The WHO estimates of excess mortality associated with the COVID-19 pandemic

Demographic Analysis of Cancer Research Priorities and Treatment Correlations

Understanding the diversity in cancer research priorities and the correlations among different treatment modalities is essential to address the evolving landscape of oncology. This study, conducted in collaboration with the European Cancer Patient Coalition (ECPC) and Childhood Cancer International-Europe (CCI-E) as part of the "UNCAN.eu" initiative, analyzed data from a comprehensive survey to explore the complex interplay of demographics, time since cancer diagnosis, and types of treatments received. Demographic analysis revealed intriguing trends, highlighting the importance of tailoring cancer research efforts to specific age groups and genders. Individuals aged 45-69 exhibited highly aligned research priorities, emphasizing the need to address the unique concerns of middle-aged and older populations. In contrast, patients over 70 years demonstrated a divergence in research priorities, underscoring the importance of recognising the distinct needs of older individuals in cancer research. The analysis of correlations among different types of cancer treatments underscored the multidisciplinary approach to cancer care, with surgery, radiotherapy, chemotherapy, precision therapy, and biological therapies playing integral roles. These findings support the need for personalized and combined treatment strategies to achieve optimal outcomes. In conclusion, this study provides valuable insights into the complexity of cancer research priorities and treatment correlations in a European context. It emphasizes the importance of a multifaceted, patient-centred approach to cancer research and treatment, highlighting the need for ongoing support, adaptation, and collaboration to address the ever-changing landscape of oncology.

Alignment of Canada's COVID-19 policy response with barriers and facilitators for coping reported by caregivers of youth with developmental delays, disorders, and disabilities

Introduction

The UNICEF-WHO Global Report on Developmental Delays, Disorders, and Disabilities is an ongoing initiative aimed at increasing awareness, compiling data, providing guidance on strengthening health systems, and engaging country-level partners. Data from its caregiver survey assessing impacts of the COVID-19 pandemic showed that half of youths with developmental delays and disabilities (DDDs) and their caregivers struggled to cope, with a significant portion reporting a lack of supports and difficulty managing the worsening of the child's symptoms in isolation. Governments created service strategies supporting vulnerable groups. Little is known about the alignment between COVID-19 policies for persons with disabilities and their lived experiences. Contextualizing caregivers' experiences can promote the development of tailored public supports for these families following a public health crisis.

Methods

Online survey data were collected from June-July 2020, leading to a convenience sample of caregivers of youth with DDDs across Canada. Respondents answered two open-ended questions regarding challenges and coping strategies during the pandemic. We conducted a thematic analysis of responses using inductive coding on NVivo software. Overarching codes derived from the dataset were contextualized using an analysis of provincial policies published during the pandemic. Parallels with these policies supported the exploration of families' and youths' experiences during the same period.

Results

Five hundred and seventy-six (N = 576) participants answered open-ended questions. Barriers to coping included family mental health issues, concerns about the youths' regression, challenges in online schooling, limited play spaces, and managing physical health during quarantine. Environmental barriers encompassed deteriorating family finances, loss of public services, and a lack of accessible information and supports. In contrast, caregivers reported coping facilitators, such as family time, outdoor activities, and their child's resilience. Environmental facilitators included community resources, public financial supports, and access to telehealth services. Few COVID-19 policies effectively addressed caregiver-identified barriers, while some restrictions hindered access to facilitators.

Conclusion

Prioritizing needs of families of youths with DDDs during public health emergencies can significantly impact their experiences and mental health. Enhancing financial benefits, providing telehealth services, and creating inclusive public play spaces are priority areas as we navigate the post-pandemic landscape.

How does the SARS-CoV-2 reinfection rate change over time? The global evidence from systematic review and meta-analysis

BACKGROUND

There is a significant increase in the number of SARS-CoV-2 reinfection reports in various countries. However, the trend of reinfection rate over time is not clear.

METHODS

We searched PubMed, Web of Science, Medline, Embase, Cochrane Central Register of Controlled Trials, China National Knowledge Infrastructure, and Wanfang for cohort studies, case-control studies, and cross-sectional studies up to March 16, 2023, to conduct a meta-analysis of global SARS-CoV-2 reinfection rate. Subgroup analyses were performed for age, country, study type, and study population, and time-varying reinfection rates of SARS-CoV-2 were estimated using meta-regression. The risk of bias was assessed using the Newcastle-Ottawa Scale and the Joanna Briggs Institute critical appraisal tool.

RESULT

A total of 55 studies involving 111,846 cases of SARS-CoV-2 reinfection were included. The pooled SARS-CoV-2 reinfection rate was 0.94% (95% CI: 0.65 -1.35%). In the subgroup analyses, there were statistically significant differences in the pooled reinfection rates by reinfection variant, and study type (P < 0.05). Based on meta-regression, the reinfection rate fluctuated with time.

CONCLUSION

Meta-regression analysis found that the overall reinfection rate increased and then decreased over time, followed by a period of plateauing and then a trend of increasing and then decreasing, but the peak of the second wave of reinfection rate was lower than the first wave. SARS-CoV-2 is at risk of reinfection and the Omicron variant has a higher reinfection rate than other currently known variants. The results of this study could help guide public health measures and vaccination strategies in response to the Coronavirus Disease 2019 (COVID-19) pandemic.

The association between high mobility group box 1 (HMGB1) and Interleukin-18 (IL-18) serum concentrations in COVID-19 inpatients

Background

High mobility group box 1 (HMGB1) and interleukin-18 (IL-18) are involved in various non-coronavirus disease pathogenesis and are reported as potential biomarkers for coronavirus disease (COVID-19). However, their association with COVID-19 pathogenesis has not yet been explored.

Aim

This study aimed to investigate the association between HMGB1 and IL-18 concentrations in the sera of COVID-19 patients versus non-COVID-19 patients.

Material and methods

We used stored serum samples obtained from 30 COVID-19 patients and 30 non-COVID-19 patients. We collected data on age, gender, treatment status, principal diagnosis, and comorbidity from patient medical records. HMGB1 and IL-18 concentrations were analyzed in the serum by enzyme-linked immunosorbent assay (ELISA). The swab samples' RT-PCR cycle threshold (CT) values were obtained from the laboratory database.

Results

HMGB1 concentrations were increased in the COVID-19 inpatients and non-COVID-19 inpatients compared to non-COVID-19 outpatients (COVID-19 inpatients vs. non-COVID-19 outpatients: 151.33 (90.27-192.38) vs. 80.75 (54.16-128.72) ng/ml; p = 0.0316; non-COVID-19 inpatients vs. non-COVID-19 outpatients: 152.66 (104.04-288.51) vs. 80.75 (54.16-128.72) ng/ml; p = 0.0199). IL-18 concentrations were also higher in the COVID-19 inpatients and non-COVID-19 inpatients compared to non-COVID-19 outpatients (COVID-19 inpatients vs. non-COVID-19 outpatients: 620.00 (461.50-849.6) vs. 403.10 (372.70-556.90) pg/ml; p = 0.0376; non-COVID-19 inpatients vs. non-COVID-19 outpatients: 835.70 (558.30-1602.00) vs. 403.10 (372.70-556.90) pg/ml; p = 0.0026). Moreover, HMGB1 was associated with IL-18 concentrations in the sera of COVID-19 inpatients (p = 0.0337; r = 0.5500).

Conclusion

The association of HMGB1 and IL-18 in COVID-19 might indicate the potential for a dangerous cycle leading to a cytokine storm to occur.

Systems-wide view of host-pathogen interactions across COVID-19 severities using integrated omics analysis

The mechanisms explaining the variability in COVID-19 clinical manifestations (mild, moderate, and severe) are not fully understood. To identify key gene expression markers linked to disease severity, we employed an integrated approach, combining host-pathogen protein-protein interaction data and viral-induced host gene expression data. We analyzed an RNA-seq dataset from peripheral blood mononuclear cells across 12 projects representing the spectrum of disease severity. We identified genes showing differential expression across mild, moderate, and severe conditions. Enrichment analysis of the pathways in host proteins targeted by each of the SARS-CoV-2 proteins revealed a strong association with processes related to ribosomal biogenesis, translation, and translocation. Interestingly, most of these pathways and associated cellular machinery, including ribosomal biogenesis, ribosomal proteins, and translation, were upregulated in mild conditions but downregulated in severe cases. This suggests that COVID-19 exhibits a paradoxical host response, boosting host/viral translation in mild cases but slowing it in severe cases.

Kernel Bayesian nonlinear matrix factorization based on variational inference for human-virus protein-protein interaction prediction

Identification of potential human-virus protein-protein interactions (PPIs) contributes to the understanding of the mechanisms of viral infection and to the development of antiviral drugs. Existing computational models often have more hyperparameters that need to be adjusted manually, which limits their computational efficiency and generalization ability. Based on this, this study proposes a kernel Bayesian logistic matrix decomposition model with automatic rank determination, VKBNMF, for the prediction of human-virus PPIs. VKBNMF introduces auxiliary information into the logistic matrix decomposition and sets the prior probabilities of the latent variables to build a Bayesian framework for automatic parameter search. In addition, we construct the variational inference framework of VKBNMF to ensure the solution efficiency. The experimental results show that for the scenarios of paired PPIs, VKBNMF achieves an average AUPR of 0.9101, 0.9316, 0.8727, and 0.9517 on the four benchmark datasets, respectively, and for the scenarios of new human (viral) proteins, VKBNMF still achieves a higher hit rate. The case study also further demonstrated that VKBNMF can be used as an effective tool for the prediction of human-virus PPIs.

The SARS coronavirus accessory protein ORF3a rescues potassium conductance in yeast

ORF3a is an accessory protein expressed by all human pathogen coronaviruses and is the only accessory protein that strongly affects viral fitness. Its deletion reduces severity in both alpha- and beta-coronaviruses, demonstrating a conserved function across the superfamily. Initially regarded as a non-selective cation channel, ORF3a's function is now disputed. Here, we show that ORF3a from SARS, but not SARS-CoV-2, promotes potassium conductance in a yeast model system commonly used to study potassium channels. ORF3a-mediated potassium conductance is also sensitive to inhibitors, including emodin, carbamazepine, and nifedipine. This model may be used in future studies on ORF3a and related proteins.

National COVID-19 preparedness and response plans: a global review from the perspective of services for maternal, newborn, child and adolescent health and older people

INTRODUCTION

Infectious disease outbreaks have historically led to widespread disruptions in routine essential health services. Disruptions due to COVID-19 responses led to excess deaths, including among women and children. This review builds on earlier reviews of essential health services in national COVID-19 response and preparedness plans, focusing specifically on maternal, newborn, child, adolescent and ageing health (MNCAAH) in the context of renewed global emphasis on monitoring, recovering and strengthening these services.

METHODS

Using Google searches, we identified publicly available COVID-19 response and preparedness plans authored by a national government body or Public Health Institute from any country, territory and/or area, published between January 2020 and December 2022. We assessed whether each plan considered maintenance of MNCAAH services with related activities, costing or monitoring plans, and whether these considerations were integrated into the national incident management system for COVID-19.

RESULTS

We identified plans from 110 countries, representing 56% of our sample, in 10 languages. Most plans came from low-income and middle-income countries. Three quarters of dated documents were published between February and April 2020. 22% of plans referenced the impact of COVID-19 on MNCAAH, but only 13% included a planned activity for monitoring or mitigating this impact and less than 5% included relevant indicators, costing or integration of services in the incident management system.

CONCLUSION

We propose that unless content specifically related to the services and needs of these populations is integrated, these services will suffer in a future disruptive event. The COVID-19 response demonstrated the need for an interdisciplinary response to address the unforeseen impacts that arose, yet plans continue to have a narrow focus and a generic approach which may be limiting.

Pediatric and adult patients with ME/CFS following COVID-19: A structured approach to diagnosis using the Munich Berlin Symptom Questionnaire (MBSQ)

A subset of patients with post-COVID-19 condition (PCC) fulfill the clinical criteria of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). To establish the diagnosis of ME/CFS for clinical and research purposes, comprehensive scores have to be evaluated. We developed the Munich Berlin Symptom Questionnaires (MBSQs) and supplementary scoring sheets (SSSs) to allow for a rapid evaluation of common ME/CFS case definitions. The MBSQs were applied to young patients with chronic fatigue and post-exertional malaise (PEM) who presented to the MRI Chronic Fatigue Center for Young People (MCFC). Trials were retrospectively registered (NCT05778006, NCT05638724). Using the MBSQs and SSSs, we report on ten patients aged 11 to 25 years diagnosed with ME/CFS after asymptomatic SARS-CoV-2 infection or mild to moderate COVID-19. Results from their MBSQs and from well-established patient-reported outcome measures indicated severe impairments of daily activities and health-related quality of life.    Conclusions: ME/CFS can follow SARS-CoV-2 infection in patients younger than 18 years, rendering structured diagnostic approaches most relevant for pediatric PCC clinics. The MBSQs and SSSs represent novel diagnostic tools that can facilitate the diagnosis of ME/CFS in children, adolescents, and adults with PCC and other post-infection or post-vaccination syndromes. What is Known: • ME/CFS is a debilitating disease with increasing prevalence due to COVID-19. For diagnosis, a differential diagnostic workup is required, including the evaluation of clinical ME/CFS criteria. • ME/CFS after COVID-19 has been reported in adults but not in pediatric patients younger than 19 years. What is New: • We present the novel Munich Berlin Symptom Questionnaires (MBSQs) as diagnostic tools to assess common ME/CFS case definitions in pediatric and adult patients with post-COVID-19 condition and beyond. • Using the MBSQs, we diagnosed ten patients aged 11 to 25 years with ME/CFS after asymptomatic SARS-CoV-2 infection or mild to moderate COVID-19.

Modularized viromimetic polymer nanoparticle vaccines (VPNVaxs) to elicit durable and effective humoral immune responses

Virus-like particle (VLP) vaccines had shown great potential during the COVID-19 pandemic, and was thought to be the next generation of antiviral vaccine technology due to viromimetic structures. However, the time-consuming and complicated processes in establishing a current recombinant-protein-based VLP vaccine has limited its quick launch to the out-bursting pandemic. To simplify and optimize VLP vaccine design, we herein report a kind of viromimetic polymer nanoparticle vaccine (VPNVax), with subunit receptor-binding domain (RBD) proteins conjugated to the surface of polyethylene glycol-b-polylactic acid (PEG-b-PLA) nanoparticles for vaccination against SARS-CoV-2. The preparation of VPNVax based on synthetic polymer particle and chemical post-conjugation makes it possible to rapidly replace the antigens and construct matched vaccines at the emergence of different viruses. Using this modular preparation system, we identified that VPNVax with surface protein coverage of 20%-25% had the best immunostimulatory activity, which could keep high levels of specific antibody titers over 5 months and induce virus neutralizing activity when combined with an aluminum adjuvant. Moreover, the polymer nano-vectors could be armed with more immune-adjuvant functions by loading immunostimulant agents or chemical chirality design. This VPNVax platform provides a novel kind of rapidly producing and efficient vaccine against different variants of SARS-CoV-2 as well as other viral pandemics.

Excess Deaths During the COVID-19 Pandemic in Southern Iran: Estimating the Absolute Count and Relative Risk Using Ecological Data

OBJECTIVES

The coronavirus disease 2019 (COVID-19) pandemic led to increased mortality rates. To assess this impact, this ecological study aimed to estimate the excess death counts in southern Iran.

METHODS

The study obtained weekly death counts by linking the National Death Registry and Medical Care Monitoring Center repositories. The P-score was initially estimated using a simple method that involved calculating the difference between the observed and expected death counts. The interrupted time series analysis was then used to calculate the mean relative risk (RR) of death during the first year of the pandemic.

RESULTS

Our study found that there were 5571 excess deaths from all causes (P-score=33.29%) during the first year of the COVID-19 pandemic, with 48.03% of these deaths directly related to COVID-19. The pandemic was found to increase the risk of death from all causes (RR, 1.26; 95% confidence interval [CI], 1.19 to 1.33), as well as in specific age groups such as those aged 35-49 (RR, 1.21; 95% CI, 1.12 to 1.32), 50-64 (RR, 1.38; 95% CI, 1.28 to 1.49), and ≥65 (RR, 1.29; 95% CI, 1.12 to 1.32) years old. Furthermore, there was an increased risk of death from cardiovascular diseases (RR, 1.17; 95% CI, 1.11 to 1.22).

CONCLUSIONS

There was a 26% increase in the death count in southern Iran during the COVID-19 pandemic. More than half of these excess deaths were not directly related to COVID-19, but rather other causes, with cardiovascular diseases being a major contributor.

COVID-19 immune signatures in Uganda persist in HIV co-infection and diverge by pandemic phase

Little is known about the pathobiology of SARS-CoV-2 infection in sub-Saharan Africa, where severe COVID-19 fatality rates are among the highest in the world and the immunological landscape is unique. In a prospective cohort study of 306 adults encompassing the entire clinical spectrum of SARS-CoV-2 infection in Uganda, we profile the peripheral blood proteome and transcriptome to characterize the immunopathology of COVID-19 across multiple phases of the pandemic. Beyond the prognostic importance of myeloid cell-driven immune activation and lymphopenia, we show that multifaceted impairment of host protein synthesis and redox imbalance define core biological signatures of severe COVID-19, with central roles for IL-7, IL-15, and lymphotoxin-α in COVID-19 respiratory failure. While prognostic signatures are generally consistent in SARS-CoV-2/HIV-coinfection, type I interferon responses uniquely scale with COVID-19 severity in persons living with HIV. Throughout the pandemic, COVID-19 severity peaked during phases dominated by A.23/A.23.1 and Delta B.1.617.2/AY variants. Independent of clinical severity, Delta phase COVID-19 is distinguished by exaggerated pro-inflammatory myeloid cell and inflammasome activation, NK and CD8+ T cell depletion, and impaired host protein synthesis. Combining these analyses with a contemporary Ugandan cohort of adults hospitalized with influenza and other severe acute respiratory infections, we show that activation of epidermal and platelet-derived growth factor pathways are distinct features of COVID-19, deepening translational understanding of mechanisms potentially underlying SARS-CoV-2-associated pulmonary fibrosis. Collectively, our findings provide biological rationale for use of broad and targeted immunotherapies for severe COVID-19 in sub-Saharan Africa, illustrate the relevance of local viral and host factors to SARS-CoV-2 immunopathology, and highlight underemphasized yet therapeutically exploitable immune pathways driving COVID-19 severity.

Inequalities in regional excess mortality and life expectancy during the COVID-19 pandemic in Europe

Using data for 201 regions (NUTS 2) in Europe, we examine the mortality burden of the COVID-19 pandemic and how the mortality inequalities between regions changed between 2020 and 2022. We show that over the three years of the pandemic, not only did the level of excess mortality rate change considerably, but also its geographical distribution. Focusing on life expectancy as a summary measure of mortality conditions, we find that the variance of regional life expectancy increased sharply in 2021 but returned to the pre-pandemic level in 2022. The 2021 increase was due to a much higher-than-average excess mortality in regions with lower pre-pandemic life expectancy. While the life expectancy inequality has returned to its pre-pandemic level in 2022, the observed life expectancy in almost all regions is far below that expected without the pandemic.

Efficacy of Host Cell Serine Protease Inhibitor MM3122 against SARS-CoV-2 for Treatment and Prevention of COVID-19

We have developed a novel class of peptidomimetic inhibitors targeting several host cell human serine proteases including transmembrane protease serine 2 (TMPRSS2), matriptase and hepsin. TMPRSS2 is a membrane associated protease which is highly expressed in the upper and lower respiratory tract and is utilized by SARS-CoV-2 and other viruses to proteolytically process their glycoproteins, enabling host cell receptor binding, entry, replication, and dissemination of new virion particles. We have previously shown that compound MM3122 exhibited sub nanomolar potency against all three proteases and displayed potent antiviral effects against SARS-CoV-2 in a cell-viability assay. Herein, we demonstrate that MM3122 potently inhibits viral replication in human lung epithelial cells and is also effective against the EG.5.1 variant of SARS-CoV-2. Further, we have evaluated MM3122 in a mouse model of COVID-19 and have demonstrated that MM3122 administered intraperitoneally (IP) before (prophylactic) or after (therapeutic) SARS-CoV-2 infection had significant protective effects against weight loss and lung congestion, and reduced pathology. Amelioration of COVID-19 disease was associated with a reduction in pro-inflammatory cytokines and chemokines production after SARS-CoV-2 infection. Prophylactic, but not therapeutic, administration of MM3122 also reduced virus titers in the lungs of SARS-CoV-2 infected mice. Therefore, MM3122 is a promising lead candidate small molecule drug for the treatment and prevention of infections caused by SARS-CoV-2 and other coronaviruses.

IMPORTANCE

SARS-CoV-2 and other emerging RNA coronaviruses are a present and future threat in causing widespread endemic and pandemic infection and disease. In this paper, we have shown that the novel host-cell protease inhibitor, MM3122, blocks SARS-CoV-2 viral replication and is efficacious as both a prophylactic and therapeutic drug for the treatment of COVID-19 in mice. Targeting host proteins and pathways in antiviral therapy is an underexplored area of research but this approach promises to avoid drug resistance by the virus, which is common in current antiviral treatments.

Assessing the heterogeneity of the impact of COVID-19 incidence on all-cause excess mortality among healthcare districts in Lombardy, Italy, to evaluate the local response to the pandemic: an ecological study

OBJECTIVES

The fragmentation of the response to the COVID-19 pandemic at national, regional and local levels is a possible source of variability in the impact of the pandemic on society. This study aims to assess how much of this variability affected the burden of COVID-19, measured in terms of all-cause 2020 excess mortality.

DESIGN

Ecological retrospective study.

SETTING

Lombardy region of Italy, 2015-2020.

OUTCOME MEASURES

We evaluated the relationship between the intensity of the epidemics and excess mortality, assessing the heterogeneity of this relationship across the 91 districts after adjusting for relevant confounders.

RESULTS

The epidemic intensity was quantified as the COVID-19 hospitalisations per 1000 inhabitants. Five confounders were identified through a directed acyclic graph: age distribution, population density, pro-capita gross domestic product, restriction policy and population mobility.Analyses were based on a negative binomial regression model with district-specific random effects. We found a strong, positive association between COVID-19 hospitalisations and 2020 excess mortality (p<0.001), estimating that an increase of one hospitalised COVID-19 patient per 1000 inhabitants resulted in a 15.5% increase in excess mortality. After adjusting for confounders, no district differed in terms of COVID-19-unrelated excess mortality from the average district. Minimal heterogeneity emerged in the district-specific relationships between COVID-19 hospitalisations and excess mortality (6 confidence intervals out of 91 did not cover the null value).

CONCLUSIONS

The homogeneous effect of the COVID-19 spread on the excess mortality in the Lombardy districts suggests that, despite the unprecedented conditions, the pandemic reactions did not result in health disparities in the region.

Non-COVID-19 hospitalization and mortality during the COVID-19 pandemic in Iran: a longitudinal assessment of 41 million people in 2019-2022

BACKGROUND

During a COVID-19 pandemic, it is imperative to investigate the outcomes of all non-COVID-19 diseases. This study determines hospital admissions and mortality rates related to non-COVID-19 diseases during the COVID-19 pandemic among 41 million Iranians.

METHOD

This nationwide retrospective study used data from the Iran Health Insurance Organization. From September 23, 2019, to Feb 19, 2022, there were four study periods: pre-pandemic (Sept 23-Feb 19, 2020), first peak (Mar 20-Apr 19, 2020), first year (Feb 20, 2020-Feb 18, 2021), and the second year (Feb 19, 2021-Feb 19, 2022) following the pandemic. Cause-specific hospital admission and in-hospital mortality are the main outcomes analyzed based on age and sex. Negative binomial regression was used to estimate the monthly adjusted Incidence Rate Ratio (IRR) to compare hospital admission rates in aggregated data. A logistic regression was used to estimate the monthly adjusted in-hospital mortality Odds Ratio (OR) for different pandemic periods.

RESULTS

During the study there were 6,522,114 non-COVID-19 hospital admissions and 139,679 deaths. Prior to the COVID-19 outbreak, the standardized hospital admission rate per million person-month was 7115.19, which decreased to 2856.35 during the first peak (IRR 0.40, [0.25-0.64]). In-hospital mortality also increased from 20.20 to 31.99 (OR 2.05, [1.97-2.13]). All age and sex groups had decreased admission rates, except for females at productive ages. Two years after the COVID-19 outbreak, the non-COVID-19 hospital admission rate (IRR 1.25, [1.13-1.40]) and mortality rate (OR 1.05, [1.04-1.07]) increased compared to the rates before the pandemic. The respiratory disease admission rate decreased in the first (IRR 0.23, [0.17-0.31]) and second years (IRR 0.35, [0.26-0.47] compared to the rate before the pandemic. There was a significant reduction in hospitalizations for pneumonia (IRR 0.30, [0.21-0.42]), influenza (IRR 0.04, [0.03-0.06]) and COPD (IRR 0.39, [0.23-0.65]) during the second year. There was a significant and continuous rise in the hematological admission rate during the study, reaching 186.99 per million person-month in the second year, reflecting an IRR of 2.84 [2.42-3.33] compared to the pre-pandemic period. The mortality rates of mental disorders (OR 2.15, [1.65-2.78]) and musculoskeletal (OR 1.48, [1.20-1.82), nervous system (OR 1.42, [1.26-1.60]), metabolic (OR 1.99, [1.80-2.19]) and circulatory diseases (OR 1.35, [1.31-1.39]) increased in the second year compare to pre-pandemic. Myocardial infarction (OR 1.33, [1.19-1.49]), heart failure (OR 1.59, [1.35-1.87]) and stroke (OR 1.35, [1.24-1.47]) showed an increase in mortality rates without changes in hospitalization.

CONCLUSIONS

In the era of COVID-19, the changes seem to have had a long-term effect on non-COVID-19 diseases. Countries should prepare for similar crises in the future to ensure medical services are not suspended.

Effectiveness and Respiratory Adverse Events Following Inactivated and mRNA COVID-19 Vaccines in Patients with COPD and Asthma: A Chinese Population-Based Study

INTRODUCTION

Effectiveness and respiratory adverse events following coronavirus disease-2019 (COVID-19) vaccines have not been well investigated in Chinese patients with chronic obstructive pulmonary disease (COPD) and asthma.

METHODS

Using electronic health care records in Hong Kong, we included adults with COPD or asthma or both and hospitalised for severe respiratory exacerbation in a self-controlled case series (SCCS) study between 23/02/2021 and 30/11/2022. Conditional Poisson regression models were used to estimate the incidence of outcomes within exposure periods (28 days after each dose) compared with baseline periods. Cox proportional hazard models evaluated vaccine effectiveness (VE) against COVID-related mortality, hospitalisation, and severe complications, including admission to intensive care units or ventilatory support. The VE assessment was based on vaccine types and the number of doses.

RESULTS

In the SCCS, 343 CoronaVac recipients and 212 BNT162b2 recipients were included. No increased risk of outcomes was observed within the exposure periods. In the cohort study, 108,423 and 83,323 patients received ≥ 2 doses of CoronaVac and BNT162b2, respectively. The VE (95% CI) against COVID-related mortality, hospitalisation, and severe complications after two-dose CoronaVac was 77% (74-80%), 18% (6-23%), and 29% (12-43%), respectively, while for the two-dose regimen of BNT162b2, it was 92% (91-94%), 33% (30-37%), and 57% (45-66%), respectively. Higher VE against COVID-related mortality, hospitalisation, and severe complications was found for the three-dose regimen of CoronaVac (94%, 40%, and 71%) and BNT162b2 (98%, 65%, and 83%). Administering a fourth dose of either vaccine showed additional reductions in COVID-related outcomes.

CONCLUSIONS

Among people with COPD and asthma, the COVID-19 vaccines CoronaVac and BNT162b2 did not increase severe exacerbations and achieved moderate-to-high effectiveness against COVID-related outcomes. COVID-19 vaccination remains essential and should be encouraged to protect this vulnerable population in future epidemic waves.

Excess suicides in Brazil during the first 2 years of the COVID-19 pandemic: Gender, regional and age group inequalities

BACKGROUND

While the COVID-19 pandemic's total impact on global mortality is uncertain, an estimated 15 million excess deaths occurred during the first two pandemic years, suggesting that a broad impact, since several causes of death showed a substantial rise.

AIMS

To estimate excess suicides in Brazil and evaluate differences within and between subgroups during the first 2 years of the COVID-19 pandemic.

METHOD

Based on suicide data from the mortality information system of the Brazilian Ministry of Health, the expected number of suicides was estimated by age group, gender, 4-month periods and regions through quasi-Poisson generalized additive models. Analyses were performed in R software and RStudio.

RESULTS

Between March 2020 and February 2022, 29,295 suicides were reported in Brazil, close to what would be expected (30,116; 95% Confidence Interval (95% CI): [28,009, 32,224]), albeit in males and females aged 30 to 59 years and 60 years and over, there were excess suicides in at least one of the six 4-month periods evaluated, especially in the second pandemic year. In the Southeast region, a 28% increase was observed in women 60 years and older during the second year. In the North region, suicide increased 23% and 32% among women aged 30 to 59 years during the first and second pandemic years, respectively. The Northeast region had a 16% excess in suicides among men aged 30 to 59 years and 61% among women 60 years old and older during the second pandemic year, reaching 83% in July to October 2021.

CONCLUSIONS

During the first 2 pandemic years, the pattern of suicides was not homogeneous in Brazil. There were substantial excess suicides in women aged 30 to 59 years from the North and Northeast, while among the elderly and men there was a consistent pattern in several four-month periods throughout Brazil.

What can we learn from historical pandemics? A systematic review of the literature

What are the insights from historical pandemics for policymaking today? We carry out a systematic review of the literature on the impact of pandemics that occurred since the Industrial Revolution and prior to Covid-19. Our literature searches were conducted between June 2020 and September 2023, with the final review encompassing 169 research papers selected for their relevance to understanding either the demographic or economic impact of pandemics. We include literature from across disciplines to maximise our knowledge base, finding many relevant articles in journals which would not normally be on the radar of social scientists. Our review identifies two gaps in the literature: (1) the need to study pandemics and their effects more collectively rather than looking at them in isolation; and (2) the need for more study of pandemics besides 1918 Spanish Influenza, especially milder pandemic episodes. These gaps are a consequence of academics working in silos, failing to draw on the skills and knowledge offered by other disciplines. Synthesising existing knowledge on pandemics in one place provides a basis upon which to identify the lessons in preparing for future catastrophic disease events.

Fragment-based screening targeting an open form of the SARS-CoV-2 main protease binding pocket

To identify starting points for therapeutics targeting SARS-CoV-2, the Paul Scherrer Institute and Idorsia decided to collaboratively perform an X-ray crystallographic fragment screen against its main protease. Fragment-based screening was carried out using crystals with a pronounced open conformation of the substrate-binding pocket. Of 631 soaked fragments, a total of 29 hits bound either in the active site (24 hits), a remote binding pocket (three hits) or at crystal-packing interfaces (two hits). Notably, two fragments with a pose that was sterically incompatible with a more occluded crystal form were identified. Two isatin-based electrophilic fragments bound covalently to the catalytic cysteine residue. The structures also revealed a surprisingly strong influence of the crystal form on the binding pose of three published fragments used as positive controls, with implications for fragment screening by crystallography.

Excess mortality among kidney transplant recipients: Impact of COVID-19-related deaths during the pandemic

BACKGROUND

Because COVID-19 has been associated with high lethality rates among kidney transplant recipients (KTR), but also with a severe disruption and delays in overall healthcare, this study aims to evaluate the excess mortality in the pandemic era among KTR in a high-volume Brazilian transplant center.

METHODS

This study used data from a single center that provides follow-up on all its transplant recipients. The population of interest included all the patients who were transplanted between August 31, 1983 and December 31, 2022 and who were live from January 1, 2014. Using the "AutoRegressive Integrated Moving Average" forecasting algorithm, the expected mortality for the pandemic era (2020-2022) was modeled from the pre-pandemic era (2014-2019).

RESULTS

There were 12 077 KTRs at risk of dying in the entire observation period. In the pre-pandemic era, there were 21 deaths per 1000 patients at risk. In the pandemic era, there were 1429 observed deaths (rate of 47 deaths per 1000 patients at risk) versus the expected 587 deaths, resulting in an absolute number of 842 excess deaths, or an observed-to-expected ratio of 2.4, or an absolute rate of 26 deaths in excess per 1000 patients at risk. The excess deaths exhibited a temporal pattern mirroring that of the surges in new cases and lethality rates of COVID-19. COVID-19-related deaths drove 94% of excess mortality in the pandemic era.

CONCLUSION

In this large cohort of KTR under centralized follow-up, more than twofold excess mortality was primarily driven by COVID-19-related deaths, highlighting the vulnerability of this population to the most severe presentation of SARS-CoV-2 infection.

All-cause excess mortality among end-stage renal disease (ESRD) patients during the COVID-19 pandemic in Thailand: a cross-sectional study from a national-level claims database

OBJECTIVES

COVID-19 infection increased nephrology-related risks and mortality rate among end-stage renal disease (ESRD) patients. The pandemic also disrupted essential healthcare services. We aim to explore all-cause excess mortality among ESRD patients who were members of the Universal Coverage Scheme (UCS), the largest public health insurance scheme in Thailand covering citizens who are not employed in the formal sector, including children and older persons.

DESIGN

A cross-sectional study.

SETTING

We retrieved the dataset from the UCS claims database-electronic health records used for processing healthcare expense claims from medical facilities of all UCS members. This database links mortality outcome to civil registration. We employed the WHO's excess mortality methodology using pre-pandemic data to estimate expected deaths during the pandemic period (March 2020 to August 2022).

PARTICIPANTS

This study included ESRD patients from across Thailand, covered by the UCS.

PRIMARY OUTCOME MEASURE

Excess deaths are the difference between predicted and reported deaths.

RESULTS

Over a 30-month period of the pandemic, the total number of all-cause excess deaths among ESRD patients was 4966 (male 1284; female 3682). The excess death per 100 000 ESRD patients was 3601 (male 2012; female 4969). The relative excess death was 5.7% of expected deaths (95% CI 1.7%, 10.0%). The excess deaths were highly concentrated among patients aged 65 and older.

CONCLUSION

ESRD patients are significantly more vulnerable to pandemic-related mortality than the general population. Health systems' capacity to contain the pandemic at varying virulence and maintain essential health services for ESRD patients might be related to the size of excess deaths at different periods. The observed excess deaths highlight the importance of established strategies to reduce all-cause mortality such as rapid vaccine rollout for ESRD patients and sustaining dialysis and other essential services for older patients and other high-risk groups.

Quercetin inhibits SARS-CoV-2 infection and prevents syncytium formation by cells co-expressing the viral spike protein and human ACE2

BACKGROUND

Several in silico studies have determined that quercetin, a plant flavonol, could bind with strong affinity and low free energy to SARS-CoV-2 proteins involved in viral entry and replication, suggesting it could block infection of human cells by the virus. In the present study, we examined the ex vivo ability of quercetin to inhibit of SARS-CoV-2 replication and explored the mechanisms of this inhibition.

METHODS

Green monkey kidney Vero E6 cells and in human colon carcinoma Caco-2 cells were infected with SARS-CoV-2 and incubated in presence of quercetin; the amount of replicated viral RNA was measured in spent media by RT-qPCR. Since the formation of syncytia is a mechanism of SARS-CoV-2 propagation, a syncytialization model was set up using human embryonic kidney HEK293 co-expressing SARS-CoV-2 Spike (S) protein and human angiotensin converting enzyme 2 (ACE2), [HEK293(S + ACE2) cells], to assess the effect of quercetin on this cytopathic event by microscopic imaging and protein immunoblotting.

RESULTS

Quercetin inhibited SARS-CoV-2 replication in Vero E6 cells and Caco-2 cells in a concentration-dependent manner with a half inhibitory concentration (IC50) of 166.6 and 145.2 µM, respectively. It also inhibited syncytialization of HEK293(S + ACE2) cells with an IC50 of 156.7 µM. Spike and ACE2 co-expression was associated with decreased expression, increased proteolytic processing of the S protein, and diminished production of the fusogenic S2' fragment of S. Furin, a proposed protease for this processing, was inhibited by quercetin in vitro with an IC50 of 116 µM.

CONCLUSION

These findings suggest that at low 3-digit micromolar concentrations of quercetin could impair SARS-CoV-2 infection of human cells partly by blocking the fusion process that promotes its propagation.

Spatialized PM2.5 during COVID-19 pandemic in Brazil's most populous southern city: implications for post-pandemic era

Brazil has experienced one of the highest COVID-19 fatality rates globally. While numerous studies have explored the potential connection between air pollution, specifically fine particulate matter (PM2.5), and the exacerbation of SARS-CoV-2 infection, the majority of this research has been conducted in foreign regions-Europe, the United States, and China-correlating generalized pollution levels with health-related scopes. In this study, our objective is to investigate the localized connection between exposure to air pollution exposure and its health implications within a specific Brazilian municipality, focusing on COVID-19 susceptibility. Our investigation involves assessing pollution levels through spatial interpolation of in situ PM2.5 measurements. A network of affordable sensors collected data across 9 regions in Curitiba, as well as its metropolitan counterpart, Araucaria. Our findings distinctly reveal a significant positive correlation (with r-values reaching up to 0.36, p-value < 0.01) between regions characterized by higher levels of pollution, particularly during the winter months (with r-values peaking at 0.40, p-value < 0.05), with both COVID-19 mortality and incidence rates. This correlation gains added significance due to the intricate interplay between urban atmospheric pollution and regional human development indices. Notably, heightened pollution aligns with industrial hubs and intensified vehicular activity. The spatial analysis performed in this study assumes a pivotal role by identifying priority regions that require targeted action post-COVID. By comprehending the localized dynamics between air pollution and its health repercussions, tailored strategies can be implemented to alleviate these effects and ensure the well-being of the public.

Excess mortality during the COVID-19 pandemic in low-income and lower middle-income countries: protocol for a systematic review and meta-analysis

INTRODUCTION

The COVID-19 pandemic has been marked by a massive death toll. However, the overall effect of the pandemic, including potential unintended negative impacts of some control measures, on mortality remains poorly understood in low-income and lower middle-income countries (LLMICs). This review aims to summarise the available literature on excess mortality in LLMICs, focusing on the methods and data sources used in estimating excess mortality and the drivers of excess mortality.

METHODS AND ANALYSIS

We will review the available literature and report results in line with the Preferred Reporting Items for Systematic Review and Meta-Analysis. Searches will be conducted in PubMed, Embase, Web of Science, Cochrane Library, Google Scholar and Scopus. All published studies that report on the estimates of excess mortality in populations of LLMICs will be included. This will include those with a publication date from 2019 onwards and those with at least a 1-year non-COVID-19 period as the comparator in the estimation of excess mortality during the pandemic. There will be no language restrictions on the search. The meta-analysis will include studies with extractable data on excess mortality, methods, population size, and observed and expected deaths. We will use the Mantel-Haenszel method to estimate the pooled risk ratio with 95% CIs.

ETHICS AND DISSEMINATION

As there is no primary data collection, there is no requirement for ethical review. The results will be disseminated through peer-reviewed journal publication and conference presentations.

PROSPERO REGISTRATION NUMBER

CRD42022378267.

Reconstructing the COVID-19 incidence in India using airport screening data in Japan

BACKGROUND

A major epidemic of COVID-19 caused by the Delta variant (B.1.617.2) occurred in India from March to July 2021, resulting in 19 million documented cases. Given the limited healthcare and testing capacities, the actual number of infections is likely to have been greater than reported, and several modelling studies and excess mortality research indicate that this epidemic involved substantial morbidity and mortality.

METHODS

To estimate the incidence during this epidemic, we used border entry screening data in Japan to estimate the daily incidence and cumulative incidence of COVID-19 infection in India. Analysing the results of mandatory testing among non-Japanese passengers entering Japan from India, we calculated the prevalence and then backcalculated the incidence in India from February 28 to July 3, 2021.

RESULTS

The estimated number of infections ranged from 448 to 576 million people, indicating that 31.8% (95% confidence interval (CI): 26.1, 37.7) - 40.9% (95% CI: 33.5, 48.4) of the population in India had experienced COVID-19 infection from February 28 to July 3, 2021. In addition to obtaining cumulative incidence that was consistent with published estimates, we showed that the actual incidence of COVID-19 infection during the 2021 epidemic in India was approximately 30 times greater than that based on documented cases, giving a crude infection fatality risk of 0.47%. Adjusting for test-negative certificate before departure, the quality control of which was partly questionable, the cumulative incidence can potentially be up to 2.3-2.6 times greater than abovementioned estimates.

CONCLUSIONS

Our estimate of approximately 32-41% cumulative infection risk from February 28 to July 3, 2021 is roughly consistent with other published estimates, and they can potentially be greater, given an exit screening before departure. The present study results suggest the potential utility of border entry screening data to backcalculate the incidence in countries with limited surveillance capacity owing to a major surge in infections.

Causes and costs of global COVID-19 vaccine inequity

Despite the rapid development of safe and effective COVID-19 vaccines and the widely recognized health and economic benefits of vaccination, there exist stark differences in vaccination rates across country income groups. While more than 70% of the population is fully vaccinated in high-income countries, vaccination rates in low-income countries are only around 30%. The paper reviews the factors behind global COVID-19 vaccine inequity and the health, social, and economic costs triggered by this inequity. The main contributors to vaccine inequity include vaccine nationalism, intellectual property rights, constraints in manufacturing capacity, poor resilience of healthcare systems, and vaccine hesitancy. Vaccine inequity has high costs, including preventable deaths and cases of illnesses in low-income countries, slow economic recovery, and large learning losses among children. Increasing vaccination rates in low-income countries is in the self-interest of higher-income countries as it may prevent the emergence of new variants and continuous disruptions to global supply chains.

Life-expectancy changes from 2019 to 22: A case study of Japan using provisional death count

Many countries struggled with suppressing the incidence of COVID-19 caused by SARS-CoV-2 Omicron variant (B.1.1.529). As the epidemic size of COVID-19 in 2022 became bigger than earlier years in Japan, the present study aimed to estimate life expectancy at birth at the end of 2022, using provisional death datasets in Aichi and Fukui prefectures. We collected monthly death count from 2019 to the end of 2022, computing the period life table. While the life expectancy at birth in Aichi, 2019 was 84.6 years, it was very slightly extended to 84.7 years in 2020 and 2021, followed by a shortening for nearly 0.4 years in 2022. In Fukui, monotonous extension pattern was seen, i.e., 85.5 years in 2019, 85.6 in 2020, followed by 85.8 and 86.2 years in 2021 and 2022, respectively. Although decades-long trend of extending life expectancy at birth was partly discontinued from 2020 due to the pandemic at the national level, we have shown that the pandemic impact was still small in Japan by the end of 2022. First Omicron wave occurred shortly after primary series vaccination, and even real time booster program was underway during that wave. Different demographic consequences between Aichi and Fukui are explained by differential epidemic sizes prior to vaccination.

Influence of respiratory infections pandemics on the mortality of the population of Ukraine

OBJECTIVE

Aim: To analyze the dynamics and structure of the excess mortality of the population of Ukraine for 76 years (1945-2021).

PATIENTS AND METHODS

Materials and Methods: An observational population study was conducted. Epidemiological methods were used, in particular, the method of graphical construction of time series, intensive, extensive indicators and indicators of excess mortality were calculated.

CONCLUSION

Conclusions: The coronavirus disease pandemic in Ukraine became the largest documented respiratory infection pandemic after 76 years, but did not outweigh the dramatic increase in mortality in the 1990s-2000s, in including death in 1995.

Asian flush is a potential protective factor against COVID-19: a web-based retrospective survey in Japan

BACKGROUND

Coronavirus disease 2019 (COVID-19), first reported in December 2019, spread worldwide in a short period, resulting in numerous cases and associated deaths; however, the toll was relatively low in East Asia. A genetic polymorphism unique to East Asians, Aldehyde dehydrogenase 2 rs671, has been reported to confer protection against infections.

METHOD

We retrospectively investigated the association between the surrogate marker of the rs671 variant, the skin flushing phenomenon after alcohol consumption, and the timing of COVID-19 incidence using a web-based survey tool to test any protective effects of rs671 against COVID-19.

RESULTS

A total of 807 valid responses were received from 362 non-flushers and 445 flushers. During the 42 months, from 12/1/2019 to 5/31/2023, 40.6% of non-flushers and 35.7% of flushers experienced COVID-19. Flushers tended to have a later onset (Spearman's partial rank correlation test, p = 0.057, adjusted for sex and age). Similarly, 2.5% of non-flushers and 0.5% of flushers were hospitalized because of COVID-19. Survival analysis estimated lower risks of COVID-19 and associated hospitalization among flushers (p = 0.03 and <0.01, respectively; generalized Wilcoxon test). With the Cox proportional hazards model covering 21 months till 8/31/2021, when approximately half of the Japanese population had received two doses of COVID-19 vaccine, the hazard ratio (95% confidence interval) of COVID-19 incidence was estimated to be 0.21 (0.10-0.46) for flusher versus non-flusher, with adjustment for sex, age, steroid use, and area of residence.

CONCLUSIONS

Our study suggests an association between the flushing phenomenon after drinking and a decreased risk of COVID-19 morbidity and hospitalization, suggesting that the rs671 variant is a protective factor. This study provides valuable information for infection control and helps understand the unique constitutional diversity of East Asians.

Comparative impact assessment of COVID-19 policy interventions in five South Asian countries using reported and estimated unreported death counts during 2020-2021

There has been raging discussion and debate around the quality of COVID death data in South Asia. According to WHO, of the 5.5 million reported COVID-19 deaths from 2020-2021, 0.57 million (10%) were contributed by five low and middle income countries (LMIC) countries in the Global South: India, Pakistan, Bangladesh, Sri Lanka and Nepal. However, a number of excess death estimates show that the actual death toll from COVID-19 is significantly higher than the reported number of deaths. For example, the IHME and WHO both project around 14.9 million total deaths, of which 4.5-5.5 million were attributed to these five countries in 2020-2021. We focus our gaze on the COVID-19 performance of these five countries where 23.5% of the world population lives in 2020 and 2021, via a counterfactual lens and ask, to what extent the mortality of one LMIC would have been affected if it adopted the pandemic policies of another, similar country? We use a Bayesian semi-mechanistic model developed by Mishra et al. (2021) to compare both the reported and estimated total death tolls by permuting the time-varying reproduction number (Rt) across these countries over a similar time period. Our analysis shows that, in the first half of 2021, mortality in India in terms of reported deaths could have been reduced to 96 and 102 deaths per million compared to actual 170 reported deaths per million had it adopted the policies of Nepal and Pakistan respectively. In terms of total deaths, India could have averted 481 and 466 deaths per million had it adopted the policies of Bangladesh and Pakistan. On the other hand, India had a lower number of reported COVID-19 deaths per million (48 deaths per million) and a lower estimated total deaths per million (80 deaths per million) in the second half of 2021, and LMICs other than Pakistan would have lower reported mortality had they followed India's strategy. The gap between the reported and estimated total deaths highlights the varying level and extent of under-reporting of deaths across the subcontinent, and that model estimates are contingent on accuracy of the death data. Our analysis shows the importance of timely public health intervention and vaccines for lowering mortality and the need for better coverage infrastructure for the death registration system in LMICs.

Effects of the COVID-19 pandemic on life expectancy and premature mortality in the German federal states in 2020 and 2021

The mortality impact of COVID-19 has mainly been studied at the national level. However, looking at the aggregate impact of the pandemic at the country level masks heterogeneity at the subnational level. Subnational assessments are essential for the formulation of public health policies. This is especially important for federal countries with decentralised healthcare systems, such as Germany. Therefore, we assess geographical variation in the mortality impact of COVID-19 for the 16 German federal states in 2020 and 2021 and the sex differences therein. For this purpose, we adopted an ecological study design, using population-level mortality data by federal state, age, and sex, for 2005-2021 obtained from the German Federal Statistical Office. We quantified the impact of the pandemic using the excess mortality approach. We estimated period life expectancy losses (LE losses), excess premature mortality, and excess deaths by comparing their observed with their expected values. The expected mortality was based on projected age-specific mortality rates using the Lee-Carter methodology. Saxony was the most affected region in 2020 (LE loss 0.77 years, 95% CI 0.74;0.79) while Saarland was the least affected (-0.04, -0.09;0.003). In 2021, the regions with the highest losses were Thuringia (1.58, 1.54;1.62) and Saxony (1.57, 1.53;1.6) and the lowest in Schleswig-Holstein (0.13, 0.07;0.18). Furthermore, in 2021, eastern regions experienced higher LE losses (mean: 1.13, range: 0.85 years) than western territories (mean: 0.5, range: 0.72 years). The regional variation increased between 2020 and 2021, and was higher among males than among females, particularly in 2021. We observed an unequal distribution of the mortality impact of COVID-19 at the subnational level in Germany, particularly in 2021 among the male population. The observed differences between federal states might be partially explained by the heterogeneous spread of the virus in 2020 and by differences in the population's propensity to follow preventive guidelines.

Inhibition potential of natural flavonoids against selected omicron (B.1.19) mutations in the spike receptor binding domain of SARS-CoV-2: a molecular modeling approach

The omicron (B.1.19) variant of contagious severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is considered a variant of concern (VOC) due to its increased transmissibility and highly infectious nature. The spike receptor-binding domain (RBD) is a hotspot of mutations and is regarded as a prominent target for screening drug candidates owing to its crucial role in viral entry and immune evasion. To date, no effective therapy or antivirals have been reported; therefore, there is an urgent need for rapid screening of antivirals. An extensive molecular modelling study has been performed with the primary goal to assess the inhibition potential of natural flavonoids as inhibitors against RBD from a manually curated library. Out of 40 natural flavonoids, five natural flavonoids, namely tomentin A (-8.7 kcal/mol), tomentin C (-8.6 kcal/mol), hyperoside (-8.4 kcal/mol), catechin gallate (-8.3 kcal/mol), and corylifol A (-8.2 kcal/mol), have been considered as the top-ranked compounds based on their binding affinity and molecular interaction profiling. The state-of-the-art molecular dynamics (MD) simulations of these top-ranked compounds in complex with RBD exhibited stable dynamics and structural compactness patterns on 200 nanoseconds. Additionally, complexes of these molecules demonstrated favorable free binding energies and affirmed the docking and simulation results. Moreover, the post-simulation validation of these interacted flavonoids using principal component analysis (PCA) revealed stable interaction patterns with RBD. The integrated results suggest that tomentin A, tomentin C, hyperoside, catechin gallate, and corylifol A might be effective against the emerging variants of SARS-CoV-2 and should be further evaluated using in-vitro and in-vivo experiments.Communicated by Ramaswamy H. Sarma.

To Gain Insights into the Pathophysiological Mechanisms of the Thrombo-Inflammatory Process in the Atherosclerotic Plaque

Thromboinflammation, the interplay between thrombosis and inflammation, is a significant pathway that drives cardiovascular and autoimmune diseases, as well as COVID-19. SARS-CoV-2 causes inflammation and blood clotting issues. Innate immune cells have emerged as key modulators of this process. Neutrophils, the most predominant white blood cells in humans, are strategically positioned to promote thromboinflammation. By releasing decondensed chromatin structures called neutrophil extracellular traps (NETs), neutrophils can initiate an organised cell death pathway. These structures are adorned with histones, cytoplasmic and granular proteins, and have cytotoxic, immunogenic, and prothrombotic effects that can hasten disease progression. Protein arginine deiminase 4 (PAD4) catalyses the citrullination of histones and is involved in the release of extracellular DNA (NETosis). The neutrophil inflammasome is also required for this process. Understanding the link between the immunological function of neutrophils and the procoagulant and proinflammatory activities of monocytes and platelets is important in understanding thromboinflammation. This text discusses how vascular blockages occur in thromboinflammation due to the interaction between neutrophil extracellular traps and ultra-large VWF (von Willebrand Factor). The activity of PAD4 is important for understanding the processes that drive thromboinflammation by linking the immunological function of neutrophils with the procoagulant and proinflammatory activities of monocytes and platelets. This article reviews how vaso-occlusive events in thrombo-inflammation occur through the interaction of neutrophil extracellular traps with von Willebrand factor. It highlights the relevance of PAD4 in neutrophil inflammasome assembly and neutrophil extracellular traps in thrombo-inflammatory diseases such as atherosclerosis and cardiovascular disease. Interaction between platelets, VWF, NETs and inflammasomes is critical for the progression of thromboinflammation in several diseases and was recently shown to be active in COVID-19.

COVID-19 vaccination and corneal allograft rejection- a review

Aim

To provide a comprehensive literature review on the perceived correlation between COVID-19 vaccination and corneal allograft rejection, and to characterize risk factors, time course, graft outcomes and proposed immunological basis.

Methods

A literature review was conducted in August 2023 using 4 electronic databases: PubMed, EMBASE, MEDLINE and Scopus. Articles were sourced using key words associated with COVID-19 vaccination and corneal graft. All articles were screened for relevance by abstract review. Duplicates and articles related to COVID-19 infection were excluded. No time limits were set. Additional literature searches regarding cause of corneal graft rejection, rates of graft rejection associated with other vaccines and the cellular mechanism of rejection were also performed.

Results

262 articles were identified from the literature search. 37 papers were included in the analysis based on defined inclusion criteria. This consisted of systematic reviews (n=6), review articles (n=5), retrospective studies (n=3), case series (n=8), letter to the editor (n=1) and case reports (n= 14). The majority of reported allograft rejections were in penetrating keratoplasties. Risk factors for COVID-19 vaccination associated rejection were previous allograft rejection episodes, repeat grafts and penetrating keratoplasty. Most reported rejection episodes were mild and resolved with treatment. Notably, several studies reported nil increase in corneal allograft rejection episodes over the COVID-19 vaccination period. Rejection episodes are associated with a broad spectrum of other vaccines and the complete pathophysiology is undetermined.

Conclusion

Corneal allograft rejection appears to be a rare complication of COVID-19 vaccination most frequently observed in high-risk corneal transplants. The true extent of this correlation remains controversial; however, clinician awareness of this risk is essential to its mitigation. Patient counselling around symptom monitoring following vaccination and discussion around topical steroid prophylaxis may be prudent.

Association of eosinopenia with worsening prognosis in hospitalized Azvudine-treated COVID-19 patients: a retrospective cohort study

Background

Current guidelines prioritize the use of Azvudine in Coronavirus Disease 2019 (COVID-19) patients, while biomarkers for prognosis in Azvudine-treated COVID-19 patients are still lacking. Here, we aim to assess the prognostic value of eosinopenia in Azvudine-treated COVID-19 patients.

Methods

We retrospectively reviewed 290 consecutive Azvudine-treated hospitalized COVID-19 patients. Clinical characteristics and prognosis data were analyzed between patients with eosinopenia and with normal eosinophil levels.

Results

A total of 290 patients were enrolled in this study, with a median age of 69 years. Among them, 40.69% presented with eosinopenia and 59.31% had normal eosinophil levels. Common symptoms included cough (87.6%), expectoration (76.2%), fever (67.9%), poor appetite (47.2%), and polypnea (46.6%). Compared to patients with normal eosinophil levels, those with eosinopenia were older and less likely to experience fatigue (25.4% vs. 39.0%, P=0.016). Significant differences in laboratory parameters, particularly in blood routine and blood biochemical indicators, were observed between the two groups. Patients with eosinopenia were also less likely to develop severe illness subtypes, requiring more medication and oxygen support. The Cox proportional hazard model showed that eosinopenia was associated with worsening progression in Azvudine-treated COVID-19 patients (adjusted hazard ratio=2.79, 95% confidence interval: 1.04, 7.50), adjusting for potential confounders.

Conclusion

Eosinopenia is associated with worsening prognosis in Azvudine-treated COVID-19 patients.

The impacts of COVID-19 hospitalizations on non-COVID-19 deaths and hospitalizations: A panel data analysis using Brazilian municipalities

The COVID-19 pandemic in Brazil has brought many challenges, particularly regarding the management of hospital capacity, and a new demand for healthcare that added to the preexisting demands, such as neoplasms, cardiovascular diseases and births. In this paper, we estimate the impact of the pandemic on the number of deaths and hospitalizations for other diseases. We construct a monthly panel data of deaths and hospitalizations for various causes by the municipality of residence and relate them to COVID-19 hospitalizations using regression models that control for municipalities fixed-effects and interactions between State and month fixed-effects. The standard errors are clustered at the municipality level. Our estimates imply that 100 more hospitalizations by COVID-19 is associated with a drop of 49 non-COVID-19 hospitalizations and an additional four deaths for other reasons (all measured per 100,000 pop.). The impact of intensive care units COVID-19 hospitalizations on mortality is larger. The groups most affected are the African Brazilians, less-educated and the elderly. Additional deaths occurred both at households and at hospitals. The main causes of additional deaths were diseases related to the circulatory and endocrine system. The decline in hospitalizations for other causes seems to be related to the overcrowding of hospitals in periods of surge in the COVID-19, alongside with the fall in the demand for care by the citizens who were afraid of COVID-19 infection. These mechanisms affected more strongly the vulnerable groups of the population. Our results highlight the importance of promoting the awareness of heightened risk of non-communicable chronic diseases during a health emergency context. This should be done preferably through already established channels with community outreach, such as the Family Health Program in Brazil.

Ischaemic stroke in patients with diabetes requiring urgent procedures during the COVID-19 pandemic in South Korea: a retrospective, nationwide, population-based cohort study using data from the National Emergency Department Information System

OBJECTIVES

The COVID-19 pandemic resulted in suboptimal care for ischaemic stroke. Patients with diabetes mellitus (DM), a high-risk group for stroke, had compromised routine care during the pandemic, which increases the chance of stroke. We examined influence of the COVID-19 pandemic on the management of ischaemic stroke in patients with DM in South Korea.

DESIGN

Retrospective, nationwide, population-based cohort study.

SETTING

Data from the National Emergency Department Information System.

PARTICIPANTS

We analysed 11 734 patients diagnosed with acute ischaemic stroke who underwent intravenous thrombolysis or endovascular thrombectomy between 2019 (the reference year) and 2020 (the pandemic year). Among them, 1014 subjects with DM were analysed separately.

OUTCOME MEASURES

The frequency of emergency department (ED) visits, time from symptom onset to ED, from ED visit to admission and in-hospital mortality were compared between two periods in the overall population and in patients with DM.

RESULTS

During the pandemic, the incidence of ischaemic stroke requiring urgent procedures increased by 7.57% in total and by 9.03% in patients with DM. Time delay from symptom onset to ED (reference vs pandemic, total: 1.50 vs 1.55 hours; p<0.01) and from ED visit to admission (total: 3.88 vs 3.92 hours; p=0.02) occurred during the pandemic in the overall population, but not significantly in patients with DM specifically. Older patients with DM showed higher chances of intensive care unit (ICU) admission during the pandemic: 53.5% vs 62.8% in age 70-79, 60.5% vs 71.9% in age 80-89 and 20.0% vs 70.8% in age ≥90 years (all p=0.01). There was no significant difference in in-hospital mortality between two periods (total: 8.2% vs 8.4%, p=0.65; DM: 8.1% vs 6.7%, p=0.25).

CONCLUSIONS

During the COVID-19 pandemic, the incidence of ischaemic stroke requiring urgent procedures increased, and older patients with DM showed a higher ICU admission rate. However, the pandemic was not associated with an increased in-hospital stroke mortality.

Cytomegalovirus-vectored COVID-19 vaccines elicit neutralizing antibodies against the SARS-CoV-2 Omicron variant (BA.2) in mice

IMPORTANCE

Cytomegalovirus (CMV) has been used as a novel viral vector for vaccine development and gene therapy. Coronavirus disease 2019 is an infectious disease caused by the SARS-CoV-2 virus, which is highly mutable and is still circulating globally. The study showed that the CMV viral vector caused transient systemic infection and induced robust transgene expression in vivo. CMV vectors expressing different SARS-CoV-2 proteins were immunogenic and could elicit neutralizing antibodies against a highly mutated Omicron variant (BA.2). The expression level of receptor-binding domain (RBD) protein was higher than that of full-length S protein using CMV as a vaccine vector, and CMV vector expression RBD protein elicited higher RBD-binding and neutralizing antibodies. Moreover, the study showed that CMV-vectored vaccines would not cause unexpected viral transmission, and pre-existing immunity might impair the immunogenicity of subsequent CMV-vectored vaccines. These works provide meaningful insights for the development of a CMV-based vector vaccine platform and the prevention and control strategies for SARS-CoV-2 infection.

Variability in excess deaths across countries with different vulnerability during 2020-2023

Excess deaths provide total impact estimates of major crises, such as the COVID-19 pandemic. We evaluated excess death trajectories across countries with accurate death registration and population age structure data and assessed relationships with vulnerability indicators. Using the Human Mortality Database on 34 countries, excess deaths were calculated for 2020-2023 (to week 29, 2023) using 2017-2019 as reference, with adjustment for 5 age strata. Countries were divided into less and more vulnerable; the latter had per capita nominal GDP < $30,000, Gini > 0.35 for income inequality and/or at least ≥2.5% of their population living in poverty. Excess deaths (as proportion of expected deaths, p%) were inversely correlated with per capita GDP (r = -0.60), correlated with proportion living in poverty (r = 0.66), and modestly correlated with income inequality (r = 0.45). Incidence rate ratio for deaths was 1.062 (95% CI, 1.038-1.087) in more versus less vulnerable countries. Excess deaths started deviating in the two groups after the first wave. Between-country heterogeneity diminished gradually within each group. Less vulnerable countries had mean p% = -0.8% and 0.4% in 0-64 and >65-y-old strata. More vulnerable countries had mean p% = 7.0% and 7.2%, respectively. Lower death rates were seen in children of age 0-14 y during 2020-2023 versus prepandemic years. While the pandemic hit some countries earlier than others, country vulnerability dominated eventually the cumulative impact. Half the analyzed countries witnessed no substantial excess deaths versus prepandemic levels, while the others suffered major death tolls.

Slow data public health

Surveillance and research data, despite their massive production, often fail to inform evidence-based and rigorous data-driven health decision-making. In the age of infodemic, as revealed by the COVID-19 pandemic, providing useful information for decision-making requires more than getting more data. Data of dubious quality and reliability waste resources and create data-genic public health damages. We call therefore for a slow data public health, which means focusing, first, on the identification of specific information needs and, second, on the dissemination of information in a way that informs decision-making, rather than devoting massive resources to data collection and analysis. A slow data public health prioritizes better data, ideally population-based, over more data and aims to be timely rather than deceptively fast. Applied by independent institutions with expertise in epidemiology and surveillance methods, it allows a thoughtful and timely public health response, based on high-quality data fostering trustworthiness.

Obstetric Intervention and Perinatal Outcomes During the Coronavirus Disease 2019 (COVID-19) Pandemic

OBJECTIVE

To quantify pandemic-related changes in obstetric intervention and perinatal outcomes in the United States.

METHODS

We carried out a retrospective study of all live births and fetal deaths in the United States, 2015-2021, with data obtained from the natality, fetal death, and linked live birth-infant death files of the National Center for Health Statistics. Analyses were carried out among all singletons; singletons of patients with prepregnancy diabetes, prepregnancy hypertension, and hypertensive disorders of pregnancy; and twins. Outcomes of interest included preterm birth, preterm labor induction or preterm cesarean delivery, macrosomia, postterm birth, and perinatal death. Interrupted time series analyses were used to estimate changes in the prepandemic period (January 2015-February 2020), at pandemic onset (March 2020), and in the pandemic period (March 2020-December 2021).

RESULTS

The study population included 26,604,392 live births and 155,214 stillbirths. The prepandemic period was characterized by temporal increases in preterm birth and preterm labor induction or cesarean delivery rates and temporal reductions in macrosomia, postterm birth, and perinatal mortality. Pandemic onset was associated with absolute decreases in preterm birth (decrease of 0.322/100 live births, 95% CI 0.506-0.139) and preterm labor induction or cesarean delivery (decrease of 0.190/100 live births, 95% CI 0.334-0.047) and absolute increases in macrosomia (increase of 0.046/100 live births), postterm birth (increase of 0.015/100 live births), and perinatal death (increase of 0.501/1,000 total births, 95% CI 0.220-0.783). These changes were larger in subpopulations at high risk (eg, among singletons of patients with prepregnancy diabetes). Among singletons of patients with prepregnancy diabetes, pandemic onset was associated with a decrease in preterm birth (decrease of 1.634/100 live births) and preterm labor induction or cesarean delivery (decrease of 1.521/100 live births) and increases in macrosomia (increase of 0.328/100 live births) and perinatal death (increase of 9.840/1,000 total births, 95% CI 3.933-15.75). Most changes were reversed in the months after pandemic onset.

CONCLUSION

The onset of the coronavirus disease 2019 (COVID-19) pandemic was associated with a transient decrease in obstetric intervention (especially preterm labor induction or cesarean delivery) and a transient increase in perinatal mortality.

Locked Up and Left Behind: Addressing Cruel and Unusual Punishments among Senior Inmates during COVID-19 across US Prisons

The COVID-19 pandemic has shed light on long-standing constitutional violations within the US correctional system, particularly affecting vulnerable populations such as senior inmates. By analyzing the impact of COVID-19 in prisons, the challenges faced in implementing preventive strategies, and the specific vulnerabilities of elderly prisoners, this paper identifies potential constitutional infringements experienced by senior inmates during the pandemic and the physical, mental, and social effects of the pandemic on this population. Specifically, this paper aims to bridge the fields of constitutional law, prison reform, elder law, and the COVID-19 pandemic by examining the impact of the pandemic on the rights of senior inmates under the US Constitution's Eighth Amendment protection against cruel and unusual punishment. The objective is to examine whether potential violations have occurred and propose actions to prevent violations in the future while ensuring accountability and redress if such violations occur. To address such violations, the paper emphasizes the need for increased sanitation measures and decarceration as preventive measures in future public health crises.

Lessons learnt from the COVID-19 pandemic in selected countries to inform strengthening of public health systems: a qualitative study

INTRODUCTION

The COVID-19 pandemic has prompted governments internationally to consider strengthening their public health systems. To support the work of Ireland's Public Health Reform Expert Advisory Group, the Health Information and Quality Authority, an independent governmental agency, was asked to describe the lessons learnt regarding the public health response to COVID-19 internationally and the applicability of this response for future pandemic preparedness.

METHODS

Semi-structured interviews with key public health representatives from nine countries were conducted. Interviews were conducted in March and April 2022 remotely via Zoom and were recorded. Notes were taken by two researchers, and a thematic analysis undertaken.

RESULTS

Lessons learnt from the COVID-19 pandemic related to three main themes: 1) setting policy; 2) delivering public health interventions; and 3) providing effective communication. Real-time surveillance, evidence synthesis, and cross-sectoral collaboration were reported as essential for policy setting; it was noted that having these functions established prior to the pandemic would lead to a more efficient implementation in a health emergency. Delivering public health interventions such as testing, contact tracing, and vaccination were key to limiting and or mitigating the spread of the SARS-CoV-2 virus. However, a number of challenges were highlighted such as staff capacity and burnout, delays in vaccination procurement, and reduced delivery of regular healthcare services. Clear, consistent, and regular communication of the scientific evidence was key to engaging citizens with mitigation strategies. However, these communication strategies had to compete with an infodemic of information being circulated, particularly through social media.

CONCLUSIONS

Overall, functions relating to policy setting, public health interventions, and communication are key to pandemic response. Ideally, these should be established in the preparedness phase so that they can be rapidly scaled-up during a pandemic.

COVAX - Time to reconsider the strategy and its target

COVAX, the international initiative supporting COVID-19 vaccination campaigns globally, is budgeted to be the costliest public health initiative in low- and middle-income countries, with over 16 billion US dollars already committed. While some claim that the target of vaccinating 70% of people worldwide is justified on equity grounds, we argue that this rationale is wrong for two reasons. First, mass COVID-19 vaccination campaigns do not meet standard public health requirements for clear expected benefit, based on costs, disease burden and intervention effectiveness. Second, it constitutes a diversion of resources from more cost-effective and impactful public health programmes, thus reducing health equity. We conclude that the COVAX initiative warrants urgent review.

Bariatric Surgery and COVID-19: a Change of Perspective in a New Phase of the Pandemic

PURPOSE

The protective role of bariatric surgery (BS) against COVID-19 has been reported by several studies, showing, in the first pandemic waves, better outcome of the infection in patients that had undergone BS. With the virus progressive endemicity, BS benefits on COVID-19 clinical course could appear less evident, while COVID-19 effects on BS outcomes must be investigated. In this national multicentric cross-sectional study, we compared COVID-19 incidence and clinical course between a cohort of patients that had undergone BS (OP) and a cohort of candidates to BS (WS); moreover, we analyzed BS outcomes based on SARS-CoV-2 positivity/negativity.

METHODS

From June to December 2021, 522 patients from five Italian referral centers were administered an 87-item telephonic questionnaire completing the analysis of electronic medical records. Demographics, COVID-19 "tested" incidence, suggestive symptoms and clinical outcome parameters of OP and WS were compared. BS outcomes parameters were compared between OP that developed the disease or not.

RESULTS

COVID-19 incidence was the same in OP and WS, while symptoms and clinical course seemed milder in OP, with no data individually reaching statistical significance. OP who developed SARS-CoV-2 infection had higher excess weight loss than negative OP (66.8% ± 22.1 vs. 57.7% ± 22.8, p = 0.029). Positive OP had had gastric-bypass (RYGB/OAGB) more frequently than negative ones (38.4% vs. 18.2%, p = 0.025).

CONCLUSION

With the disease becoming endemic, BS protective role against COVID-19 seems clinically less relevant. BS outcomes can be affected by COVID-19, thus imposing careful follow-up for positive patients, especially if undergoing gastric-bypass.

Disruption Of Non-COVID-19 Health Care In Latin America During The Pandemic: Effects On Health, Lessons For Policy

COVID-19 had severe direct and indirect effects on health and well-being in Latin America. To understand the extent to which disruptions among non-COVID-19-related health services affected population health, we used administrative data from the period 2015-21 to examine public hospital discharges and mortality for conditions amenable to health care in four Latin American countries: Brazil, Ecuador, Mexico, and Peru. Between March 2020 and December 2021, hospitalization rates for these conditions declined by 28 percent and mortality rates increased by 15 percent relative to prepandemic years. Noncommunicable diseases accounted for 89 percent of this rise in mortality. The poorest states in each country experienced relatively larger increases in mortality. Our results, which focus on the health effects of service disruption, suggest that maintaining health care services in this region during the pandemic could have avoided at least 96,000 deaths. Policies should focus on maintaining essential health care services during emergencies, particularly for patients with noncommunicable diseases, and on minimizing negative consequences by ensuring coordinated and continuous care; leveraging alternative modalities of care, such as telemedicine; broadening the role of nonphysician health care workers; and expanding options for medication delivery.

Lives Versus Livelihoods: The Epidemiological, Social, And Economic Impact Of COVID-19 In Latin America And The Caribbean

During the COVID-19 pandemic, Latin American and Caribbean countries implemented stringent public health and social measures that disrupted economic and social activities. This study used an integrated model to evaluate the epidemiological, economic, and social trade-offs in Argentina, Brazil, Jamaica, and Mexico throughout 2021. Argentina and Mexico displayed a higher gross domestic product (GDP) loss and lower deaths per million compared with Brazil. The magnitude of the trade-offs differed across countries. Reducing GDP loss at the margin by 1 percent would have increased daily deaths by 0.5 per million in Argentina but only 0.3 per million in Brazil. We observed an increase in poverty rates related to the stringency of public health and social measures but no significant income-loss differences by sex. Our results indicate that the economic impact of COVID-19 was uneven across countries as a result of different pandemic trajectories, public health and social measures, and vaccination uptake, as well as socioeconomic differences and fiscal responses. Policy makers need to be informed about the trade-offs to make strategic decisions to save lives and livelihoods.

M, Armas R, de Mora D, Pinos J, Olmedo A, Salas R, Jimbo-Sotomayor R, Chiluisa C, Acosta P, Sánchez X, Whittembury A. Effectiveness of COVID-19 vaccines in Ecuador: A test-negative design

Background

The COVID-19 pandemic poses a significant global health threat, characterized by high morbidity, severity, and the emergence of concerning variants. Latin America has been greatly affected, with high infection and mortality rates. Vaccination plays a crucial role in mitigating severe disease and controlling the pandemic. This study aims to assess the effectiveness of COVID-19 vaccines in preventing SARS-CoV-2 severe acute respiratory infections (SARI) in hospitalized vaccination target groups in Ecuador.

Methods

This is a test-negative design study. We used data reported through sentinel surveillance of SARI between May 2021 and March 2022 in Ecuador. Patients with case criteria of SARI and hospitalized for a minimum of 24 hours were included in the study. Cases were defined as patients with SARI with a positive RT-qPCR test for SARS-CoV-2 and controls were those with a negative result. Information on vaccination status was obtained from the national vaccination registry, a valid dose of vaccination was considered when it was administered at least 14 days prior to symptom onset. Vaccine effectiveness (VE) (1-OR/OR) was calculated using a logistic regression.

Results

A total of 1,277 patients were included in the analysis of VE. The adjusted vaccine effectiveness (aVE) in preventing hospitalization, adjusted for sex, age group, presence of one or more comorbidities, and period of the predominance of the omicron variant, was 44.5% for the partial primary schedule, 74.7% for the complete primary schedule, and 79.9% for the complete primary schedule plus booster doses. The aVE in avoiding ICU admissions was close to 80% with both the complete primary schedule and the booster doses, and in avoiding deaths, the aVE was 89% and 98%, respectively.

Conclusions

In Ecuador, COVID-19 vaccination prevents hospitalizations, ICU admissions, and deaths. The effectiveness of the vaccines improves with more doses, offering increased protection across all age groups.

[Post COVID care needs rehabilitation]

Fast drei Jahre nach dem Ausbruch der COVID-19-Pandemie zählt die Weltgesundheitsorganisation rund 7 Millionen Tote aufgrund von COVID-19 und knapp 771 Millionen bestätigte Infektionen mit SARS-CoV-2 1. Die weltweite Übersterblichkeit in den ersten zwei Jahren der Pandemie wird sogar zwei- bis dreimal höher geschätzt, teilweise bedingt durch überlastete Gesundheitssysteme 2.