The patients characteristics, comorbidities, pattern of steroid received, airway assessment, intraoperative hemodynamic perturbations, and outcome data were retrieved.
Results: A total of 130 patients were included. Thirty got admitted to ICU, out of which 26 expired. Amongst the various comorbidities, diabetes was the most common (93.85%) and was associated with higher chances of ICU requirement. Of patients with a history of steroid intake,71% had a significantly higher risk of ICU admission. Out of 30 patients admitted to ICU, 87% (n=26) received invasive ventilation, and the rest were admitted for observation only.
Conclusion: Middle age, uncontrolled diabetes, history of steroid intake, increased levels ofserum creatinine with low potassium, and increased total leucocyte count are the independent risk factors predicting postoperative ICU admission amongst patients with CAM scheduled for sinonasal debridement.
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes coronavirus disease 2019 (COVID-19), which is associated with a wide range of bacterial and fungal infections that co-exist during or following the disease [1-5]. One of these infections is mucormycosis, which is angioinvasive in nature. A sharp surge in cases occurred during the COVID-19 pandemic. Specifically, the prevalence of COVID-19-associated mucormycosis (CAM) has varied from 0.005 to 1.7 per million population globally [6]. The prevalence of CAM in India is nearly 80 times the average in other developed countries [7]. Researchers have pointed to the ample presence of Mucorales in Indian communities, the large number of diabetic patients, and the neglect of regular health check-ups in the country as probable explanations for this outcome [8].
Anesthesiologists often encounter CAM patients when they are scheduled for neurosurgery, ophthalmological surgery, or oro-sinonasal debridement [9]. Patients scheduled for sinonasal debridement often have associated difficult airways in addition to the aforementioned comorbidities [10]. We conducted a literature search that retrieved no studies that have explored the various factors and anesthetic concerns relating to patients scheduled for surgery for the management of CAM.
In the present retrospective observational cohort study, we evaluated the demographic profiles, comorbidities, patterns of steroid and other treatments, airway assessments, and intraoperative hemodynamic perturbations and complications associated with postoperative ICU visits by patients scheduled for either elective or emergency sinonasal debridement for CAM during the second wave of COVID-19 pandemic (March-May, 2021) in India.
The participants included patients who were scheduled for sinonasal debridement in the ENT operation theater (OT). The duration of the study was from May 24 (i.e., the inception of the mucormycosis) through July 31, 2021. During this period, the University College of Medical Sciences and Guru Tegh Bahadur Hospital in New Delhi, India, was the designated facility for the management of CAM cases following the second wave of COVID-19 in the country. We undertook this retrospective cohort study following approval from theInstitutional Ethics Committee For Human Research, University College of Medical Sciences, New Delhi, India, for conducting human research (IECHR-2021-50-16-R1).
We included all the adult patients (those over 17 years old) diagnosed with CAM scheduled for sinonasal debridement surgery during the study period in our sample and excluded obstetric and pediatric patients. We retrieved the case files retrospectively from the medical records department and coded them so as to maintain anonymity. The data was extracted manually. The data covered the patients characteristics, laboratory and radiological investigations, and treatments, such as patterns of steroid use, preoperative airway assessments, anesthetic practices including intraoperative hemodynamic parameters, blood loss, and outcomes. The data was checked twice, and a third researcher adjudicated the differences in their interpretations.
The demographic profiles of the patients in our sample included age, gender, American Society of Anesthesiologists (ASA) physical status classification, duration of surgery, co-morbidities such as hypertension, chronic obstructive pulmonary disease (COPD), and diabetes mellitus, and the duration of the hospital stay prior to surgery (i.e., total days from hospital admission till the day of surgery). We also recorded baseline laboratory and radiological investigations before the surgery as well as the details regarding any previous use of oxygen therapy or steroids for the management of COVID-19. For those with a history of steroid use, we also recorded the dose, duration, and time since ceasing this treatment. We noted from the case files the patients complete airway assessments, such as mouth opening, Mallampati grade (MPG), thyromental distance in the preoperative period, and Cormack-Lehane (CL) grading at the time of intubation as well as the method for securing the airway, whether awake fiberoptic bronchoscopy, fiberoptic bronchoscopy following induction of anesthesia, or use of any airway adjunct such as a stylet, McCoy laryngoscope, bougie, video laryngoscope, or tracheostomy. We also recorded from the case files the results of routine blood examination, including complete blood count, total leucocyte count (TLC), coagulation profile, and serum biochemical test (including renal and liver function and electrolytes) of the patients.
We noted from the case file as well any hemodynamic perturbations (i.e., hypotension or bradycardia) during the intraoperative period. We defined hypotension and bradycardia as a drop in the systolic blood pressure of 20% and heart rate of 20%, respectively, below the baseline recorded on the operation theatre table before the induction of anesthesia. When necessary, hypotension was managed with IV fluids and vasopressors, and bradycardia with 0.6 mg of atropine IV. As per the records, the absence of tachycardia or hypertension indicated an adequate depth of anesthesia with optimum neuromuscular blockade, and analgesia was maintained throughout the surgery. For the patients who experienced hemodynamic perturbations, we noted any history of steroid treatment for COVID-19 and the time since the treatment had ceased.
We further recorded the other treatments that the patients had received retrospectively from their case files, including amphotericin, anticoagulants, and steroids. We noted as well the outcome, that is, whether the patients were sent to a ward or the ICU and, if so, any critical event or final outcome. The factors mandating postoperative ICU admission for elective/emergency postoperative ventilation or for observation included the presence of various comorbidities, significant intraoperative blood loss, intraoperative hemodynamic perturbations, and prolonged duration of surgery. In cases of morbidity or mortality, we noted from the case files the evident cause, such as acute respiratory distress syndrome (ARDS), heart failure, septic shock, coagulopathy, or acute kidney injury, and the number of days on a ventilator. We compared the various preoperative parameters, including demographic characteristics, comorbidities, preoperative investigations, airway assessment, and intraoperative parameters between the patients who required ICU and those who did not to identify the independent predictors of ICU admission among the patients scheduled for sinonasal debridement to treat CAM.
We analyzed the data with IBM SPSS Statistics for Windows, Version 20.0 (Released 2011; IBM Corp., Armonk, New York, United States). We present the descriptions of variables as means, medians (IQRs), or proportions depending on the nature of the data. Since we retrieved the data retrospectively, we omitted the rows that contained three or more missing variables from the analysis, and we replicated the rows with one or two missing variables with the mean, IQR, or mode, again depending on the nature of the data. We used multivariate forward logistic regression to explore the association of such factors as clinical characteristics and laboratory parameters with the risk of ICU requirement and mortality. We included all of the parameters in the regression model after removing multicollinearity and estimating the probability of entry at 0.05. We considered p-values of less than 0.05 to be significant.
A total of 160 patients were scheduled for various mucormycosis surgeries during the study period, sinonasal debridement being the most common procedure. Out of 160 patients, 130 were scheduled for sinonasal debridement and all had a history of COVID-19 and, hence, were labeled to have CAM. Of these 130 patients, only 10 patients had received COVID-19 vaccination (one dose only). Table 1 shows the demographic profile. CAM was seen in the age group of 40 to 60 years and the middle-aged group had significantly more chances of postoperative ICU admission with more preponderance in males. The mean duration of surgery was two hours.
Amongst the various comorbidities, diabetes was the most common (94%) in these patients with more risk of ICU requirement in diabetic patients as compared to any other comorbidity. Sixty-five percent of patients had other comorbidities like hypertension, COPD, chronic kidney disease, coronary arterial disease, or cerebrovascular accident.
Out of 130, 92 patients had a history of steroid intake, of which 93% (n=28) had a significantly higher risk of ICU admission (p-value < 0.005). The average mean duration of steroid intake was 14-20 days. Four patients out of 130 were found to be currently on steroid treatment. The mean time since the stoppage of steroids was found to be 10-20 days. None of the patients who had received steroids earlier were observed to have developed hemodynamic perturbations intraoperatively. Also, four patients who were currently on steroids at the time of surgery also did not report any hemodynamic disturbance. Only 29% of patients had received oxygen therapy during their management of COVID-19. Of the total patients in the study,85% (n=110) were on amphotericin, out of which 87% (n=26) patients required ICU admission.
The preoperative laboratory investigations are shown in Table 2. Fasting blood sugar, blood urea, and serum creatinine were deranged in 43% (n=56), 68% (n=89) and 50% (n=65) of the patients, respectively. TLC was significantly deranged in 35% (n=46) of patients. However, hemoglobin, sodium, and potassium levels were within the normal range in most of the patients. Patients with deranged values of blood sugar, serum creatinine, and TLC had significantly higher chances of requiring ICU admission in the postoperative period.
Airway assessment revealed that 11% (n=14) of patients had difficult mask ventilation. Also, it was noted that 26% of patients had difficult laryngoscopy (Cormack-Lehane grading >2b) and 35% (n=46) had difficult intubation with MPG >2. In Table 3, in context to the use of different airway devices, over 35% (n=46) of patients required either ambuscope (24%) or video laryngoscope (11%); whereas, in 65% (n=84) conventional direct laryngoscopy was used to secure airway.
Intraoperative parameters like hemodynamic perturbations and blood loss were also noted. Only 8% (n=10) of patients showed hemodynamic perturbations. Table 4 shows a significant correlation between intraoperative blood loss to postoperative ICU requirement as all the 20 patients who had massive blood loss got admitted to the ICU in the postoperative period. It was also noted that out of a total of 30 patients admitted to ICU, 26 (87%) expired and only four recovered and were shifted back to the ward and later discharged. Out of 30 patients admitted to ICU, 87% (n=26) received invasive ventilation, and the rest were admitted for observation only.
Table 5 shows the various causes of death amongst subjects. Sepsis (65%,n=17) was the most common cause of mortality in these patients followed by acute respiratory distress syndrome (ARDS) (23%,n=6). Further, acute kidney injury and heart failure were the causes in 8% and 4% of patients, respectively.
Multivariate forward logistic regression of independent risk factors is shown in Table 6. It was observed that old age, history of steroid intake, uncontrolled sugar, serum creatinine, serum potassium levels, and TLC are independent risk factors predicting the risk of ICU admission in patients scheduled for elective surgery.
Multivariate forward logistic regression to find out the risk factors of mortality following the removal of multicollinearity is shown in Table 7. It reveals that deranged TLC and significant blood loss were significantly associated with mortality in these patients.
This retrospective cohort study, therefore, showed middle age, a history of steroid intake, elevated serum creatinine, blood sugar, and TLC levels to be independent factors predicting the risk of postoperative ICU admission among patients scheduled for surgery for the management of CAM. This fungal infection is angioinvasive in nature, and the organism responsible is common in the environment. Increasing reports of this disease have created alarm and drawn attention to the need for an effective treatment since it is associated with an extremely high mortality rate [11]. The COVID-19 pandemic has been associated with a surge in mucormycosis cases in India, especially after the second wave of COVID-19 [12,13]. Patients with rhino-orbital-cerebral mucormycosis commonly receive sinonasal debridement as well as orbital exoneration and decompression. During these surgical procedures, the anesthetic management of the patients has become challenging because theyhave associated co-morbidities and difficult airways and may also be receiving nephrotoxic drugs such as amphotericin. Therefore, it is necessary to mandate the evaluation of the various predictors of postoperative morbidity and mortality for COVID-19 patients associated with mucormycosis, an issue that no previous study has explored.
Regarding the patients demographic profiles, our study is consistent with previous research showing that CAM is more prevalent in male patients than female [9,14-17]. Our findings are also consistent with those of a collaborative study of 2,826 CAM patients showing that their mean age was 51.9 years (with a range of 12-88 years) and that most were male (71%; n=1,993) [11]. Likewise, a multicentric study observed that the patients with CAM tended to be middle-aged (mean age 56.9 years) and male (80.2%) than non-CAM patients [12].
The literature is replete with studies that identify diabetes mellitus and steroid intake as common and pertinent risk factors for the development of CAM. Singhet al., in a systemic review of 101 cases of CAM patients, identified diabetes mellitus (83.3%) and corticosteroid therapy (76.3%) as the most common risk factors for the disease and reported mortality in 30.7% of the cases [9]. Likewise, Sen et al. found, in a study of 2,826 CAM patients, 87% of patients had a history of steroid use and 78% had diabetes mellitus [11]. Similarly, Johnet al. reported that 94% of the CAM patients in their study had diabetes mellitus [14]. Other studies have also observed that the majority of CAM patients had diabetes mellitus and were receiving corticosteroid therapy [9,12,13]. Similarly, Ravaniet al. conducted a retrospective study and identified uncontrolled diabetes mellitus (97.7%), COVID-19 infection (61.2%), and corticosteroid use (61.2%) as significant risk factors with a mortality rate of 9.78% [15]. Sharma et al. studied 23 CAM patients with a history of steroid use during their COVID-19 treatment, of whom 21 were diabetic; of these patients, 12 had uncontrolled blood sugar levels [16]. The non-diabetic patients in another retrospective comparative study showed a better survival rate than the diabetic patients (70% and 51%, respectively), and the mortality rate was 7.4 times higher in the mucormycosis patients with diabetes mellitus [18]. Consistent with the information available in the existing literature, we found diabetes mellitus and steroid use to be strong independent risk factors predicting ICU admission following sinonasal debridement for the treatment of CAM.
The use of steroids to manage COVID-19 appeared to be an important risk factor predisposing patients to mucormycosis. The literature pertaining to the use pattern of these medications, such as dose and duration, is scant. Our results indicate that patients with a history of extensive steroid intake tend to have a relatively higher risk of ICU admission after surgery as compared to those without such a history. In a collaborative study, Sen et al. observed that cumulative doses of greater than 600 mg of prednisone and 2-7 g of methylprednisolone have been found to predispose immunocompromised patients to mucormycosis [11]. Hoang et al. reported observing this effect with short courses of corticosteroids based on the case of a 66-year-old man with well-controlled type 2 diabetes mellitus (hemoglobin A1c of 6.4)who received a cumulative dose of over 600 mg of prednisolone over two weeks after being diagnosed with influenza A and contracted life-threatening pulmonary mucormycosis [19]. For the present retrospective study, we were unable to retrieve the type, dose, or duration of steroid use for the management of COVID-19 because we lacked access to the case files of those who were hospitalized for the management of COVID-19. Since many of the patients were undergoing isolation and treatment at home, the details of their steroid use were not uniformly available.
Because of the involvement of the eyes and sinuses in the infection, these patients may endure difficult mask ventilation and intubation. In the only study of this issue of which we are aware, Karaaslan et al. observed that three of 12 patients experienced difficult intubation because of fungal debris [10]. Similarly, more than 35% of the patients in our study required either a flexible fiberoptic bronchoscope or a video laryngoscope to secure their airways, potentially because of epiglottitis and fungal debris.
Moreover, most of the patients in our study had deranged blood urea, serum creatinine, and potassium levels, probably as a result of amphotericin B therapy, and these patients had a higher risk of postoperative ICU admission and mortality as compared to those without these characteristics. Various studies have shown that amphotericin B has significant renal toxicity at high doses [20-22].
The main cause of mortality among the patients in our study was sepsis followed by ARDS. Hong et al. also found that disseminated infection leading to sepsis correlated with an increased risk of death in mucormycosis patients [23]. Other studies have shown that other underlying conditions predispose individuals to the infection, including trauma, burns, intravenous drug use, use of broad-spectrum antibiotics, increases in iron or ferritin in the system, malnutrition, and use of voriconazole [24-26]. Additional studies are needed to explore and identify other various risk factors.
The present study has some limitations. To begin with, a few of the laboratory tests, such as those for serum iron and serum ferritin, that have been found to predict infections were not conducted in all cases and hence, were not considered risk parameters. Also, we followed the patients only during the in-hospital course of treatment and had no access to the follow-up details of the survivors. Lastly, the generalizability of our findings may be limited by the sample size. Of note, more studies are needed to evaluate these factors for management.
Upon our literature search, we could not retrieve any study exploring various factors predicting postoperative ICU requirement in patients scheduled for sinonasal debridement for CAM. Our study highlighted that middle age, uncontrolled diabetes, history of corticosteroid usage, increased serum creatinine, low serum potassium, and deranged TLC are independent risk factors predicting the postoperative ICU admission amongst patients of CAM scheduled for sinonasal debridement. There were certain limitations of this study such as a few laboratory tests like serum iron and serum ferritinwere not conducted in all patients and hence were not included as risk parameters.Also, the study followed the patients during the in-hospital course only and, therefore, the follow-up details of the survivors could not be commented on. Lastly, the interpretation of our findings might be limited by the sample size. Hence, more studies are needed to evaluate these factors for management.
Read more from the original source:
Predictors of Postoperative ICU Admission in Patients With COVID-19-Associated Mucormycosis - Cureus
The novel coronavirus SARS-CoV-2 (COVID-19) has progressed rapidly to reach pandemic levels, killing an estimated nearly one million Americans as of May 8, 2022 [1]. Its presentation varies from asymptomatic to acute respiratory distress syndrome (ARDS) and death. A striking feature of COVID-19 is that it affects every organ system, having various symptoms and complications unrelated to the respiratory system. Notably, patients with COVID-19 have an increased tendency to a prothrombotic state, most commonly presenting as stroke or pulmonary embolism. However, atypical sites of thrombosis have been reported, including basilic vein thrombosis, digital ischemia, and thoracic aorta [2-4]. We present a patient with COVID-19 ARDS who developed pulmonary vein thrombosis (PVT), a rare but life-threatening condition. To our knowledge, only two other cases have been reported of PVT in the setting of COVID-19 pneumonia [4,5].
A 67-year-old African American female with a history of hypertension, hyperlipidemia, and osteoarthritis presented to the emergency department with complaints of shortness of breath and a positive COVID-19 RT-PCR (reverse transcription-polymerase chain reaction) test on admission. Three days prior to admission, she experienced general fatigue, anorexia, productive cough, and dyspnea on exertion. On the day of admission, she experienced shortness of breath, which worsened throughout the day, prompting her to seek medical attention. She arrived at the emergency department via EMS (emergency medical service), and on arrival, she was hypoxic with oxygen saturation at 78% on a 100% oxygen non-rebreather mask. She transitioned to high-flow nasal cannula and eventually reached maximum settings with oxygen saturation ranging between 85% and 95%. She was placed on non-invasive positive pressure ventilation. However, she remained hypoxic, and was eventually intubated five hours after admission. The patient was admitted to the intensive care unit with the diagnosis of ARDS secondary to COVID-19 pneumonia and was placed on dexamethasone and remdesivir for treatment. She was also given subcutaneous heparin for prevention of deep venous thrombosis (DVT). She failed spontaneous awakening trials on the fourth, fifth, and sixth days post-admission. On the seventh day, she developed a fever and began treatment with vancomycin for Staphylococcus pneumonia. The patient was extubated on day 14 and placed on high-flow nasal cannula. Due to recurrent desaturations, she was reintubated the following day. A computed tomography (CT) angiography of the chest on day 15 showed a PVT, which was not seen on prior chest CT angiography from day 1 (Figure 1). She began treatment with therapeutic dosing of apixaban. As the patient failed extubation, she required tracheostomy and percutaneous endoscopic gastrostomy (PEG). She was discharged to a rehabilitation facility 20 days after admission and continued her anticoagulation therapy.
The pathophysiology of COVID-19 coagulopathy is poorly understood. Nevertheless, we know that COVID-19 affects all divisions of Virchow's triad: endothelial injury, hypercoagulability, and stasis. Direct cell injury occurs when COVID-19 enters endothelial cells via the angiotensin-converting enzyme 2 (ACE-2) receptor. As COVID-19 invades endothelial cells, it induces inflammation, which activates the complement system, enhancing cellular dysfunction. Furthermore, the systemic inflammatory response and neutrophil extracellular traps (NETs) promote endothelial dysfunction, furthering the prothrombotic state [6,7]. Reportedly, alterations in prothrombotic factor levels occur in severely ill COVID-19 patients. One study found that 15 critically ill patients with COVID-19 pneumonia had plasma viscosity exceeding 90% of normal [8]. Finally, immobilization due to sedation or severe disease causes blood stasis.
PVT is a rare type of DVT that is potentially fatal. It is commonly associated with lung cancer, lung transplants, left atrial thrombus, and pulmonary lobectomy. In addition, polycythemia vera and blunt chest trauma are rare, documented causes of PVT. Previous to the COVID-19 pandemic, infection was not a known etiology for PVT [6,9-11].
The mechanisms that promote PVT development include mechanical, vascular torsion, hypercoagulation, and direct injury. Of these mechanisms, COVID-19 may influence the latter two. PVT may be underdiagnosed as it can be asymptomatic or have nonspecific symptoms such as cough, dyspnea, pleuritic chest pain, and hemoptysis. Furthermore, PVT and COVID-19 pneumonia share the same nonspecific symptoms, and infection with COVID-19 may mask the presence of a PVT [12]. The significance of PVT in the setting of COVID-19 infection can be related to shared complications of pulmonary infarction, pulmonary edema, right ventricular failure, and potential risk of thromboembolic disease [10]. Diagnosis of PVT is through imaging and pathology. The imaging modalities used include transesophageal echocardiography, CT scanning, MRI (magnetic resonance imaging), and pulmonary angiography [4]. There is no specific treatment for PVT. However, anticoagulation is used for preventing thrombus expansion and embolization, and for promoting vein recanalization. It is also important to initiate early DVT prophylaxis. Trending D-dimers and early hypercoagulable workup may also be recommended in patients with a high risk of clot formation.
COVID-19 infection causes an increased risk of thrombosis due to endothelial dysfunction or hypercoagulability. The rarity and nonspecific presentation of PVT may cause clinicians to overlook it. The concurrence of the PVT in the setting of COVID-19 can potentially increase symptom severity, morbidity, and mortality, but further investigations should be made, and high clinical suspicion is required to establish early diagnosis and treatment.
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Pulmonary Vein Thrombosis in the Setting of COVID-19 Infection: A Case Report - Cureus
1. EXECUTIVE SUMMARY
The COVID-19 pandemic requires a complete public health response that spans non-pharmaceutical interventions and medical countermeasures to mitigate the impact of the virus on lives and livelihoods. Despite this need, equitable roll-out of COVID-19 diagnostics and therapeutics continues to be inadequate and threatens to undo public health gains achieved throughout the pandemic. With limited attention on procurement, delivery models and in-country planning, low-income and lower middleincome countries, are disproportionally affected, placing equitable access at risk.
Testing rates, already low in low-income and lowermiddle-income countries, have fallen everywhere since the beginning of 2022. As a result, the world lacks a complete understanding of the full evolution of the pandemic and emerging variants. The delay and shortfall in community-based diagnostics and self-testing with antigen rapid diagnostic tests is particularly concerning. This risks compromising the rollout of new lifesaving outpatient oral antivirals, which are most effective at reducing hospitalisation and death when given within 5 days of symptom onset, and thus reliant on targeted and effective testing to identify early those at risk of severe disease progression. Alongside the challenges of getting treatments to the right people in the right timeframe, realizing the full potential of these new medicines also continues to be hampered by limited access to these products for LMICs, unaffordable prices, delays in adopting test-to-treat strategies, lack of guidance, and a limited ability to deploy these medicines to the primary care and community level. Furthermore, most LMICs are making challenging resource allocation decisions within scarce resource environments and the priority given to COVID-19 diagnostics and therapeutics will therefore depend on broader health demands. The case for supporting greater efficiencies through integration of COVID-19 interventions with existing primary health care systems is strong.
Affordability is an important aspect that will impact availability and equitable distribution of therapeutics and diagnostics. It is critical that affordable diagnostics and therapeutics are not treated as siloed interventions, and to recognise the importance of the broader ecosystem in enabling their development, such as a strong R&D and clinical trials infrastructure. Strengthening primary health care systems is necessary for the rollout of medical countermeasures and general pandemic response. As such, we need to consider medical countermeasures within the wider context of primary health care systems and universal health coverage. National and local ownership and co-investment, alongside strong regional level support, are essential if integrated diagnostics and treatment approaches are to have sustained impact.
This reports central premise is that diagnostics and therapeutics, and associated test to treat strategies, are fundamental components of the pandemic response, both for COVID-19 and for future health threats. Addressing this is as much a structural problem as a technical one: diagnostics and therapeutics are often considered different markets with independent stakeholders. But integration of diagnostics and therapeutics including test to treat strategies in primary health care systems, along with vaccines and public health measures, is a core part of pandemic response. Two and a half years into the COVID-19 pandemic, this report reflects on the main challenges and key solutions on the road to equitable access to diagnostics and therapeutics.
Our Approach
This report draws from experience gained through the Access to COVID-19 Tools (ACT) Accelerator Diagnostics and Therapeutics pillars, and also includes the perspectives of collaborating stakeholders (countries, civil society representatives and the private sector). To ensure a consistent analysis, each pillar evaluated - as of July/August 2022 - the state of play across three areas:
a. regulation, manufacturing and supply;
b. sustainable markets and demand; and
c. in-country delivery and health system approaches.
Equitable access and effective uptake of tests and treatments are complex issues. For both diagnos-tics and therapeutics, recurring challenges have been identified:
Regulation: slow or incomplete at global level, regional level and in countries.
Manufacturing: highly concentrated in a few countries and manufacturers, with variable diagnostic product quality.
Allocation: lack of volumes reserved for low- and middle-income countries, including upper-middle income countries (UMICs).
Funding: delays in mobilizing funds in a timely manner, and scarce and uncertain funding for development of medical countermeasures, with vaccines receiving most attention and funding.
Access & Deployment: global, regional and national efforts to promote equitable access to medical countermeasures have had variable implementation and accountability. This has not resulted in equitable or affordable access.
Forecasting: dynamic and unpredictable nature of the pandemic has led to challenges in demand forecasting. Determinants of local demand and fragmented international response have hindered efficient planning.
Demand: evidence suggests diagnostics and therapeutics continue to be crucial for those at highest risk of progression to severe disease, but awareness and demand remain low.
Building on these findings, this report proposes sixteen recommended actions to address what have been identified as key structural challenges and specifies a potential owner for each action. The report offers a potential high-level roadmap of where efforts should be concentrated to support country-level decisionmaking.
The recommended actions follow two different time frames:
Six recommended actions are in the context of the six-month ACT-A plan (October 2022 to March 2023). These actions are relevant during the next period of the ACT-Accelerators work and thus focus on the downstream part of the value chain. It is recommended that the ACT-Accelerator Tracking and Accelerating Progress Working Group - or the mechanism that will continue to track and monitor ACT-A's work - together with the G20 & G7 health track, review the implementation of the recommended actions.
Ten recommended actions are made in the context of long-term COVID-19 control and the broader Pandemic Prevention Preparedness and Response (PPR) agenda. Therefore, these actions span across the value chain (upstream and downstream).1 This reports long-term recommendations consider ongoing proposals to strengthen the Global Health Architecture, as identified in the WHO White Paper and the G20 health track, as well as the new Financial Intermediary Fund (FIF) for pandemic prevention preparedness and response and the Pact for Pandemic Readiness launched by the German G7 Presidency, which will help ensure the world is better prepared for future pandemics.
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In this study we investigated potential correlations between detected antibody levels indicating exposure to Borrelia and the risk of increased severity of COVID-19. Previous exposure to Borrelia was identified by multi-antigenic serological testing, and it revealed that increased levels of Borrelia-specific IgGs strongly correlated with COVID-19 severity and with the risk of hospitalization (Fig.1 and 3, Supplementary Tables S1 and S2). For Borrelia-specific IgMs, correlations were weaker and mostly insignificant (Fig.2 and Supplementary Fig. S3, Supplementary Tables S3 and S4).
Typically, pathogen-specific IgM increases at the early stage of infection, while IgG development takes more time. In borreliosis, at the early stage of infection (24weeks) the immunological system detects only a few antigens of Borrelia, e.g. p41 (flagellin) and Osp proteins (outer surface proteins), targeted by IgM antibodies. Borrelia-specific IgGs, in turn, can be observed several weeks after the tick bite, and their increased serum concentration can remain for a long time, even after the resolution of clinical symptoms. OspC, OspA, and p41 are considered the most immunogenic proteins of B. burgdorferi19,20,21; consistently, in this study IgGs targeting these antigens were also the most frequent and they reached the highest levels (Fig.1). Other important targets for IgG diagnostics include VisE, p83, p58, and p17 19,20,21, also detected in this study. Interestingly, in many patients we observed antibodies targeting different species (e.g. B. burgdorferi sensu stricto, and at the same time B. afzelii, and/or B. garinii). This may reflect some cross-reactivity of antibodies, but likely it may result from co-infections with more than one species, which according to the literature may also occur 22. Also, severe COVID-19 patients demonstrated significantly higher levels of IgG specific to Anaplasma (Fig.1), which is often co-transmitted with Borrelia by ticks. This further supports the suggestion that increased risks in COVID-19 are linked to a history of tick bites and related infections (Fig.4).
Risks in COVID-19 are linked to a history of tick bites and related infections.
Important limitations should be considered for a full understanding of this studys results. First, diagnostics of Lyme disease (active borreliosis) is still difficult and often unclear. Laboratory testing should be considered in conjunction with potential exposure and compatible clinical symptoms10; data on patients history of tick bites and on potential borreliosis-related symptoms were not available here. Particularly severe COVID-19 patients under intensive care were not able to give them. Thus, in the investigated group at least some individuals may demonstrate immunological memory of previous Borrelia infection/s but not an active disease. On the other hand, difficulties with rapid and unambiguous diagnosis may lead to some Borrelia-infected patients going untreated, with the pathogen affecting their health condition even for a long time.
Second, although this study demonstrated a significant correlation between serum levels of anti-Borrelia antibodies and COVID-19 severity observed in the same individuals, a correlation cannot be assumed to indicate causation. One cannot exclude that there was an unidentified primary factor that in these patients caused both higher vulnerability to Borrelia infection and to severe COVID-19. This could possibly be immunodeficiency, other physiological disorders or comorbidities. Of note, patients in the severe COVID cohort were likely to have more comorbidities than those in the other two groups. For instance, obesity has been indicated as associated with the risk of COVID-19-related hospitalizations and death23. In Lyme disease, obesity was associated with attenuated and delayed IgG responses to B. burgdorferi, thus suggesting less efficient protection from adaptive immunity in obese individuals24. Since these patients demonstrated an efficient antibody response to SARS-CoV-2 (Fig.1), this issue calls for further research. Demographic parameters, in turn, have been agreed between groups (Supplementary Fig. S2), so for instance elderly age was not a contributing factor here.
Alternatively, prolonged Lyme disease might affect the immune system, decreasing its efficacy in antiviral responses in the viral infection. This has never been demonstrated yet, though important effects that Borrelia may have on the immune system have been described25,26. Furthermore, one of the possible explanations for studied relationship may be a more detailed insight into the mechanisms of the immune system, more specifically the Toll-like receptor pathway (TLR), whose innate immunity receptors recognize ligands derived from bacteria, fungi, and viruses27. Studies indicate that the TLR pathway mediates, at least in part, the release of inflammatory mediators in human monocytes stimulated with live B. burgdorferi spirochetes28. Similarly, the role of TLR receptors has been described in SARS-CoV-2 infection, which contributes to the elimination of viruses, but it can also harm the host due to persistent inflammation and tissue destruction29. Particularly, B. burgdorferi has been demonstrated to interact with TLR1/TLR2 heterodimers with resulting stimulation of inflammatory response, including increased inflammatory cytokine markers, like IL-6 and TNF-28. The same molecular pathway is targeted by SARS-CoV-2, where stimulation via TLR1 and TLR2 has been indicated as the key factor of excessively upregulated cytokine response and its harmful effects within severe COVID-1930,31. This suggests that co-stimulation from both B. burgdorferi and SARS-CoV-2 may result in even more pronounced excessive inflammatory response and a higher risk of severe COVID-19. This hypothesis needs to be further verified in future studies.
In spite of above mentioned important reservations and considerations, a strong link between detected anti-Borrelia antibodies and COVID-19 severity was observed in this study (Fig.1, 2, and 3). This was further supported by post-hoc analysis of IgG targeting selected antigens of Borrelia. These antigens included Osp proteins, p41, and VlsE, being highly immunogenic19,20,21 and important in the life cycle of spirochetes; they are engaged in bacterial colonization of ticks and mammals, virulence, and immune evasion by Borrelia32,33,34. The analysis with multivariant logistic regression revealed that increased levels of IgG targeting Osp proteins (only) can be significant predictors of hospitalization due to COVID-19; in this study OspB, OspC B. burgdorferi sensu stricto, and OspC B. spielmanii demonstrated significance in this model (Supplementary Fig. S4, Supplementary Table S5).
To the best of our knowledge, this is the first observation that suggests links between Lyme disease and COVID-19 prognostics. Screening for antibodies targeting Borrelia may contribute to accurately assessing the odds of hospitalization for SARS-CoV-2 infected patients. Though mechanisms of this association are not clear yet, it may help in establishing optimal treatment schedules and in efficient predictions of individual patients prognostics, supporting efforts for efficient control of COVID-19.
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