COVID-19 as the Leading Cause of Death in the United States

Did Climate Change Influence the Emergence, Transmission, and Expression of the COVID-19 Pandemic?

The human race has survived many epidemics and pandemics that have emerged and reemerged throughout history. The novel coronavirus Severe Acute Respiratory Syndrome SARS-CoV-2/COVID-19 is the latest pandemic and this has caused major health and socioeconomic problems in almost all communities of the world. The origin of the virus is still in dispute but most likely, the virus emerged from the bats and also may involve an intermediate host before affecting humans. Several other factors also may have affected the emergence and outcome of the infection but in this review, we make a case for a possible role of climate change. The rise in industrialization-related human activities has created a marked imbalance in the homeostasis of environmental factors such as temperature and other weather and these might even have imposed conditions for the emergence of future coronavirus cycles. An attempt is made in this review to explore the effect of ongoing climate changes and discuss if these changes had a role in facilitating the emergence, transmission, and even the expression of the COVID-19 pandemic. We surmise that pandemics will be more frequent in the future and more severely impactful unless climate changes are mitigated.

Transmission dynamics and successful control measures of SARS-CoV-2 in the mega-size city of Guangzhou, China

The severe acute respiratory syndrome coronavirus 2 has caused a worldwide pandemic. Control measures differ among countries and have a varying degree of effectiveness, which requires assessment. To evaluate the effectiveness of public health interventions of the coronavirus disease 2019 (COVID-19) in Guangzhou by 3 periods according to interventions: January 7 to 22 (no intervention), January 23 to February 23 (implemented intensive interventions), and February 24 to May 17 (the normalization mode of COVID-19 prevention and control).We collected the information of 745 COVID-19 patients and their close contacts as well as control measures in Guangzhou from January 7 to May 17, 2020. We estimated the epidemiological characteristics, disease spectrum of COVID-19 cases, key time-to-event intervals, and effective reproduction number over the 3 periods. The basic reproduction number of severe acute respiratory syndrome coronavirus 2 was also calculated over period 1.Approximately 45.8%, 49.8%, and 4.4% of cases from close contacts were asymptomatic, symptomatic, and severe, respectively. The median incubation period was 5.3 days (the percentiles of 2.5-97.5, 1.5-18.4 days) and the median serial interval fitted with gamma distribution was 5.1 days (the percentiles of 2.5-97.5, 0.8-15.9 days). The estimated median of onset-to-quarantined time in Period 1 to 3 were 7.5, 3.4, and 2.9 days (the percentiles of 2.5-97.5, 2.1-14.2, 3.9-14.7, and 6.0-20.0 days) respectively and the median of onset-to-confirmation time in period 1 to 3 were 8.9, 4.9 and 2.4 days (the percentiles of 2.5-97.5, 2.6-16.6, 0.9-14.6, and 0.5-11.8 days). In period 1, the reproduction number was 0.9 (95% confidence interval, 0.5-1.4) and fluctuated below 1.0 before January 22 except for January 14. The effective reproduction number gradually decreased in the period 2 with the lowest point of 0.1 on February 20, then increased again since March 27 and reach a spike of 1.8 on April 12. The number decreased to below 1.0 after April 17 and decreased further to <0.2 after May 7 in the period 3.Under prospective dynamic observation, close contacts turned into infected cases could provide a spectrum of COVID-19 cases from real-world settings. The lockdown of Wuhan and closed-loop management of people arriving Guangzhou were effective in halting the spread of the COVID-19 cases to Guangzhou. The spread of COVID-19 was successfully controlled in Guangzhou by social distancing, wearing a face mask, handwashing, disinfection in key places, mass testing, extensive contact tracing, and strict quarantine of close contacts.

Proposed approaches for coronaviruses elimination from wastewater: Membrane techniques and nanotechnology solutions

Since the beginning of the third Millennium, specifically during the last 18 years, three outbreaks of diseases have been recorded caused by coronaviruses (CoVs). The latest outbreak of these diseases was Coronavirus Disease 2019 (COVID-19), which has been declared by the World Health Organization (WHO) as a pandemic. For this reason, current efforts of the environmental, epidemiology scientists, engineers, and water sector professionals are ongoing to detect CoV in environmental components, especially water, and assess the relative risk of exposure to these systems and any measures needed to protect the public health, workers, and public, in general. This review presents a brief overview of CoV in water, wastewater, and surface water based on a literature search providing different solutions to keep water protected from CoV. Membrane techniques are very attractive solutions for virus elimination in water. In addition, another essential solution is nanotechnology and its applications in the detection and protection of human and water systems.

Reactogenicity and Immunogenicity of the Pfizer and AstraZeneca COVID-19 Vaccines

Background

The relationships of the coronavirus disease 2019 (COVID-19) vaccination with reactogenicity and the humoral immune response are important to study. The current study aimed to assess the reactogenicity and immunogenicity of the Pfizer and AstraZeneca COVID-19 vaccines among adults in Madinah, Saudi Arabia.

Methods

A cross-sectional study, including 365 randomly selected adult Pfizer or AstraZeneca vaccine recipients who received a homologous prime-boost vaccination between February 1st and June 30th, 2021. Data of height and weight were collected to assess the weight status of percipients. An evaluation of seropositivity for anti-severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antibodies was assessed using enzyme-linked immunosorbent assay (ELISA).

Results

Among the participants, 69% (n = 250) reported at least one vaccine-related symptom. Pain at the injection site was the most frequently reported vaccine-related symptom. The mean total score for vaccine-related symptoms was significantly higher among participants who received the AstraZeneca vaccine, women, and participants with no previous COVID-19 infection (p < 0.05). Spike-specific IgG antibodies were detected in 98.9% of participants after the receipt of two vaccine doses, including 99.5% of Pfizer vaccine recipients and 98.3% of AstraZeneca vaccine recipients. Significantly, higher proportions of participants in the <35-year age group developed a humoral immune response after the first vaccine dose compared with the participants in other age groups.

Conclusion

Participants who received the Pfizer COVID-19 vaccine reported fewer vaccine-related complications compared with those who received the AstraZeneca COVID-19 vaccine, but no serious side effects were reported in response to either vaccine. Health status and age were factors that may influence COVID-19 vaccine effectiveness for the generation of antibodies against the SARS-CoV-2 spike protein.

Impact of COVID-19 pandemic on routine immunization

The current COVID-19 global pandemic continues to impact healthcare services beyond those directly related to the management of SARS-CoV-2 transmission and disease. We reviewed the published literature to assess the pandemic impact on existing global immunization activities and how the impact may be addressed. Widespread global disruption in routine childhood immunization has impacted a majority of regions and countries, especially in the initial pandemic phases. While data indicate subsequent recovery in immunization rates, a substantial number of vulnerable people remain unvaccinated. The downstream impact may be even greater in resource-limited settings and economically poorer populations, and consequently there are growing concerns around the resurgence of vaccine-preventable diseases, particularly measles. Guidance on how to address immunization deficits are available and continue to evolve, emphasizing the importance of maintaining and restoring routine immunization and necessary mass vaccination campaigns during and after pandemics. In this, collaboration between a broad range of stakeholders (governments, industry, healthcare decision-makers and frontline healthcare professionals) and clear communication and engagement with the public can help achieve these goals.Key messagesThe COVID-19 pandemic has a substantial impact on essential immunization activities.Disruption to mass vaccination campaigns increase risk of VPD resurgence.Catch-up campaigns are necessary to limit existing shortfalls in vaccine uptake.Guidance to mitigate these effects continues to evolve.

Multicenter Study of Outcomes Among Persons With HIV Who Presented to US Emergency Departments With Suspected SARS-CoV-2

BACKGROUND

There is a need to characterize patients with HIV with suspected severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).

SETTING

Multicenter registry of patients from 116 emergency departments in 27 US states.

METHODS

Planned secondary analysis of patients with suspected SARS-CoV-2, with (n = 415) and without (n = 25,306) HIV. Descriptive statistics were used to compare patient information and clinical characteristics by SARS-CoV-2 and HIV status. Unadjusted and multivariable models were used to explore factors associated with death, intubation, and hospital length of stay. Kaplan-Meier curves were used to estimate survival by SARS-CoV-2 and HIV infection status.

RESULTS

Patients with both SARS-CoV-2 and HIV and patients with SARS-CoV-2 but without HIV had similar admission rates (62.7% versus 58.6%, P = 0.24), hospitalization characteristics [eg, rates of admission to the intensive care unit from the emergency department (5.0% versus 6.3%, P = 0.45) and intubation (10% versus 13.3%, P = 0.17)], and rates of death (13.9% versus 15.1%, P = 0.65). They also had a similar cumulative risk of death (log-rank P = 0.72). However, patients with both HIV and SARS-CoV-2 infections compared with patients with HIV but without SAR-CoV-2 had worsened outcomes, including increased mortality (13.9% versus 5.1%, P < 0.01, log-rank P < 0.0001) and their deaths occurred sooner (median 11.5 versus 34 days, P < 0.01).

CONCLUSIONS

Among emergency department patients with HIV, clinical outcomes associated with SARS-CoV-2 infection are not worse when compared with patients without HIV, but SARS-CoV-2 infection increased the risk of death in patients with HIV.

Cardiovascular Disease Prevention During the COVID-19 Pandemic: Lessons Learned and Future Opportunities

The coronavirus disease 2019 (COVID-19) pandemic has been the defining healthcare issue since its outbreak, consuming healthcare systems and disrupting all aspects of human life throughout 2020 and continuing through 2021. When reviewing cardiovascular disease (CVD) prevention throughout the COVID-19 pandemic, the first tendency may be to focus on the negative disruption. Months of quarantine, isolation, and missed healthcare visits or delayed care may have exacerbated the epidemic of CVD in the United States. Looking back, however, perhaps it wasn't a lost year as much as a health crisis that better prepared us for the battle to improve cardiovascular health. The pandemic brought new platforms for interacting with patients eager to engage, presenting a unique opportunity to reset how we approach preventive care. In this review, we discuss what the pandemic has taught us about caring for those vulnerable patients who were most afflicted-older adults, persons of color, and people facing adverse socioeconomic circumstances-and who continue to be impacted by CVD. We also identify opportunities for enhanced CVD prevention now boosted by the overnight adoption of telemedicine and other innovative cardiac care models. Lastly, we discuss how the COVID-19 pandemic has motivated physicians and patients alike to prioritize our health above all else, if only transiently, and how we can leverage this increased health awareness and investment into long-term, meaningful disease prevention.

Impact of androgen deprivation therapy on mortality of prostate cancer patients with COVID-19: a propensity score-based analysis

BACKGROUND

Previous studies hypothesized that androgen deprivation therapy (ADT) may reduce severe acute respiratory syndrome coronavirus 2 (SARS-COV2) infectivity. However, it is unknown whether there is an association between ADT and a higher survival in prostate cancer patients with COVID-19.

METHODS

We performed a retrospective analysis of prostate cancer (PC) patients hospitalized to treat COVID-19 in Brazil's public health system. We compared patients with the active use of ADT versus those with non-active ADT, past use. We constructed propensity score models of patients in active versus non-active use of ADT. All variables were used to derive propensity score estimation in both models. In the first model we performed a pair-matched propensity score model between those under active and non-active use of ADT. To the second model we initially performed a multivariate backward elimination process to select variables to a final inverse-weight adjusted with double robust estimation model.

RESULTS

We analyzed 199 PC patients with COVID-19 that received ADT. In total, 52.3% (95/199) of our patients were less than 75 years old, 78.4% (156/199) were on active ADT, and most were using a GnRH analog (80.1%; 125/156). Most of patients were in palliative treatment (89.9%; 179/199). Also, 63.3% of our cohort died from COVID-19. Forty-eight patients under active ADT were pair matched against 48 controls (non-active ADT). All patients (199) were analyzed in the double robust model. ADT active use were not protective factor in both inverse-weight based propensity score (OR 0.70, 95% CI 0.38-1.31, P = 0.263), and pair-matched propensity score (OR 0.67, 95% CI 0.27-1.63, P = 0.374) models. We noticed a significant imbalance in the propensity score of patients in active and those in non-active ADT, with important reductions in the differences after the adjustments.

CONCLUSIONS

The active use of ADT was not associated with a reduced risk of death in patients with COVID-19.

Modeling SARS-CoV-2 propagation using rat coronavirus-associated shedding and transmission

At present, global immunity to SARS-CoV-2 resides within a heterogeneous combination of susceptible, naturally infected and vaccinated individuals. The extent to which viral shedding and transmission occurs on re-exposure to SARS-CoV-2 is an important determinant of the rate at which COVID-19 achieves endemic stability. We used Sialodacryoadenitis Virus (SDAV) in rats to model the extent to which immune protection afforded by prior natural infection via high risk (inoculation; direct contact) or low risk (fomite) exposure, or by vaccination, influenced viral shedding and transmission on re-exposure. On initial infection, we confirmed that amount, duration and consistency of viral shedding, and seroconversion rates were correlated with exposure risk. Animals were reinfected after 3.7-5.5 months using the same exposure paradigm. 59% of seropositive animals shed virus, although at lower amounts. Previously exposed seropositive reinfected animals were able to transmit virus to 25% of naive recipient rats after 24-hour exposure by direct contact. Rats vaccinated intranasally with a related virus (Parker's Rat Coronavirus) were able to transmit SDAV to only 4.7% of naive animals after a 7-day direct contact exposure, despite comparable viral shedding. Cycle threshold values associated with transmission in both groups ranged from 29-36 cycles. Observed shedding was not a prerequisite for transmission. Results indicate that low-level shedding in both naturally infected and vaccinated seropositive animals can propagate infection in susceptible individuals. Extrapolated to COVID-19, our results suggest that continued propagation of SARS-CoV-2 by seropositive previously infected or vaccinated individuals is possible.

An Ultrafast One-Step Quantitative Reverse Transcription-Polymerase Chain Reaction Assay for Detection of SARS-CoV-2

We developed an ultrafast one-step RT-qPCR assay for SARS-CoV-2 detection, which can be completed in only 30 min on benchtop Bio-Rad CFX96. The assay significantly reduces the running time of conventional RT-qPCR: reduced RT step from 10 to 1 min, and reduced the PCR cycle of denaturation from 10 to 1 s and extension from 30 to 1 s. A cohort of 60 nasopharyngeal swab samples testing showed that the assay had a clinical sensitivity of 100% and a clinical specificity of 100%.

Factors associated with fatal coronavirus disease 2019 infections among cancer patients in the US FDA Adverse Event Reporting System database

Aim: To explore factors affecting coronavirus disease 2019 (COVID-19) mortality among cancer patients based on a pharmacovigilance database. Methods: US FDA Adverse Event Reporting System (FAERS) quarterly data extract files were reviewed for quarters two, three and four of 2020 (i.e., April to December). Patients with an indication related to malignancy and a reported COVID-related reaction were selected. Multivariate logistic regression analysis for factors associated with a fatal outcome was conducted. Results: A total of 2708 patients were included. The following factors were associated with fatal COVID-19 infection: older age (odds ratio [OR]: 1.03; 95% CI: 1.01-1.04), male sex (OR: 1.43; 95% CI: 1.07-1.91), non-US report source (OR: 2.46; 95% CI: 1.93-3.13), hematological malignancy (OR: 1.62; 95% CI: 1.28-2.07), potentially immunosuppressive treatment (OR: 1.83; 95% CI: 1.30-2.58) and diagnosis in quarter two versus quarter four (OR: 1.62; 95% CI: 1.27-2.07). Conclusion: Within FAERS reports, cancer patients who are older, males and receiving immunosuppressive treatment and those with hematological malignancies were at a higher risk of death because of COVID-19 infection.

COVID-19 and influenza vaccine hesitancy among college students

BACKGROUND

Successful vaccination against coronavirus disease 2019 (COVID-19) is an essential component of achieving community immunity to bring the COVID-19 pandemic to an end. Vaccine hesitancy, identified as a top threat to global health by the World Health Organization, is a significant barrier to vaccine uptake. With COVID-19 vaccination programs in effect since December 2020, it is critical that vaccination barriers are proactively identified. With limited information surrounding college students' perspectives on COVID-19 vaccines, outreach measures will play a pivotal role in vaccine uptake in this population. Development of informative, cohort-driven vaccination campaigns requires proactive assessment of factors influencing vaccine hesitancy, access, and uptake.

OBJECTIVES

The primary objective of this study was to investigate the spectrum of vaccine hesitancy among college students at the University of Rhode Island (URI). The secondary objective was to identify differences in COVID-19 and influenza vaccine hesitancy rates in this population.

METHODS

A 22-item, Institutional Review Board-approved, anonymous questionnaire was developed to survey URI students who voluntarily attended 2 joint University Health Services and College of Pharmacy influenza vaccination clinics in November 2020.

RESULTS

A total of 237 vaccination clinic participants consented and responded to at least 1 question on the survey. Once available to their respective priority group, 92% are very/somewhat likely to receive a COVID-19 vaccine and 50% will receive a COVID-19 vaccine as soon as possible. Only 3% of the participants stated that they would never receive a COVID-19 vaccine. The top 3 reported COVID-19 vaccine-related concerns were safety (37%), effectiveness (24%), and limited information (16%). When asked if COVID-19 vaccines and influenza vaccines should be mandated, 85% and 83%, respectively, were in favor.

CONCLUSION

Understanding the spectrum of vaccine hesitancy is critical in achieving COVID-19 community immunity thresholds. URI students are willing to be vaccinated against COVID-19 provided that the vaccines are proven safe and efficacious.

COVID-19 vaccine hesitancy in underserved communities of North Carolina

BACKGROUND

In the United States, underserved communities including Blacks and Latinx are disproportionately affected by COVID-19. This study sought to estimate the prevalence of COVID-19 vaccine hesitancy, describe attitudes related to vaccination, and identify correlates among historically marginalized populations across 9 counties in North Carolina.

METHODS

We conducted a cross-sectional survey distributed at free COVID-19 testing events in underserved rural and urban communities from August 27 -December 15, 2020. Vaccine hesitancy was defined as the response of "no" or "don't know/not sure" to whether the participant would get the COVID-19 vaccine as soon as it became available.

RESULTS

The sample comprised 948 participants including 27.7% Whites, 59.6% Blacks, 12.7% Latinx, and 63% female. 32% earned <$20K annually, 60% owned a computer and ~80% had internet access at home. The prevalence of vaccine hesitancy was 68.9% including 62.7%, 74%, and 59.5% among Whites, Blacks, and Latinx, respectively. Between September and December, the largest decline in vaccine hesitancy occurred among Whites (27.5 percentage points), followed by Latinx (17.6) and only 12.0 points among Blacks. 51.2% of respondents reported vaccine safety concerns, 23.7% wanted others to get vaccinated first, and 63.1% would trust health care providers about the COVID-19 vaccine. Factors associated with hesitancy in multivariable logistic regression included being female (OR = 1.90 95%CI [1.36, 2.64]), being Black (OR = 1.68 1.16, 2.45]), calendar month (OR = 0.76 [0.63, 0.92]), safety concerns (OR = 4.28 [3.06, 5.97]), and government distrust (OR = 3.57 [2.26, 5.63]).

CONCLUSIONS

This study engaged the community to directly reach underserved minority populations at highest risk of COVID-19 that permitted assessment of vaccine hesitancy (which was much higher than national estimates), driven in part by distrust, and safety concerns.

Outcomes of Patients with COPD Hospitalized for Coronavirus Disease 2019

RATIONALE

There is controversy concerning the association of chronic obstructive pulmonary disease (COPD) as an independent risk factor for mortality in patients hospitalized with Coronavirus Disease 2019 (COVID-19). We hypothesize that patients with COPD hospitalized for COVID-19 have increased mortality risk.

OBJECTIVE

To assess whether COPD increased the risk of mortality among patients hospitalized for COVID-19.

METHODS

We conducted a retrospective cohort analysis of patients with COVID-19 between February 10, 2020, and November 10, 2020, and hospitalized within 14 days of diagnosis. Electronic health records from U.S. facilities (Optum COVID-19 data) were used.

RESULTS

In our cohort of 31,526 patients, 3030 (9.6%) died during hospitalization. Mortality in patients with COPD was higher than that of patients without COPD, 14.02% and 8.8%, respectively. Univariate (odds ratio [OR] 1.68; 95% confidence interval [CI] 1.54 to 1.84) and multivariate (OR 1.33; 95% CI 1.18 to 1.50) analysis showed that patients with COPD had greater odds of death due to COVID-19 than patients without COPD. We found significant interactions between COPD and sex and COPD and age. Specifically, the increased mortality risk associated with COPD was observed among female (OR 1.62; 95% CI 1.36 to 1.95) but not male patients (OR 1.14; 95% CI 0.97 to 1.34); and in patients aged 40 to 64 (OR 1.42; 95% CI 1.07 to 1.90) and 65 to 79 (OR 1.48; 95% CI 1.23 to 1.78) years.

CONCLUSIONS

COPD is an independent risk factor for death in adults aged 40 to 79 years hospitalized with COVID-19 infection.

COVID-19 and the lungs: A review

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) attacks pulmonary alveolar cells via angiotensin-converting enzyme 2 (ACE2) receptors and causes pulmonary infections that result in coronavirus disease (COVID-19), inducing immune responses that can result in severe pneumonia. We reviewed the clinical experiences of lung diseases during the COVID-19 pandemic to offer insights into the adaptations made by experts in the diagnosis and treatment of these comorbidities. Various lung comorbidities increase the severity of COVID-19 and associated mortality by amplifying ACE2 expression. Additionally, the COVID-19 pandemic has changed the use of routine diagnostic pulmonary imaging methods, making chest sonography scoring the most convenient, as it can be conducted bedside. Treatment protocols for SARS-CoV-2 infection and the underlying lung diseases are also affected owing to potential interactions. The optimal diagnostic methods and treatment protocols for lung diseases have been adapted worldwide to increase survival rates and attenuate acute lung injuries during the COVID-19 pandemic.

Impact of COVID-19 on life expectancy at birth in India: a decomposition analysis

BACKGROUND

Quantifying excess deaths and their impact on life expectancy at birth (e0) provide a more comprehensive understanding of the burden of coronavirus disease of 2019 (COVID-19) on mortality. The study aims to comprehend the repercussions of the burden of COVID-19 disease on the life expectancy at birth and inequality in age at death in India.

METHODS

The mortality schedule of COVID-19 disease in the pandemic year 2020 was considered one of the causes of death in the category of other infectious diseases in addition to other 21 causes of death in the non-pandemic year 2019 in the Global Burden of Disease (GBD) data. The measures e0 and Gini coefficient at age zero (G0) and then sex differences in e0 and G0 over time were analysed by assessing the age-specific contributions based on the application of decomposition analyses in the entire period of 2010-2020.

RESULTS

The e0 for men and women decline from 69.5 and 72.0 years in 2019 to 67.5 and 69.8 years, respectively, in 2020. The e0 shows a drop of approximately 2.0 years in 2020 when compared to 2019. The sex differences in e0 and G0 are negatively skewed towards men. The trends in e0 and G0 value reveal that its value in 2020 is comparable to that in the early 2010s. The age group of 35-79 years showed a remarkable negative contribution to Δe0 and ΔG0. By causes of death, the COVID-19 disease has contributed - 1.5 and - 9.5%, respectively, whereas cardiovascular diseases contributed the largest value of was 44.6 and 45.9%, respectively, to sex differences in e0 and G0 in 2020. The outcomes reveal a significant impact of excess deaths caused by the COVID-19 disease on mortality patterns.

CONCLUSIONS

The COVID-19 pandemic has negative repercussions on e0 and G0 in the pandemic year 2020. It has severely affected the distribution of age at death in India, resulting in widening the sex differences in e0 and G0. The COVID-19 disease demonstrates its potential to cancel the gains of six to eight years in e0 and five years in G0 and has slowed the mortality transition in India.

Association of pre-existing comorbidities with mortality and disease severity among 167,500 individuals with COVID-19 in Canada: A population-based cohort study

Background

The novel coronavirus disease 2019 (COVID-19) has infected 1.9% of the world population by May 2, 2021. Since most previous studies that examined risk factors for mortality and severity were based on hospitalized individuals, population-based cohort studies are called for to provide evidence that can be extrapolated to the general population. Therefore, we aimed to examine the associations of comorbidities with mortality and disease severity in individuals with COVID-19 diagnosed in 2020 in Ontario, Canada.

Methods and findings

We conducted a retrospective cohort study of all individuals with COVID-19 in Ontario, Canada diagnosed between January 15 and December 31, 2020. Cases were linked to health administrative databases maintained in the ICES which covers all residents in Ontario. The primary outcome is all-cause 30-day mortality after the first COVID-19 diagnosis, and the secondary outcome is a composite severity index containing death and hospitalization. To examine the risk factors for the outcomes, we employed Cox proportional hazards regression models and logistic regression models to adjust for demographic, socio-economic variables and comorbidities. Results were also stratified by age groups. A total of 167,500 individuals were diagnosed of COVID-19 in 2020 and included in the study. About half (43.8%, n = 73,378) had at least one comorbidity. The median follow-up period were 30 days. The most common comorbidities were hypertension (24%, n = 40,154), asthma (16%, n = 26,814), and diabetes (14.7%, n = 24,662). Individuals with comorbidity had higher risk of mortality compared to those without (HR = 2.80, 95%CI 2.35–3.34; p<0.001), and the risk substantially was elevated from 2.14 (95%CI 1.76–2.60) to 4.81 (95%CI 3.95–5.85) times as the number of comorbidities increased from one to five or more. Significant predictors for mortality included comorbidities such as solid organ transplant (HR = 3.06, 95%CI 2.03–4.63; p<0.001), dementia (HR = 1.46, 95%CI 1.35–1.58; p<0.001), chronic kidney disease (HR = 1.45, 95%CI 1.34–1.57; p<0.001), severe mental illness (HR = 1.42, 95%CI%, 1.12–1.80; p<0.001), cardiovascular disease (CVD) (HR = 1.22, 95%CI, 1.15–1.30), diabetes (HR = 1.19, 95%, 1.12–1.26; p<0.001), chronic obstructive pulmonary disease (COPD) (HR = 1.19, 95%CI 1.12–1.26; p<0.001), cancer (HR = 1.17, 95%CI, 1.09–1.27; p<0.001), hypertension (HR = 1.16, 95%CI, 1.07–1.26; p<0.001). Compared to their effect in older age groups, comorbidities were associated with higher risk of mortality and severity in individuals under 50 years old. Individuals with five or more comorbidities in the below 50 years age group had 395.44 (95%CI, 57.93–2699.44, p<0.001) times higher risk of mortality compared to those without. Limitations include that data were collected during 2020 when the new variants of concern were not predominant, and that the ICES databases do not contain detailed individual-level socioeconomic and racial variables.

Conclusion

We found that solid organ transplant, dementia, chronic kidney disease, severe mental illness, CVD, hypertension, COPD, cancer, diabetes, rheumatoid arthritis, HIV, and asthma were associated with mortality or severity. Our study highlights that the number of comorbidities was a strong risk factor for deaths and severe outcomes among younger individuals with COVID-19. Our findings suggest that in addition of prioritizing by age, vaccination priority groups should also include younger population with multiple comorbidities.

Comprehensive evaluation of COVID-19 patient short- and long-term outcomes: Disparities in healthcare utilization and post-hospitalization outcomes

BACKGROUND

Understanding risk factors for short- and long-term COVID-19 outcomes have implications for current guidelines and practice. We study whether early identified risk factors for COVID-19 persist one year later and through varying disease progression trajectories.

METHODS

This was a retrospective study of 6,731 COVID-19 patients presenting to Michigan Medicine between March 10, 2020 and March 10, 2021. We describe disease progression trajectories from diagnosis to potential hospital admission, discharge, readmission, or death. Outcomes pertained to all patients: rate of medical encounters, hospitalization-free survival, and overall survival, and hospitalized patients: discharge versus in-hospital death and readmission. Risk factors included patient age, sex, race, body mass index, and 29 comorbidity conditions.

RESULTS

Younger, non-Black patients utilized healthcare resources at higher rates, while older, male, and Black patients had higher rates of hospitalization and mortality. Diabetes with complications, coagulopathy, fluid and electrolyte disorders, and blood loss anemia were risk factors for these outcomes. Diabetes with complications, coagulopathy, fluid and electrolyte disorders, and blood loss were associated with lower discharge and higher inpatient mortality rates.

CONCLUSIONS

This study found differences in healthcare utilization and adverse COVID-19 outcomes, as well as differing risk factors for short- and long-term outcomes throughout disease progression. These findings may inform providers in emergency departments or critical care settings of treatment priorities, empower healthcare stakeholders with effective disease management strategies, and aid health policy makers in optimizing allocations of medical resources.

Outcomes of obese patients hospitalized with COVID-19: the impact of prior bariatric surgery

Background

Obesity and several obesity-related co-morbidities are risk factors for severe COVID-19 disease. Because bariatric surgery successfully treats obesity-related conditions, we hypothesized that prior bariatric surgery may be associated with less severe COVID-19 disease.

Objectives

To examine the association between prior bariatric surgery and outcomes in patients with obesity admitted with COVID-19.

Setting

United States

Methods

The Vizient database was used to obtain demographic and outcomes data for adults with obesity admitted with COVID-19 from May 2020 to January 2021. Patients were divided into 2 groups: those with and those without prior bariatric surgery. The primary outcome was in-hospital mortality. Secondary outcomes were mortality by age, sex, race/ethnicity, and co-morbidity; intubation rate; hemodialysis rate; and length of stay. Because the database only provides aggregate data and not patient-level data, multivariate analysis could not be performed.

Results

Among the 124,699 patients with obesity admitted with COVID-19, 2,607 had previous bariatric surgery and 122,092 did not. The proportion of patients ≥65 years of age was higher in the non–bariatric surgery group (36.0% versus 27.6%, P < .0001). Compared with patients without prior bariatric surgery, patients with prior bariatric surgery had lower in-hospital mortality (7.8 versus 11.2%, P < .0001) and intubation rates (18.5% versus 23.6%, P = .0009). Hemodialysis rate (7.2% versus 6.9%, P = .5) and length of stay (8.8 versus 9.6 days, P = .8) were similar between groups. Mortality was significantly lower in the bariatric surgery group for patients 18–64 years of age (5.9% versus 7.4%, P = .01) and ≥65 years of age (12.9% versus 17.9%, P = .0006).

Conclusions

This retrospective cohort study found that inpatients with obesity and COVID-19 who had prior bariatric surgery had improved outcomes compared with a similar cohort without prior bariatric surgery. Further studies should examine mechanisms for the association between bariatric surgery and less severe COVID-19.

Multisystem inflammatory syndrome in adults: A case in a previously healthy adult

A 25-year-old previously healthy female presented to the emergency department (ED) with 5 days of rash, fevers, shortness of breath, and generalized weakness. She had presented to another ED 4 days previously and noted that her rash had improved, but her other symptoms were worsening. She had recovered from COVID-19, confirmed by positive antigen test 5 weeks prior. On ED arrival, she was afebrile and persistently tachycardic to a rate of 120 beats per minute, despite aggressive fluid resuscitation with 3L of IV crystalloid. She was found to have a troponin elevated to 0.06 ng/mL in addition to a d-dimer elevated to 1.42 mcg/mL FEU. She was admitted to the hospital where she developed hypotension requiring vasopressor support and was admitted to the intensive care unit (ICU). A transthoracic echocardiogram revealed a newly reduced ejection fraction of 31%. She was diagnosed with multisystem inflammatory syndrome in adults (MIS-A). The patient received intravenous immunoglobulin and methylprednisolone 60 mg Q12 hours while admitted. She was discharged on hospital day 3 with a prednisone taper and is currently doing well at her most recent follow-up with infectious disease.

Clinical Characteristics and Risk Factors of Respiratory Failure in a Cohort of Young Patients Requiring Hospital Admission with SARS-CoV2 Infection in Spain: Results of the Multicenter SEMI-COVID-19 Registry

BACKGROUND

Age is a risk factor for COVID severity. Most studies performed in hospitalized patients with SARS-CoV2 infection have shown an over-representation of older patients and consequently few have properly defined COVID-19 in younger patients who require hospital admission. The aim of the present study was to analyze the clinical characteristics and risk factors for the development of respiratory failure among young (18 to 50 years) hospitalized patients with COVID-19.

METHODS

This retrospective nationwide cohort study included hospitalized patients from 18 to 50 years old with confirmed COVID-19 between March 1, 2020, and July 2, 2020. All patient data were obtained from the SEMI-COVID Registry. Respiratory failure was defined as the ratio of partial pressure of arterial oxygen to fraction of inspired oxygen (PaO2/FiO2 ratio) ≤200 mmHg or the need for mechanical ventilation and/or high-flow nasal cannula or the presence of acute respiratory distress syndrome.

RESULTS

During the recruitment period, 15,034 patients were included in the SEMI-COVID-19 Registry, of whom 2327 (15.4%) were younger than 50 years. Respiratory failure developed in 343 (14.7%), while mortality occurred in 2.3%. Patients with respiratory failure showed a higher incidence of major adverse cardiac events (44 (13%) vs 14 (0.8%), p<0.001), venous thrombosis (23 (6.7%) vs 14 (0.8%), p<0.001), mortality (43 (12.5%) vs 7 (0.4%), p<0.001), and longer hospital stay (15 (9-24) vs 6 (4-9), p<0.001), than the remaining patients. In multivariate analysis, variables associated with the development of respiratory failure were obesity (odds ratio (OR), 2.42; 95% confidence interval (95% CI), 1.71 to 3.43; p<0.0001), alcohol abuse (OR, 2.40; 95% CI, 1.26 to 4.58; p=0.0076), sleep apnea syndrome (SAHS) (OR, 2.22; 95% CI, 1.07 to 3.43; p=0.032), Charlson index ≥1 (OR, 1.77; 95% CI, 1.25 to 2.52; p=0.0013), fever (OR, 1.58; 95% CI, 1.13 to 2.22; p=0.0075), lymphocytes ≤1100 cells/μL (OR, 1.67; 95% CI, 1.18 to 2.37; p=0.0033), LDH >320 U/I (OR, 1.69; 95% CI, 1.18 to 2.42; p=0.0039), AST >35 mg/dL (OR, 1.74; 95% CI, 1.2 to 2.52; p=0.003), sodium <135 mmol/L (OR, 2.32; 95% CI, 1.24 to 4.33; p=0.0079), and C-reactive protein >8 mg/dL (OR, 2.42; 95% CI, 1.72 to 3.41; p<0.0001).

CONCLUSIONS

Young patients with COVID-19 requiring hospital admission showed a notable incidence of respiratory failure. Obesity, SAHS, alcohol abuse, and certain laboratory parameters were independently associated with the development of this complication. Patients who suffered respiratory failure had a higher mortality and a higher incidence of major cardiac events, venous thrombosis, and hospital stay.

Health Equity, Schooling Hesitancy, and the Social Determinants of Learning

At least 62 million K-12 students in North America-disproportionately low-income children of color- have been physically out of school for over a year due to the COVID-19 pandemic. These children are at risk of significant academic, social, mental, and physical harm now and in the long-term. We review the literature about school safety and the conditions that shape families' and teachers' choices to return to in-person schooling. We identify four causes of schooling hesitancy in the U.S. even where schools can be safely reopened: high community transmission rates; the politicization of school re-openings; long-term racialized disinvestment in urban districts; and parents' rational calculations about their family's vulnerability due to the social determinants of health. Given the deep interconnections between the social determinants of health and of learning, and between schooling hesitancy and community vulnerability, stark inequities in in-person schooling access and take-up are likely to persist. We recommend that school districts invest in scientifically-based facilities upgrades, increased nursing and counseling staffing, and preparation for schools to serve as pediatric vaccination sites. School districts should also apply lessons from public health about addressing vaccine hesitancy to the challenge of schooling hesitancy by investing time in humble listening to parents and teachers about their concerns.

Early Convalescent Plasma Therapy and Mortality Among US Veterans Hospitalized With Nonsevere COVID-19: An Observational Analysis Emulating a Target Trial

BACKGROUND

Early convalescent plasma transfusion may reduce mortality in patients with nonsevere coronavirus disease 2019 (COVID-19).

METHODS

This study emulates a (hypothetical) target trial using observational data from a cohort of US veterans admitted to a Department of Veterans Affairs (VA) facility between 1 May and 17 November 2020 with nonsevere COVID-19. The intervention was convalescent plasma initiated within 2 days of eligibility. Thirty-day mortality was compared using cumulative incidence curves, risk differences, and hazard ratios estimated from pooled logistic models with inverse probability weighting to adjust for confounding.

RESULTS

Of 11 269 eligible person-trials contributed by 4755 patients, 402 trials were assigned to the convalescent plasma group. Forty and 671 deaths occurred within the plasma and nonplasma groups, respectively. The estimated 30-day mortality risk was 6.5% (95% confidence interval [CI], 4.0%-9.7%) in the plasma group and 6.2% (95% CI, 5.6%-7.0%) in the nonplasma group. The associated risk difference was 0.30% (95% CI, -2.30% to 3.60%) and the hazard ratio was 1.04 (95% CI, .64-1.62).

CONCLUSIONS

Our target trial emulation estimated no meaningful differences in 30-day mortality between nonsevere COVID-19 patients treated and untreated with convalescent plasma. Clinical Trials Registration. NCT04545047.

Prevalence of right ventricular dysfunction and impact on all-cause death in hospitalized patients with COVID-19: a systematic review and meta-analysis

The Coronavirus Disease (COVID-19) pandemic imposed a high burden of morbidity and mortality. In COVID-19, direct lung parenchymal involvement and pulmonary microcirculation dysfunction may entail pulmonary hypertension (PH). PH and direct cardiac injury beget right ventricular dysfunction (RVD) occurrence, which has been frequently reported in COVID-19 patients; however, the prevalence of RVD and its impact on outcomes during COVID-19 are still unclear. This study aims to evaluate the prevalence of RVD and associated outcomes in patients with COVID-19, through a Systematic Review and Meta-Analysis. MEDLINE and EMBASE were systematically searched from inception to 15th July 2021. All studies reporting either the prevalence of RVD in COVID-19 patients or all-cause death according to RVD status were included. The pooled prevalence of RVD and Odds Ratio (OR) for all-cause death according to RVD status were computed and reported. Subgroup analysis and meta-regression were also performed. Among 29 studies (3813 patients) included, pooled prevalence of RVD was 20.4% (95% CI 17.1-24.3%; 95% PI 7.8-43.9%), with a high grade of heterogeneity. No significant differences were found across geographical locations, or according to the risk of bias. Severity of COVID-19 was associated with increased prevalence of RVD at meta-regression. The presence of RVD was found associated with an increased likelihood of all-cause death (OR 3.32, 95% CI 1.94-5.70). RVD was found in 1 out of 5 COVID-19 patients, and was associated with all-cause mortality. RVD may represent one crucial marker for prognostic stratification in COVID-19; further prospective and larger are needed to investigate specific management and therapeutic approach for these patients.

Association Between Caseload Surge and COVID-19 Survival in 558 U.S. Hospitals, March to August 2020

BACKGROUND

Several U.S. hospitals had surges in COVID-19 caseload, but their effect on COVID-19 survival rates remains unclear, especially independent of temporal changes in survival.

OBJECTIVE

To determine the association between hospitals' severity-weighted COVID-19 caseload and COVID-19 mortality risk and identify effect modifiers of this relationship.

DESIGN

Retrospective cohort study. (ClinicalTrials.gov: NCT04688372).

SETTING

558 U.S. hospitals in the Premier Healthcare Database.

PARTICIPANTS

Adult COVID-19-coded inpatients admitted from March to August 2020 with discharge dispositions by October 2020.

MEASUREMENTS

Each hospital-month was stratified by percentile rank on a surge index (a severity-weighted measure of COVID-19 caseload relative to pre-COVID-19 bed capacity). The effect of surge index on risk-adjusted odds ratio (aOR) of in-hospital mortality or discharge to hospice was calculated using hierarchical modeling; interaction by surge attributes was assessed.

RESULTS

Of 144 116 inpatients with COVID-19 at 558 U.S. hospitals, 78 144 (54.2%) were admitted to hospitals in the top surge index decile. Overall, 25 344 (17.6%) died; crude COVID-19 mortality decreased over time across all surge index strata. However, compared with nonsurging (<50th surge index percentile) hospital-months, aORs in the 50th to 75th, 75th to 90th, 90th to 95th, 95th to 99th, and greater than 99th percentiles were 1.11 (95% CI, 1.01 to 1.23), 1.24 (CI, 1.12 to 1.38), 1.42 (CI, 1.27 to 1.60), 1.59 (CI, 1.41 to 1.80), and 2.00 (CI, 1.69 to 2.38), respectively. The surge index was associated with mortality across ward, intensive care unit, and intubated patients. The surge-mortality relationship was stronger in June to August than in March to May (slope difference, 0.10 [CI, 0.033 to 0.16]) despite greater corticosteroid use and more judicious intubation during later and higher-surging months. Nearly 1 in 4 COVID-19 deaths (5868 [CI, 3584 to 8171]; 23.2%) was potentially attributable to hospitals strained by surging caseload.

LIMITATION

Residual confounding.

CONCLUSION

Despite improvements in COVID-19 survival between March and August 2020, surges in hospital COVID-19 caseload remained detrimental to survival and potentially eroded benefits gained from emerging treatments. Bolstering preventive measures and supporting surging hospitals will save many lives.

PRIMARY FUNDING SOURCE

Intramural Research Program of the National Institutes of Health Clinical Center, the National Institute of Allergy and Infectious Diseases, and the National Cancer Institute.

Liver injury in COVID-19 and IL-6 trans-signaling-induced endotheliopathy

BACKGROUND AND AIMS

COVID-19 is associated with liver injury and elevated interleukin-6 (IL-6). We hypothesized that IL-6 trans-signaling in liver sinusoidal endothelial cells (LSECs) leads to endotheliopathy (a proinflammatory and procoagulant state) and liver injury in COVID-19.

METHODS

Coagulopathy, endotheliopathy, and alanine aminotransferase (ALT) were retrospectively analyzed in a subset (n = 68), followed by a larger cohort (n = 3,780) of patients with COVID-19. Liver histology from 43 patients with COVID-19 was analyzed for endotheliopathy and its relationship to liver injury. Primary human LSECs were used to establish the IL-6 trans-signaling mechanism.

RESULTS

Factor VIII, fibrinogen, D-dimer, von Willebrand factor (vWF) activity/antigen (biomarkers of coagulopathy/endotheliopathy) were significantly elevated in patients with COVID-19 and liver injury (elevated ALT). IL-6 positively correlated with vWF antigen (p = 0.02), factor VIII activity (p = 0.02), and D-dimer (p <0.0001). On liver histology, patients with COVID-19 and elevated ALT had significantly increased vWF and platelet staining, supporting a link between liver injury, coagulopathy, and endotheliopathy. Intralobular neutrophils positively correlated with platelet (p <0.0001) and vWF (p <0.01) staining, and IL-6 levels positively correlated with vWF staining (p <0.01). IL-6 trans-signaling leads to increased expression of procoagulant (factor VIII, vWF) and proinflammatory factors, increased cell surface vWF (p <0.01), and increased platelet attachment in LSECs. These effects were blocked by soluble glycoprotein 130 (IL-6 trans-signaling inhibitor), the JAK inhibitor ruxolitinib, and STAT1/3 small-interfering RNA knockdown. Hepatocyte fibrinogen expression was increased by the supernatant of LSECs subjected to IL-6 trans-signaling.

CONCLUSION

IL-6 trans-signaling drives the coagulopathy and hepatic endotheliopathy associated with COVID-19 and could be a possible mechanism behind liver injury in these patients.

LAY SUMMARY

Patients with SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) infection often have liver injury, but why this occurs remains unknown. High levels of interleukin-6 (IL-6) and its circulating receptor, which form a complex to induce inflammatory signals, have been observed in patients with COVID-19. This paper demonstrates that the IL-6 signaling complex causes harmful changes to liver sinusoidal endothelial cells and may promote blood clotting and contribute to liver injury.

Occurrence of BNT162b2 Vaccine Adverse Reactions Is Associated with Enhanced SARS-CoV-2 IgG Antibody Response

Promoting SARS-CoV-2 vaccination has been a global mission since the first vaccines were approved for emergency use. Alongside the excitement following the possibility of eradicating SARS-CoV-2 and ending the COVID-19 pandemic, there has been ample vaccine hesitancy, some due to the abundant reporting of adverse reactions. We report here that the occurrence of BNT162b2 vaccine adverse reactions is associated with enhanced antibody response. We found a statistically significant correlation between having an adverse reaction, whether local or systemic, and higher antibody levels. No sex difference was observed in antibody levels. However, as was recently reported, the antibody response was found to be lower among older vaccinees. The demonstration of a clear correlation between adverse reactions and antibody levels may help reduce vaccination hesitancy by reassuring that the presence of such reactions is an indication of a well-functioning immune system.

The Assessment of COVID-19 Knowledge and Attitudes Among a Middle Eastern North African Community in Dearborn, Michigan

In 2020, COVID-19 was the third leading cause of death among individuals between the ages of 45–84 years (Woolf 325:123–124, 2021). However, systemic inequities and disparities exacerbated the pandemic’s effect on racial and ethnic groups (Tai 72:703–706, 2021). The exact impact of the pandemic within the Middle Eastern North African (MENA) community is not well documented or understood due to the lack of federal recognition of MENAs as an ethnic group. Given the lack of COVID-19 research among this community, this study was created to address COVID-19 needs, perceptions, and health-seeking behaviors regarding COVID-19 precautions, mask wearing, and routine healthcare appointments. Between June and July 2020, an anonymous survey was distributed in English and Arabic using a Community Participatory Based Research design in Dearborn, Michigan. Overall, 298 individuals were surveyed and their misconceptions regarding COVID-19 infections, spread, and precautions were identified. It is important to note that about 75% of survey respondents identified as female, while only 24% of survey participants identified as male. Survey participants slightly underestimated the distance in which COVID-19 can be transmitted as 5.5 ± 3.5. Participants severely underestimated COVID-19 deaths in the US, with 23% estimating that under 250,000 individuals would die from COVID-19. Overall, 60% of participants reported that they did not have any difficulty adhering to COVID-19 precautions and self-quarantine rules during Ramadan, while this number dropped to only 36% (87/238) after Ramadan. The goal of this study was to serve as a tool to better understand the misconceptions, difficulties, and needs regarding COVID-19 among this understudied population. The MENA community may be particularly vulnerable to the economic, medical, and social changes brought about by the COVID-19 pandemic.

Upper airway gene expression reveals a more robust innate and adaptive immune response to SARS-CoV-2 in children compared with older adults

Unlike other respiratory viruses, SARS-CoV-2 disproportionately causes severe disease in older adults and only rarely in children. To investigate whether differences in the upper airway immune response could contribute to this disparity, we compared nasopharyngeal gene expression in 83 children (<19-years-old; 38 with SARS-CoV-2, 11 with other respiratory viruses, 34 with no virus) and 154 adults (>40-years-old; 45 with SARS-CoV-2, 28 with other respiratory viruses, 81 with no virus). Expression of interferon-stimulated genes (ISGs) was robustly activated in both children and adults with SARS-CoV-2 compared to the respective non-viral groups, with only relatively subtle distinctions. Children, however, demonstrated markedly greater upregulation of pathways related to B cell and T cell activation and proinflammatory cytokine signaling, including TNF, IFNγ, IL-2 and IL-4 production. Cell type deconvolution confirmed greater recruitment of B cells, and to a lesser degree macrophages, to the upper airway of children. Only children exhibited a decrease in proportions of ciliated cells, the primary target of SARS-CoV-2, upon infection with the virus. These findings demonstrate that children elicit a more robust innate and adaptive immune response to SARS-CoV-2 infection in the upper airway that likely contributes to their protection from severe disease in the lower airway.

The Use of Blood Biomarkers in Precision Medicine for the Primary Prevention of Atherosclerotic Cardiovascular Disease: a Review

Introduction

A biomarker is a substance, structure, or process that indicates the presence of a disease, infection, or environmental exposure. Clinically useful biomarkers are measurable, improve diagnostic or prognostic performance, and ultimately aid clinicians in determining the initiation, duration, or magnitude of therapy.

Areas Covered

The purpose of this review is to explore the roles of various blood biomarkers of atherosclerotic cardiovascular disease (ASCVD) and how their use may improve the precision with which clinicians can identify, treat, and ultimately prevent ASCVD. Our review will include lipid biomarkers, markers of cardiac injury and wall stress, markers of inflammation, and a few others.

Expert Opinion

Several biomarkers have recently been highlighted as "risk-enhancing factors" in the 2019 American College of Cardiology/American Heart Association Guideline for the Primary Prevention of ASCVD, which can help guide shared decision-making. These included elevated low-density lipoprotein cholesterol, triglycerides, lipoprotein(a), apolipoprotein B, or high-sensitivity C-reactive protein. However, some other biomarkers mentioned in this review are not commonly used despite showing initial promise as prognostic of ASCVD risk, as it is not clear how treatment decisions should be changed after their measurement among asymptomatic individuals. Future studies should focus on whether biomarker-directed management strategies can improve clinical outcomes.

COVID-19-Associated Mortality in US Veterans with and without SARS-CoV-2 Infection

Background: We performed an observational Veterans Health Administration cohort analysis to assess how risk factors affect 30-day mortality in SARS-CoV-2-infected subjects relative to those uninfected. While the risk factors for coronavirus disease 2019 (COVID-19) have been extensively studied, these have been seldom compared with uninfected referents. Methods: We analyzed 341,166 White/Black male veterans tested for SARS-CoV-2 from March 1 to September 10, 2020. The relative risk of 30-day mortality was computed for age, race, ethnicity, BMI, smoking status, and alcohol use disorder in infected and uninfected subjects separately. The difference in relative risk was then evaluated between infected and uninfected subjects. All the analyses were performed considering clinical confounders. Results: In this cohort, 7% were SARS-CoV-2-positive. Age >60 and overweight/obesity were associated with a dose-related increased mortality risk among infected patients relative to those uninfected. In contrast, relative to never smoking, current smoking was associated with a decreased mortality among infected and an increased mortality in uninfected, yielding a reduced mortality risk among infected relative to uninfected. Alcohol use disorder was also associated with decreased mortality risk in infected relative to the uninfected. Conclusions: Age, BMI, smoking, and alcohol use disorder affect 30-day mortality in SARS-CoV-2-infected subjects differently from uninfected referents. Advanced age and overweight/obesity were associated with increased mortality risk among infected men, while current smoking and alcohol use disorder were associated with lower mortality risk among infected men, when compared with those uninfected.

Impact of cancer and cardiovascular disease on in-hospital outcomes of COVID-19 patients: results from the american heart association COVID-19 cardiovascular disease registry

Background

While pre-existing cardiovascular disease (CVD) appears to be associated with poor outcomes in patients with Coronavirus Disease 2019 (COVID-19), data on patients with CVD and concomitant cancer is limited. The purpose of this study is to evaluate the effect of underlying CVD and CVD risk factors with cancer history on in-hospital mortality in those with COVID-19.

Methods

Data from symptomatic adults hospitalized with COVID-19 at 86 hospitals in the US enrolled in the American Heart Association’s COVID-19 CVD Registry was analyzed. The primary exposure was cancer history. The primary outcome was in-hospital death. Multivariable logistic regression models were adjusted for demographics, CVD risk factors, and CVD. Interaction between history of cancer with concomitant CVD and CVD risk factors were tested.

Results

Among 8222 patients, 892 (10.8%) had a history of cancer and 1501 (18.3%) died. Cancer history had significant interaction with CVD risk factors of age, body mass index (BMI), and smoking history, but not underlying CVD itself. History of cancer was significantly associated with increased in-hospital death (among average age and BMI patients, adjusted odds ratio [aOR] = 3.60, 95% confidence interval [CI]: 2.07–6.24; p < 0.0001 in those with a smoking history and aOR = 1.33, 95%CI: 1.01—1.76; p = 0.04 in non-smokers). Among the cancer subgroup, prior use of chemotherapy within 2 weeks of admission was associated with in-hospital death (aOR = 1.72, 95%CI: 1.05–2.80; p = 0.03). Underlying CVD demonstrated a numerical but statistically nonsignificant trend toward increased mortality (aOR = 1.18, 95% CI: 0.99—1.41; p = 0.07).

Conclusion

Among hospitalized COVID-19 patients, cancer history was a predictor of in-hospital mortality. Notably, among cancer patients, recent use of chemotherapy, but not underlying CVD itself, was associated with worse survival. These findings have important implications in cancer therapy considerations and vaccine distribution in cancer patients with and without underlying CVD and CVD risk factors.

Resilience and Equity in a Time of Crises: Investing in Public Urban Greenspace Is Now More Essential Than Ever in the US and Beyond

The intersecting negative effects of structural racism, COVID-19, climate change, and chronic diseases disproportionately affect racial and ethnic minorities in the US and around the world. Urban populations of color are concentrated in historically redlined, segregated, disinvested, and marginalized neighborhoods with inadequate quality housing and limited access to resources, including quality greenspaces designed to support natural ecosystems and healthy outdoor activities while mitigating urban environmental challenges such as air pollution, heat island effects, combined sewer overflows and poor water quality. Disinvested urban environments thus contribute to health inequity via physical and social environmental exposures, resulting in disparities across numerous health outcomes, including COVID-19 and chronic diseases such as cancer and cardiovascular diseases (CVD). In this paper, we build off an existing conceptual framework and propose another conceptual framework for the role of greenspace in contributing to resilience and health equity in the US and beyond. We argue that strategic investments in public greenspaces in urban neighborhoods impacted by long term economic disinvestment are critically needed to adapt and build resilience in communities of color, with urgency due to immediate health threats of climate change, COVID-19, and endemic disparities in chronic diseases. We suggest that equity-focused investments in public urban greenspaces are needed to reduce social inequalities, expand economic opportunities with diversity in workforce initiatives, build resilient urban ecosystems, and improve health equity. We recommend key strategies and considerations to guide this investment, drawing upon a robust compilation of scientific literature along with decades of community-based work, using strategic partnerships from multiple efforts in Milwaukee Wisconsin as examples of success.

Poliovirus Vaccination Induces a Humoral Immune Response That Cross Reacts With SARS-CoV-2

Background: Millions have been exposed to SARS-CoV-2, but the severity of resultant infections has varied among adults and children, with adults presenting more serious symptomatic cases. Children may possess an immunity that adults lack, possibly from childhood vaccinations. This retrospective study suggests immunization against the poliovirus may provide an immunity to SARS-CoV-2. Methods: Publicly available data were analyzed for possible correlations between national median ages and epidemiological outbreak patterns across 100 countries. Sera from 204 adults and children, who were immunized with the poliovirus vaccine, were analyzed using an enzyme-linked immunosorbent assay. The effects of polio-immune serum on SARS-CoV-2-induced cytopathology in cell culture were then evaluated. Results: Analyses of median population age demonstrated a positive correlation between median age and SARS-CoV-2 prevalence and death rates. Countries with effective poliovirus immunization protocols and younger populations have fewer and less pathogenic cases of COVID-19. Antibodies to poliovirus and SARS-CoV-2 were found in pediatric sera and in sera from adults recently immunized with polio. Sera from polio-immunized individuals inhibited SARS-CoV-2 infection of Vero cell cultures. These results suggest the anti-D3-pol-antibody, induced by poliovirus vaccination, may provide a similar degree of protection from SARS-CoV-2 to adults as to children. Conclusions: Poliovirus vaccination induces an adaptive humoral immune response. Antibodies created by poliovirus vaccination bind the RNA-dependent RNA polymerase (RdRp) protein of both poliovirus and SARS-CoV-2, thereby preventing SARS-CoV-2 infection. These findings suggest proteins other than "spike" proteins may be suitable targets for immunity and vaccine development.

The COVID-19 pandemic and cause of death

This article explores the emergence and development of Death Certificates as a means of establishing the cause of death for individuals and populations. The difficulty in choosing which disease caused death when several are described on the Certificate explains why the number of COVID-19-related deaths has been difficult to determine. This problem also draws attention to the dominant biomedical explanation for the cause of death that both promote and circumscribe what can be recognised as a valid cause.

Sex-Related Differences in Clinical Presentation and Risk Factors for Mortality in Patients Hospitalized With Coronavirus Disease 2019 in New York City

We evaluated sex-related differences in symptoms and risk factors for mortality in 4798 patients hospitalized with coronavirus disease 2019 in New York City. When adjusted for age and comorbidities, being male was an independent predictor of death with mortality significantly higher than females, even with low severe acute respiratory syndrome coronavirus 2 viral load at admission.

Spatiotemporal Associations Between Social Vulnerability, Environmental Measurements, and COVID-19 in the Conterminous United States

This study summarizes the results from fitting a Bayesian hierarchical spatiotemporal model to coronavirus disease 2019 (COVID-19) cases and deaths at the county level in the United States for the year 2020. Two models were created, one for cases and one for deaths, utilizing a scaled Besag, York, Mollié model with Type I spatial-temporal interaction. Each model accounts for 16 social vulnerability and 7 environmental variables as fixed effects. The spatial pattern between COVID-19 cases and deaths is significantly different in many ways. The spatiotemporal trend of the pandemic in the United States illustrates a shift out of many of the major metropolitan areas into the United States Southeast and Southwest during the summer months and into the upper Midwest beginning in autumn. Analysis of the major social vulnerability predictors of COVID-19 infection and death found that counties with higher percentages of those not having a high school diploma, having non-White status and being Age 65 and over to be significant. Among the environmental variables, above ground level temperature had the strongest effect on relative risk to both cases and deaths. Hot and cold spots, areas of statistically significant high and low COVID-19 cases and deaths respectively, derived from the convolutional spatial effect show that areas with a high probability of above average relative risk have significantly higher Social Vulnerability Index composite scores. The same analysis utilizing the spatiotemporal interaction term exemplifies a more complex relationship between social vulnerability, environmental measurements, COVID-19 cases, and COVID-19 deaths.

SARS-CoV-2 Initiates Programmed Cell Death in Platelets

Supplemental Digital Content is available in the text.

Coronavirus disease 2019 (COVID-19) is characterized by increased incidence of microthrombosis with hyperactive platelets sporadically containing viral RNA. It is unclear if SARS-CoV-2 (severe acute respiratory syndrome, corona virus-2) directly alters platelet activation or if these changes are a reaction to infection-mediated global inflammatory alterations. Importantly, the direct effect of SARS-CoV-2 on platelets has yet to be studied.

COVID-19: Perceived Infection Risk and Barriers to Uptake of Pfizer-BioNTech and Moderna Vaccines Among Community Healthcare Workers

BACKGROUND

The health and economic ramifications of the coronavirus pandemic have prompted the need for a timely and effective vaccine development. While the rollout of the COVID-19 vaccine in record time is being hailed as a scientific feat, skepticism about the safety, side effects, and even its long-term effects remain. Acceptance of the vaccine may therefore be a challenge among healthcare workers (HCWs), whose role is considered a proxy to determining the COVID-19 vaccine uptake response by the general population.

METHODS

In December 2020, prior to the arrival and receipt of the Pfizer-BioNTech and Moderna COVID-19 vaccine, we conducted a cross-sectional survey to assess the readiness for vaccine uptake among HCWs at three community-based, university-affiliated health centers.

RESULTS

A total of 205 (82%) respondents out of 250 completed the questionnaire. Fifty-four percent of respondents agreed to receive vaccine once available. Females (odds ratio (OR) =0.22, p=0.014), non-Hispanic Blacks (OR=0.066, p=0.010), and Hispanics (OR=0.11, p=0.037) were less likely to accept the vaccine. Respondents with moderate-risk perception were more likely to accept (OR=2.79, p=0.045) compared to those with low-risk perception while no association was found between high-risk perception and vaccine acceptance (p=0.226). After adjusting for perceived risk, sex, race/ethnicity, and age, acceptance in non-Hispanic Black population remained statistically significant (adjusted OR=0.07, p=0.014), with Hispanic (AOR=0.12, p=0.051) showing a trend.

CONCLUSIONS

Enthusiastic acceptance of the COVID-19 vaccine is lacking among surveyed HCWs of certain racial/ethnic groups. Provision of resources and public health interventions targeting underserved, minority populations are necessary to halt opposition to vaccine uptake.

The role of race and scientific trust on support for COVID-19 social distancing measures in the United States

Pundits and academics across disciplines note that the human toll brought forth by the novel coronavirus (COVID-19) pandemic in the United States (U.S.) is fundamentally unequal for communities of color. Standing literature on public health posits that one of the chief predictors of racial disparity in health outcomes is a lack of institutional trust among minority communities. Furthermore, in our own county-level analysis from the U.S., we find that counties with higher percentages of Black and Hispanic residents have had vastly higher cumulative deaths from COVID-19. In light of this standing literature and our own analysis, it is critical to better understand how to mitigate or prevent these unequal outcomes for any future pandemic or public health emergency. Therefore, we assess the claim that raising institutional trust, primarily scientific trust, is key to mitigating these racial inequities. Leveraging a new, pre-pandemic measure of scientific trust, we find that trust in science, unlike trust in politicians or the media, significantly raises support for COVID-19 social distancing policies across racial lines. Our findings suggest that increasing scientific trust is essential to garnering support for public health policies that lessen the severity of the current, and potentially a future, pandemic.

Mortality Associated with Idiopathic Pulmonary Fibrosis in Northeastern Italy, 2008-2020: A Multiple Cause of Death Analysis

Mortality from idiopathic pulmonary fibrosis (IPF) is increasing in most European countries, but there are no data for Italy. We analysed the registry data from a region in northeastern Italy to assess the trends in IPF-related mortality during 2008–2019, to compare results of underlying vs. multiple cause of death analyses, and to describe the impact of the COVID-19 epidemic in 2020. We identified IPF (ICD-10 code J84.1) among the causes of death registered in 557,932 certificates in the Veneto region. We assessed time trends in annual age-standardized mortality rates by gender and age (40–74, 75–84, and ≥85 years). IPF was the underlying cause of 1310 deaths in the 2251 certificates mentioning IPF. For all age groups combined, the age-standardized mortality rate from IPF identified as the underlying cause of death was close to the European median (males and females: 3.1 and 1.3 per 100,000/year, respectively). During 2008–2019, mortality rates increased in men aged ≥85 years (annual percent change of 6.5%, 95% CI: 2.0, 11.2%), but not among women or for the younger age groups. A 72% excess of IPF-related deaths was registered in March–April 2020 (mortality ratio 1.72, 95% CI: 1.29, 2.24). IPF mortality was increasing among older men in northeastern Italy. The burden of IPF was heavier than assessed by routine statistics, since less than two out of three IPF-related deaths were directly attributed to this condition. COVID-19 was accompanied by a remarkable increase in IPF-related mortality.

Estimation of delay-adjusted all-cause excess mortality in the USA: March-December 2020

We estimate the delay-adjusted all-cause excess deaths across 53 US jurisdictions. Using provisional data collected from September through December 2020, we first identify a common mean reporting delay of 2.8 weeks, whereas four jurisdictions have prolonged reporting delays compared to the others: Connecticut (mean 5.8 weeks), North Carolina (mean 10.4 weeks), Puerto Rico (mean 4.7 weeks) and West Virginia (mean 5.5 weeks). After adjusting for reporting delays, we estimate the percent change in all-cause excess mortality from March to December 2020 with range from 0.2 to 3.6 in Hawaii to 58.4 to 62.4 in New York City. Comparing the March-December with September-December 2020 periods, the highest increases in excess mortality are observed in South Dakota (36.9-54.0), North Dakota (33.9-50.7) and Missouri (27.8-33.9). Our findings indicate that analysis of provisional data requires caution in interpreting the death counts in recent weeks, while one needs also to account for heterogeneity in reporting delays of excess deaths among US jurisdictions.

COVID-19 mortality among kidney transplant candidates is strongly associated with social determinants of health

The COVID-19 pandemic has affected all portions of the global population. However, many factors have been shown to be particularly associated with COVID-19 mortality including demographic characteristics, behavior, comorbidities, and social conditions. Kidney transplant candidates may be particularly vulnerable to COVID-19 as many are dialysis-dependent and have comorbid conditions. We examined factors associated with COVID-19 mortality among kidney transplant candidates from the National Scientific Registry of Transplant Recipients from March 1 to December 1, 2020. We evaluated crude rates and multivariable incident rate ratios (IRR) of COVID-19 mortality. There were 131 659 candidates during the study period with 3534 all-cause deaths and 384 denoted a COVID-19 cause (5.00/1000 person years). Factors associated with increased COVID-19 mortality included increased age, males, higher body mass index, and diabetes. In addition, Blacks (IRR = 1.96, 95% C.I.: 1.43-2.69) and Hispanics (IRR = 3.38, 95% C.I.: 2.46-4.66) had higher COVID-19 mortality relative to Whites. Patients with lower educational attainment, high school or less (IRR = 1.93, 95% C.I.: 1.19-3.12, relative to post-graduate), Medicaid insurance (IRR = 1.73, 95% C.I.: 1.26-2.39, relative to private), residence in most distressed neighborhoods (fifth quintile IRR = 1.93, 95% C.I.: 1.28-2.90, relative to first quintile), and most urban and most rural had higher adjusted rates of COVID-19 mortality. Among kidney transplant candidates in the United States, social determinants of health in addition to demographic and clinical factors are significantly associated with COVID-19 mortality.

Benchmarking SARS CoV-2 Infection in the Workplace to Support Continuity of Operations

OBJECTIVE

The COVID-19 pandemic jeopardizes continuity of operations of workplaces and the health and safety of workers. Exemplar workplace-related SARS-CoV-2 benchmarks are described and illustrated with empirical data.

METHODS

Benchmarks were collected over a 9-month period on a large workplace (N = 5500+). These ranged from quantitative indices associated with RT-qPCR targeted testing and random surveillance screening, surveillance for new variants of SARS-CoV-2, intensive contact tracing, case management, return to work procedures, to monitoring of antibody seropositive status.

RESULTS

Data and analyses substantiated effectiveness of interventions. This was evidenced in suppressed infection rates, rapid case identification and isolation, acceptance of the program by employees, documentation of presumptive immunity, and working relationships with senior management.

CONCLUSIONS

These SARS-CoV-2 exemplar benchmarks provided an evidence-base for practice and contributed strategically to organizational decisions.

Greenspace exposure and COVID-19 mortality in the United States: January-July 2020

BACKGROUND

Mortality from the novel coronavirus disease-2019 (COVID-19) continues to rise across the United States. Evidence is emerging that environmental factors may contribute to susceptibility to disease and mortality. Greenspace exposure promotes enhanced immunity and may protect against risk of mortality among those with COVID-19.

OBJECTIVES

Our objective was to determine if high county level greenspace exposure is associated with reduced risk of COVID-19 mortality.

METHODS

Greenspace exposure was characterized in 3049 counties across the conterminous United States using Leaf Area Index (LAI) deciles that were derived from satellite imagery via Moderate Resolution Imaging Spectroradiometer from 2011 to 2015. COVID-19 mortality data were obtained from the Center for Systems Science and Engineering at Johns Hopkins University. We used a generalized linear mixed model to evaluate the association between county level LAI and COVID-19 mortality rate in analyses adjusted for 2015-2019 county level average total county population, older population, race, overcrowding in home, Medicaid, education, and physical inactivity.

RESULTS

A dose-response association was found between greenness and reduced risk of COVID-19 mortality. COVID-19 mortality was negatively associated with LAI deciles 8 [MRR = 0.82 (95% CI: 0.72, 0.93)], 9 [MRR = 0.78 (95% CI: 0.68, 0.89)], and 10 [MRR = 0.59 (95% CI: 0.50, 0.69)]. Aside from LAI decile 5, no associations were found between the remaining LAI deciles and COVID-19 mortality. Increasing prevalence of counties with older age residents, low education attainment, Native Americans, Black Americans, and housing overcrowding were significantly associated with increased risk of COVID-19 mortality, whereas Medicaid prevalence was associated with a reduced risk.

DISCUSSION

Counties with a higher amount of greenspace may be at a reduced risk of experiencing mortality due to COVID-19.

Beyond COVID-19 deaths during the COVID-19 pandemic in the United States

COVID-19 has disrupted society and health care systems, creating a fertile environment for deaths beyond the virus. The year 2020 will prove to be the most deadly year on record in the United States. Direct deaths due to COVID-19 have been well documented and reported. Older people (those over 65) have been hardest hit, with over 80% of the COVID-19 deaths in this age group. What has been less clear is the impact on those under 65 years old, particularly those under 44 years old. This study considers both COVID-19 deaths and non-COVID-19 deaths during a 39 weeks period beginning 1 March in both 2020 and averaged over the five years from 2015 to 2019. Across 22 age and gender cohorts, death risks are compared using odds ratios. The results indicate that younger people (those under 15 years old) have experienced the same or a reduction in death risk between 2020 and the average from 2015 to 2019, suggesting that societal changes were protective for some of them. With all COVID-19 deaths removed from the 2020 death counts, 15-64 year olds experienced increased death risk between 2020 and the 2015 to 2019 average. For example, 15-44 year old males experienced a significant increase in their death risk, even though the absolute number of COVID-19 deaths for this cohort is small. The key take away from this study is that COVID-19 resulted in a large number of additional deaths in 2020 compared to the average from 2015 to 2019, both directly from the virus and indirectly due to societal responses to the virus.

COVID-19 imaging: Diagnostic approaches, challenges, and evolving advances

The role of radiology and the radiologist have evolved throughout the coronavirus disease-2019 (COVID-19) pandemic. Early on, chest computed tomography was used for screening and diagnosis of COVID-19; however, it is now indicated for high-risk patients, those with severe disease, or in areas where polymerase chain reaction testing is sparsely available. Chest radiography is now utilized mainly for monitoring disease progression in hospitalized patients showing signs of worsening clinical status. Additionally, many challenges at the operational level have been overcome within the field of radiology throughout the COVID-19 pandemic. The use of teleradiology and virtual care clinics greatly enhanced our ability to socially distance and both are likely to remain important mediums for diagnostic imaging delivery and patient care. Opportunities to better utilize of imaging for detection of extrapulmonary manifestations and complications of COVID-19 disease will continue to arise as a more detailed understanding of the pathophysiology of the virus continues to be uncovered and identification of predisposing risk factors for complication development continue to be better understood. Furthermore, unidentified advancements in areas such as standardized imaging reporting, point-of-care ultrasound, and artificial intelligence offer exciting discovery pathways that will inevitably lead to improved care for patients with COVID-19.

Effect of the covid-19 pandemic in 2020 on life expectancy across populations in the USA and other high income countries: simulations of provisional mortality data

OBJECTIVE

To estimate changes in life expectancy in 2010-18 and during the covid-19 pandemic in 2020 across population groups in the United States and to compare outcomes with peer nations.

DESIGN

Simulations of provisional mortality data.

SETTING

US and 16 other high income countries in 2010-18 and 2020, by sex, including an analysis of US outcomes by race and ethnicity.

POPULATION

Data for the US and for 16 other high income countries from the National Center for Health Statistics and the Human Mortality Database, respectively.

MAIN OUTCOME MEASURES

Life expectancy at birth, and at ages 25 and 65, by sex, and, in the US only, by race and ethnicity. Analysis excluded 2019 because life table data were not available for many peer countries. Life expectancy in 2020 was estimated by simulating life tables from estimated age specific mortality rates in 2020 and allowing for 10% random error. Estimates for 2020 are reported as medians with fifth and 95th centiles.

RESULTS

Between 2010 and 2018, the gap in life expectancy between the US and the peer country average increased from 1.88 years (78.66 v 80.54 years, respectively) to 3.05 years (78.74 v 81.78 years). Between 2018 and 2020, life expectancy in the US decreased by 1.87 years (to 76.87 years), 8.5 times the average decrease in peer countries (0.22 years), widening the gap to 4.69 years. Life expectancy in the US decreased disproportionately among racial and ethnic minority groups between 2018 and 2020, declining by 3.88, 3.25, and 1.36 years in Hispanic, non-Hispanic Black, and non-Hispanic White populations, respectively. In Hispanic and non-Hispanic Black populations, reductions in life expectancy were 18 and 15 times the average in peer countries, respectively. Progress since 2010 in reducing the gap in life expectancy in the US between Black and White people was erased in 2018-20; life expectancy in Black men reached its lowest level since 1998 (67.73 years), and the longstanding Hispanic life expectancy advantage almost disappeared.

CONCLUSIONS

The US had a much larger decrease in life expectancy between 2018 and 2020 than other high income nations, with pronounced losses among the Hispanic and non-Hispanic Black populations. A longstanding and widening US health disadvantage, high death rates in 2020, and continued inequitable effects on racial and ethnic minority groups are likely the products of longstanding policy choices and systemic racism.