Category: Covid-19

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The Relationship Between COVID-19 and the Development of Diabetic Ketoacidosis and New-Onset Type 1 Diabetes … – Cureus

May 21, 2024

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The Relationship Between COVID-19 and the Development of Diabetic Ketoacidosis and New-Onset Type 1 Diabetes ... - Cureus

Diagnostic performance of rapid antigen tests (RAT) for COVID-19 and factors associated with RAT-negative results … – BMC Infectious Diseases

May 21, 2024

Study design, setting, and participants

We conducted a retrospective study among individuals who were tested for SARS-CoV-2 using RAT and RT-PCR during the same clinical encounter between 9 May 2022 and 21 November 2022. Under the Acute Respiratory Infection (ARI) surveillance programme at 11 polyclinics in Singapore which served as sentinel outpatient primary care sites, individuals presenting with acute respiratory symptoms of cough, runny nose, sore throat and/or fever were randomly selected and offered to join the surveillance programme by their clinician. Individuals who were willing to participate then underwent testing with a healthcare-administered RAT and RT-PCR. We evaluated the two RAT kits predominantly used in the sentinel clinics, Flowflex SARS-CoV-2 Antigen Rapid Test (Acon Laboratories) and STANDARD Q COVID-19 Ag Home Test (SD Biosensor).

Specimens for RT-PCR were tested using the BioFire Respiratory 2.1 (RP2.1) Panel (bioMrieux, France), a multiplex PCR which allows the simultaneous detection of multiple viral and bacterial respiratory organisms, including SARS-CoV-2 [14]. RT-PCR-positive cases were those which were SARS-CoV-2-positive on RP2.1 panel. The SARS-CoV-2-positive specimens were then tested using TaqPath COVID-19 Combo Kit (ThermoFisher, USA) and selected for whole genome sequencing (WGS) based on the cycle threshold (Ct) and S-gene target failure (SGTF) status. 40 PCR cycles were run as recommended by the manufacturer, and specimens with Ct value<30 could be selected for WGS.

WGS was conducted on specimens using the ARTIC nCoV-2019 amplicon panel (Integrated DNA Technologies) and the Nextera XT DNA Library Preparation Kit (Illumina) on the Illumina MiSeq platform in accordance with the manufacturers instructions. The viral genome sequences were assembled from raw data by in-house pipelines and the viral lineages were determined by Pangolin.

Data were collected from databases maintained by the National Public Health Laboratory and Ministry of Health, Singapore. Paired RAT and RT-PCR results for SARS-CoV-2, as well as age, sex, ethnicity, brand of RAT kit, presence of co-infection with other viral respiratory pathogen(s), clinic attended, vaccination status at time of infection, previous infection status, days between symptom onset and sample collection and SARS-CoV-2 lineage (if sequenced) were collected. Ct value was used as a proxy indicator of viral load, based on the lowest Ct value of the three targets in the TaqPath COVID-19 Combo Kit assay. Swab collection site for RT-PCR (nasopharyngeal, nasal, oropharyngeal and mid-turbinate, or throat) was recorded by healthcare staff and collected, but anatomical collection site of RAT was not known. Completion of the primary vaccination series was defined as two doses of Pfizer-BioNTech/Comirnaty or Moderna-Spikevax, three doses of Sinovac-CoronaVac or Sinopharm BBIBP-CorV, or two doses of non-mRNA vaccines approved under the World Health Organization (WHO) Emergency Use Listing besides Sinovac-CoronaVac and Sinopharm BBIBP-CorV [15]. Individuals who received additional vaccine doses after the primary vaccination series were considered boosted.

Those who had a SARS-CoV-2 infection notified to the Ministry of Health at least 90 days before the date of study inclusion were considered to have a previous documented infection [16]. In January 2022, Omicron overtook Delta as the predominant strain in Singapore and comprised over 91% of local cases which were sequenced [17]. Hence, individuals with a documented infection episode before 1 January 2022 were considered to have a previous pre-Omicron infection, while those with a previous documented infection from 1 January 2022 were assumed to have an Omicron infection. Individuals who tested RT-PCR-positive during the study period and did not have a previous documented infection were considered first infections.

RAT sensitivity, specificity, negative predictive value, and positive predictive value were calculated using BioFire RP2.1 Panel RT-PCR as the reference standard, with 95% CI calculated. Logistic regression models were used to estimate odds ratios (OR) of factors with negative RAT results among those who were SARS-CoV-2-positive by RT-PCR. Two multivariable logistic regressions were constructed. Model 1 adjusted for demographics, COVID-19 vaccination status, RAT brand, presence of co-infection with other respiratory pathogens, previous known SARS-CoV-2 infection, days between symptom onset and sample collection, SARS-CoV-2 lineage, PCR sample type and clinic visited, while Model 2 adjusted for factors in Model 1 and Ct value, to elucidate the effect of Ct values on the associations. Adjusted ORs of Models 1 and 2 were labelled aOR1 and aOR2 respectively. All data analysis was performed using Stata version 15.0(StataCorp, College Station, TX, USA).A p-value of <0.05 was considered statistically significant.

The study received ethics approval from the NHG Domain Specific Review Board (DSRB Ref: 2023/00131) with waiver of informed consent.

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Diagnostic performance of rapid antigen tests (RAT) for COVID-19 and factors associated with RAT-negative results ... - BMC Infectious Diseases

Newfound autoimmune syndrome tied to COVID-19 can trigger deadly lung scarring – Livescience.com

May 19, 2024

Researchers have discovered a new autoimmune syndrome associated with COVID-19 that can cause life-threatening lung disease.

The syndrome which scientists have dubbed "MDA5-autoimmunity and interstitial pneumonitis contemporaneous with the COVID-19 pandemic," or MIP-C for short is a rare, serious condition in which the immune system inadvertently attacks the body. In the worst cases, the lungs end up so scarred and stiff that the only way to save the patient is a full lung transplant.

However, only a portion of cases involve the lungs. "Two-thirds of our cases did not have lung disease," said Dr. Dennis McGonagle, a rheumatologist at the University of Leeds in the U.K. who first started piecing together the patterns of the new disease. "But we did see that eight cases rapidly progressed and died despite all the high-tech therapies we could throw at them."

In all, McGonagle and his colleagues have identified 60 cases of the syndrome so far. They published a study of the cases May 8 in the journal eBioMedicine.

Related: COVID-19 linked to 40% increase in autoimmune disease risk in huge study

The disease looks similar to the known condition MDA5 dermatomyositis, which is seen almost entirely in women of Asian descent, McGonagle told Live Science.

In it, patients experience joint aches, muscle inflammation and skin rashes, and in two-thirds of cases, they develop life-threatening lung scarring. MDA5 dermatomyositis happens when the immune system attacks one of its own: a protein called MDA5 that normally helps detect RNA viruses. Such viruses include those that cause influenza, Ebola and COVID-19.

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To better understand autoimmunity against MDA5, hospitals associated with the University of Leeds in Yorkshire began screening people with autoimmune symptoms for antibodies against the protein. Back in 2018, they found three patients who fit the bill. They saw another three cases the following year and eight more in 2020 but then, in 2021, there were suddenly 35.

The patients carried anti-MDA5 antibodies, but their disease was different from the previously known dermatomyositis. Most cases didn't involve the lungs; new patients were mostly white rather than of Asian descent; and affected women only slightly outnumbered men.

McGonagle reached out to Dr. Pradipta Ghosh at the University of California, San Diego to investigate further. Ghosh had been using a computational framework to take medical testing data and find common threads between conditions. Her team previously published work about lung scarring in COVID-19, as well as MIS-C, an inflammatory syndrome that arises in some children after they have COVID-19.

The team compared medical records from patients with the mystery condition, patients with COVID-induced pneumonia and patients with lung scarring unrelated to viruses. Patients with pneumonia and the autoimmune condition both showed increased activity in the gene IFIH1, which provides the blueprint for MDA5.

Most patients with the mystery syndrome did not have a recently confirmed case of COVID-19 in their records, but it's probable many were exposed to the coronavirus and had either mild or asymptomatic disease, McGonagle said, given the timing of their cases. More than half of the patients were confirmed vaccinated for COVID-19, although which specific vaccine each person got is unknown.

Related: Master regulator of inflammation found and it's in the brain stem

The new study suggests that exposure to the coronavirus's RNA, COVID-19 vaccines or both may sometimes trigger the production of anti-MDA5 antibodies, McGonagle said.

Normally, MDA5 activates when it senses viral RNA in a cell and prompts the body to make antibodies against the virus. But in people with MIP-C, this immune response goes wrong. Either the body mistakes the MDA5 protein as foreign and attacks it, or the RNA kicks off such a strong immune response that the body's own proteins, including MDA5, become targeted for immune attack, McGonagle suggested.

The activation of IFIH1 came with a flood of an inflammatory protein called interleukin-15 (IL-15), the researchers found. IL-15 activates a class of immune cells that normally kill infected cells but can sometimes go rogue and attack the body's own cells.

"Our work should alert doctors to start thinking that if you see there was some exposure to virus or the vaccine or just a contact to somebody who had COVID and they come in with joint pains, rashes, aches let's look at the lungs," Ghosh told Live Science.

The researchers are still collecting data, but new cases of MIP-C now appear to be slowing. In 2022, Yorkshire saw 17 cases about half of 2021's rate. The intense RNA exposure of the widespread COVID waves of 2021 plus mass vaccination may have driven that year's spike, McGonagle theorized. The researchers said they have received reports of possible MIP-C from other regions, as well.

The study also uncovered a particular genetic sequence within the IFIH1 gene that, in people who had that sequence, seemed to prevent the runaway IL-15 inflammatory response. The next step is to understand why others are vulnerable to it, Ghosh said.

This article is for informational purposes only and is not meant to offer medical advice.

Ever wonder why some people build muscle more easily than others or why freckles come out in the sun? Send us your questions about how the human body works to community@livescience.com with the subject line "Health Desk Q," and you may see your question answered on the website!

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Newfound autoimmune syndrome tied to COVID-19 can trigger deadly lung scarring - Livescience.com

Fed Chair Jerome Powell tests positive again for COVID-19, working from home – New York Post

May 19, 2024

Federal Reserve Chair JeromePowelltested positive for COVID-19 on Thursdayand is currently working from home, a Fed spokesperson said in an emailed statement.

ChairPowelltested positive for COVID-19 late yesterday and is experiencing symptoms. He is working from home and staying away from others, the statement said, as per guidance from the US Centers for Disease Control and Prevention.

The announcement follows a trip to Europe this week in whichPowell, 71, appeared on Tuesday on stage at an event with Dutch central bank president Klaas Knot in Amsterdam.

Powelllast tested positive for Covid in January 2023. There was little reaction in financial markets after the Feds announcement ofPowells latest COVID-19 infection. The next scheduled Fed policy meeting is not until June 11-12.

Powell, who was due to give commencement remarks in person on Sunday at Georgetown Law School, will now deliver them via prerecorded video, the statement said.

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Fed Chair Jerome Powell tests positive again for COVID-19, working from home - New York Post

US raises deep concerns over disappearance of Chinese Covid-19 journalist – South China Morning Post

May 19, 2024

The United States has raised deep concerns over the disappearance of Zhang Zhan, a Chinese citizen journalist who was expected to be released from prison on Monday.

Zhang, a former lawyer, was arrested in May 2020, about a year after she began reporting on Covid-19 from Wuhan, the epicentre of the initial coronavirus outbreak in China, where she live-streamed scenes of hospitals and the local pandemic response.

Days after she was set to be released, advocacy groups said they still had not heard from Zhang or her family.

The US Department of State released a statement on Thursday, saying it was deeply concerned over reports that [Peoples Republic of China] citizen journalist Ms Zhang Zhan has disappeared following her expected release from Shanghai Womens Prison on May 13.

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Chinese citizen journalist Zhang Zhan sentenced to four years in jail for Wuhan coronavirus reports

Chinese citizen journalist Zhang Zhan sentenced to four years in jail for Wuhan coronavirus reports

Zhang was one of the few citizen journalists in China to report on the early experiences of people in Wuhan during the citys lockdown.

She was the first to face trial for reporting on the pandemic in the central Chinese city and received the harshest punishment among several prominent peers including Chen Qiushi, Li Zehua and Fang Bin.

Zhang went on hunger strike in protest shortly after her arrest and remained on intermittent strike during her sentence.

In 2021, Zhang was awarded the prize for courage at the Reporters Without Borders Press Freedom Awards. According to the Paris-based advocacy group, China is ranked 172 out of 180 countries on its press freedom index.

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US raises deep concerns over disappearance of Chinese Covid-19 journalist - South China Morning Post

Elon Musk demands prosecution of Anthony Fauci after NIH admits to funding gain-of-function research in Wuhan lab – Hindustan Times

May 19, 2024

A day after it was revealed that the US government funded a dangerous research at Wuhan Institute of Virology in China before COVID-19 pandemic, Tesla CEO Elon Musk on Friday demanded the arrest of Dr. Anthony Fauci, the former Chief Medical Advisor to the US President.

On Thursday, Lawrence Tabak, a principal deputy director at National Institutes of Health, revealed to Congress that NIH funded risky "gain-of-function" research in Wuhan lab.

Representative Debbie Lesko (R-Ariz.), a member of the Select Subcommittee on the Coronavirus Pandemic, asked Tabak about the NIH's support to Wuhan Institute of Virology through the Manhattan-based nonprofit EcoHealth Alliance.

"It depends on your definition of gain-of-function research," Tabak replied, adding that "If you're speaking about the generic term, yes, we did."

Tabak's response contradicts Fauci's repeated denials of the same.

During his appearance in Congress in May 2021, he claimed that NIH has never and does not now fund gain-of-function research in the Wuhan Institute of Virology.

"Prosecute/Fauci," Musk tweeted, posting The Post's Friday front page with a photo of Fauci and the heading SICK LIES.

Although Musk did not specify what criminal charges Fauci should face, House Republicans have proposed fraud and misleading Congress. Both felonies can result in up to five years in jail.

Reacting to Musk's post, one of his followers wrote: Fauci deserves a prison cell! Another X user commented, He's always been a liar.

Also Read: Covid-19 social distancing was not based on scientific data, Fauci admits

Notably, the Chinese lab is accused of releasing the deadly respiratory virus, which claimed lives of at least 1,190,546 residents in the US, and caused massive financial, social, and educational loss around the world, as per the Centers for Disease Control and Prevention data.

According to documents disclosed by the Intercept in late 2021, the Manhattan-based organization EcoHealth Alliance utilised Fauci's agency money to fund the Chinese institute's trials that transformed three bat coronaviruses that were not connected to COVID 19.

When human-type receptors were introduced to "humanised" mice, the researchers discovered that the viruses became far more contagious.

On Tuesday, the Department of Health and Human Services, which oversees the NIH, prohibited EcoHealth from obtaining government funding for the next three years.

While the world remains unaware about the origins of COVID-19 due to refusal of the Chinese government to permit an unbiased international probe, the FBI and the Energy Department suspect the epidemic originated following a leak from Wuhan lab.

Moreover, US President Joe Biden has spoken less about the cause of the outbreak, but his GOP rival Donald Trump has advocated compelling China to pay $10 trillion in "reparations."

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Elon Musk demands prosecution of Anthony Fauci after NIH admits to funding gain-of-function research in Wuhan lab - Hindustan Times

COVID-19 epidemiological update 17 May 2024 – World Health Organization (WHO)

May 19, 2024

Overview

SARS-CoV-2 PCR percent positivity, as detected in integrated sentinel surveillance as part of the Global Influenza Surveillance and Response System (GISRS) and reported to FluNet was 7.3% from 79 countries during the week ending 28 April 2024.

KP.3 and KP.2, both descendent lineages of JN.1 and variants under monitoring (VUMs) accounted for 20.0% and 9.6% of sequences in week 17 compared to 3.5% and 6.4% in week 14, respectively. Globally, JN.1 is the most reported variant of interest (VOI) (now reported by 130 countries), accounting for 54.3% of sequences in week 17 and having declined from a prevalence of 69.0% in week 14.

Globally, the number of new cases decreased by 48% during the past 28-day period of 1 to 28 April 2024 compared to the previous 28-day period (4 to 31 March 2024), with over one hundred and forty-seven thousand new cases reported. The number of new deaths decreased by 44% as compared to the previous 28-day period, with over 2600 new fatalities reported. As of 28 April 2024, over 775 million confirmed cases and more than seven million deaths have been reported globally.

During the period from 1 to 28 April 2024, COVID-19 new hospitalizations and admissions to an intensive care unit (ICU) both recorded an overall decrease of 35% and 45% with over 32 000 and more than 250 admissions, respectively.

In this edition, we include:

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COVID-19 epidemiological update 17 May 2024 - World Health Organization (WHO)

New Covid-19 Wave In Singapore, Minister Advises Wearing Of Masks After 25,900 Cases Recorded In A Week – News18

May 19, 2024

Singapore is seeing a new Covid-19 wave as the authorities recorded more than 25,900 cases from May 5 to 11 even as Health Minister Ong Ye Kung on Saturday advised the wearing of masks again.

We are at the beginning part of the wave where it is steadily rising," said Ong. So, I would say the wave should peak in the next two to four weeks, which means between mid- and end of June," Minister Ong Ye was quoted as saying by The Straits Times.

The Ministry of Health (MOH) said the estimated number of COVID-19 cases in the week of May 5 to 11 rose to 25,900 cases, compared with 13,700 cases in the previous week. The average daily Covid-19 hospitalisations rose to about 250 from 181 the week before. The average daily intensive care unit (ICU) cases remained low at three cases, compared with two cases in the previous week.

The MOH said that to protect hospital bed capacity, public hospitals have been asked to reduce their non-urgent elective surgery cases and move suitable patients to transitional care facilities or back home through Mobile Inpatient Care@Home, an alternative inpatient care delivery model that offers clinically suitable patients the option of being hospitalised in their own homes instead of a hospital ward.

Ong urged those who are at greatest risk of severe disease, including individuals aged 60 years and above, medically vulnerable individuals and residents of aged care facilities, to receive an additional dose of the Covid-19 vaccine if they have not done so in the last 12 months.

Ong said that if the number of Covid-19 cases doubles one time, Singapore will have 500 patients in its healthcare system, which is what Singapore can handle. However, if the number of cases doubles a second time, there will be 1,000 patients, and that will be a considerable burden on the hospital system", he pointed out.

One thousand beds is equivalent to one regional hospital," Ong said. So, I think the healthcare system has to brace ourselves for what is to come." There are no plans for any form of social restrictions or any other mandatory kind of measures for now, as Covid-19 is treated as an endemic disease in Singapore, he said, adding that imposing additional measures would be a last resort.

Ong said that with Singapore being a transport and communications hub, it will be one of the cities to get a wave of Covid-19 earlier than others. So, Covid-19 is just something that we have to live with. Every year, we should expect one or two waves," he said. Globally, the predominant Covid-19 variants are still JN.1 and its sub-lineages, including KP.1 and KP.2. Currently, KP.1 and KP.2 account for over two-thirds of cases in Singapore.

As of May 3, the World Health Organisation has classified KP.2 as a variant under monitoring. There are currently no indications, globally or locally, that KP.1 and KP.2 are more transmissible or cause more severe disease than other circulating variants, the MOH said. However, members of the public are urged to stay updated with vaccinations to protect themselves against current and emerging virus strains. The MOH said that to date, about 80 per cent of the local population have completed their initial or additional dose, but have not received a dose within the last year.

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New Covid-19 Wave In Singapore, Minister Advises Wearing Of Masks After 25,900 Cases Recorded In A Week - News18

COVID-19: New FLiRT variant threatens another wave, but experts say risk remains uncertain – Newshub

May 19, 2024

COVID-19 levels are about the lowest they've ever been in the US but another new crop of virus variants once again threatens to disrupt the downward trend as the country heads into summer.

KP.2 - one of the so-called FLiRT variants - has overtaken JN.1 to become the dominant coronavirus variant in the US, according to data from the United States Centers for Disease Control and Prevention (CDC). Data through May 11 shows it's responsible for more than a quarter of cases in the country, which is nearly twice as many as JN.1.

A related variant, KP.1.1, has caused about 7 percent of cases, CDC data shows.

FLiRT variants are offshoots of the JN.1 variant - all part of the broader Omicron family - that caused this winter's wave. The acronym in the name refers to the locations of the amino acid mutations that the virus has picked up - some in places that help it evade the body's immune response and others that help it become more transmissible.

COVID-19 variants are "accumulating mutations that do one of two things: They either cause antibodies that you've accumulated from vaccination or infection to no longer bind to the to the virus - we call that escape from immunity - or they increase the strength in which the viruses bind to cells", said Andy Pekosz, a virologist at the Johns Hopkins Bloomberg School of Public Health.

This has become a familiar pattern in the way the virus that causes COVID-19 continues to evolve, but experts say we still don't know enough to predict exactly where the changes will occur next or how they will affect the way the virus moves through the population.

The mutations of the FLiRT variants make increased transmissibility - and a possible summer wave - a real threat. COVID-19 is settling into some seasonal patterns, which have included a summer bump in years past, but the exact level of risk for this year is unclear.

"We've had some variants in the past that start out kind of strong and then don't take over. These subvariants could progressively become dominant or they could get up to accounting for somewhere between 20 percent and 40 percent of the cases and then just stay there," said William Schaffner, an infectious disease expert at Vanderbilt University. "We just have to see.

"The virus continues to be in charge. It's going to tell us what it's going to do.

"All of our crystal balls are...cloudy."

COVID-19 surveillance has scaled back significantly since the US public health emergency ended a year ago, which also adds to the uncertainty. But the data that is available is consistent.

For now, wastewater surveillance suggests viral activity is very low and decreasing in all regions of the country, and COVID-19 hospitalisation rates remain extremely low.

"We learned from the laboratories that FLiRT variants appeared, so far, to be as transmissible as the other Omicron subvariants, which means they're really quite contagious. But they do not appear to be producing more severe disease or any sort of illness that's distinctive from the point of view of clinical presentation symptoms," Dr Schaffner said.

As of May 1, the requirement for all hospitals to report COVID-19 data to the federal government has expired. But Dr Schaffner's Vanderbilt University Medical Center is part of a CDC-run surveillance network that continues to track trends based on a sample of hospitals that cover about 10 percent of the US population.

COVID-19 hospitalisation rates have fallen from nearly 8 new admissions for every 100,000 people in the first week of the year to about 1 new admission for every 100,000 people at the end of April, the data shows.

While the FLiRT variants pose some risk this summer, experts remain focused on what might happen in the fall.

"If I were to predict, I would say that this might result in a few extra cases, a small surge this summer. But it's really going to be about which variant is around when we get to the fall," Dr Pekosz said. "The fall is probably when we should expect to see a surge of COVID cases. And if we have a variant around there that has a lot of these mutations that avoid immunity, then the potential in the fall to have a larger surge is greater."

The autumn and winter pose a greater risk because of the immunity that has built up in the population, he said.

"The virus now needs better conditions to transmit and those better conditions to transmit are probably going to happen in the fall when weather gets cooler, people are spending more time indoors and they're more likely to be in environments where respiratory virus transmission occurs more efficiently."

Research published on Wednesday in the medical journal JAMA is a reminder of the burden that COVID-19 continues to have in the US. This winter, while COVID-19 hospitalisation rates were far lower than they were in earlier years, it was still deadlier than the flu.

A study of thousands of people in hospital found 5.7 percent of COVID-19 patients died, compared with 4.2 percent of those hospitalised for influenza. In other words, COVID-19 carried about a 35 percent higher risk of death than flu.

People who received the latest COVID-19 vaccine this past fall may still have some protection against the latest variants; that immunisation targeted a different strain but was found to be similarly effective against JN.1 and experts saidsome of those benefits may extend to its FLiRT relatives.

People who had a recent infection - especially since the start of the year, when JN.1 was prominent - may also have some protection. But immunity wanes over time.

In June, the US Food and Drug Administration's vaccine advisory committee will meet to discuss recommendations for the version of the COVID-19 vaccine that will be available this fall. The meeting was postponed by about three weeks to "allow for additional time to obtain surveillance data" to have "more up-to-date information when discussing and making recommendations", according to a post on the federal agency's website.

For now, experts said, risk remains relatively low.

"As with all things COVID, our outlook may change in a week or two. But... we're in really a very good place - the best place we've been in for a long, long time," Dr Schaffner said.

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COVID-19: New FLiRT variant threatens another wave, but experts say risk remains uncertain - Newshub

Covid Inquiry: What have we learned after three weeks in Belfast? – BBC.com

May 19, 2024

18 May 2024

Image source, Getty Images

The UK Covid-19 Inquiry in Northern Ireland has heard devastating evidence with multiple failings across several departments, including the Department of Health (DoH).

Three weeks of hearings in Belfast has seen forensic scrutiny of health policy, and how crucial information was communicated by health officials and sought by others.

We learned that "political dysfunction" hampered the roll-out and compliance of some Covid-19 policies.

By January 2021, this had a direct impact on cases and fatalities, counsel to the inquiry said.

The inquiry has left a trail of unanswered questions and talking points for the health service.

On day one and in opening statements the plight of care home residents, owners, staff and families was laid bare.

The inquiry heard how older people had become the first casualties of the pandemic and had been "forgotten" about.

The commissioner for older people's description of a sense of "hospitals being cleared of old people and sent into care homes, not tested" was chilling.

Eddie Lynch said the action by the Department of Health was "reckless".

However, in his evidence to the inquiry, the chief medical officer said that discharges were not the "major factor" in terms of infection.

Over the next three weeks a stream of questions examined plans around protecting the vulnerable in advance of, or during, the pandemic.

Image source, Getty Images

Among the questions: "Where was the risk analysis?"

Care home owners said they had felt "forgotten about" in the planning for an emergency.

In the closing statement, counsel for the commission said: "Older people were left horribly exposed."

Three years without an assembly prior to the pandemic left its toll.

In closing remarks, counsel for the bereaved said the years of austerity and underfunding with single year budgets left departments including health "ravaged and worn".

That impacted on staffing across the system which, when required to act quickly, simply wasn't there.

Image source, Getty Images

The test and tracing system was "understaffed" and, according to the chief medical officer, the Public Health Agency (PHA) did not react with speed to the severity of what was unfolding.

The chief scientific advisor was on sick leave from mid-February in 2020.

The DoH did not replace Prof Ian Young - he returned at the end of March.

To answer this, we first need to confirm who was in charge.

The inquiry attempted to - but with little success.

The answer depended on who was in the witness box.

Evidence confirmed that health officials had agreed to discharge care home residents to hospitals without testing.

In his evidence the Health Minister, Robin Swann, said more could have been done to prevent care home deaths and that it wasn't until 10 March that the "penny dropped" for him about the "grave position" Northern Ireland was in.

While Mr Swann said he did not believe it was his responsibility for other ministers not understanding the seriousness of Covid, he said if there was a failure on his part to sound the alarm bell louder, he accepted that.

The families said the UK Covid Inquiry should have spent longer looking into what happened in Northern Ireland.

Spokesperson Brenda Doherty said the inquiry revealed failings in health and social care and how badly Northern Ireland had been let down by its politicians.

Those who lost loved ones said some days they felt "deflated others they got a result".

Nothing will bring back their dads, mums, aunts and grannies, but legislation to prevent other mistakes from happening would be a result, the families said.

According to both the inquiry and bereaved families, the government can start planning for civil contingencies and name who is responsible for initiating and leading a cross-departmental response in a crisis.

Legislation is required to safeguard the elderly, those with disabilities and the vulnerable.

A small but important example, the inquiry heard, is for care homes to be equipped with visiting pods and protective equipment that they can install without families losing contact even for one day.

Public inquiries aren't designed to be pleasant, easy, even satisfactory. And the UK Covid-19 Inquiry sitting in Belfast is no exception.

The families aren't satisfied with the time it spent examining the situation in Northern Ireland, who was probed, and the answers revealed.

But when questioning was forensic it managed to expose what happened in care homes and the huge mistakes that followed.

According to the families, it also exposed the lack of "overarching responsibility" for leading and managing the pandemic.

History proves that inquiries tend not to deliver a great deal in Northern Ireland with families often left fighting the system for decades.

To borrow a phrase from the inquiry, who borrowed it from the late Mo Mowlam, there is hope that enough people listening will "bloody well get on and do it".

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Covid Inquiry: What have we learned after three weeks in Belfast? - BBC.com

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