The Impact of COVID-19 Vaccination on the Italian Healthcare System: A Scenario Analysis

A Comprehensive Review on the Intricate Interplay between COVID-19 Immunization and the New Onset of Pemphigus Foliaceus

Autoimmune bullous diseases (AIBDs) are characterized by the formation of vesicles, bullous lesions, and mucosal erosions. The autoantibodies target the cellular anchoring structures from the surface of epidermal keratinocyte named desmosomes, leading to a loss of cellular cohesion named acantholysis. AIBDs are classified into intraepidermal or subepidermal types based on clinical features, histological characteristics, and immunofluorescence patterns. Pemphigus foliaceus (PF) is an acquired, rare, autoimmune skin condition associated with autoantibodies that specifically target desmoglein-1, leading to a clinical presentation characterized by delicate cutaneous blisters, typically sparing the mucous membranes. Several factors, including genetic predisposition, environmental triggers, malignancies, medication use, and vaccination (for influenza, hepatitis B, rabies, tetanus, and more recently, severe acute respiratory syndrome Coronavirus 2 known as SARS-CoV-2), can potentially trigger the onset of pemphigus. With the advent of vaccines playing a pivotal role in combatting the 2019 coronavirus disease (COVID-19), extensive research has been conducted globally to ascertain their efficacy and potential cutaneous adverse effects. While reports of AIBDs post-COVID-19 vaccination exist in the medical literature, instances of PF following vaccination have been less commonly reported worldwide. The disease's pathophysiology is likely attributed to the resemblance between the ribonucleic acid (RNA) antigen present in these vaccines and cellular nuclear matter. The protein produced by the BNT-162b2 messenger ribonucleic acid (mRNA) vaccine includes immunogenic epitopes that could potentially trigger autoimmune phenomena in predisposed individuals through several mechanisms, including molecular mimicry, the activation of pattern recognition receptors, the polyclonal stimulation of B cells, type I interferon production, and autoinflammation. In this review, we present a comprehensive examination of the existing literature regarding the relationship between COVID-19 and PF, delving into their intricate interactions. This exploration improves the understanding of both pemphigus and mRNA vaccine mechanisms, highlighting the importance of close monitoring for PF post-immunization.

Neurovascular Adverse Effects of Sars-Cov-2 Vaccination

The global deployment of SARS-CoV-2 vaccines has been pivotal in curbing the COVID-19 pandemic, reducing morbidity and mortality associated with the virus. While most of these vaccines have demonstrated high efficacy and overall safety, emerging reports have highlighted potential neurovascular adverse effects, albeit uncommon, associated with these vaccinations. This review aims to assess and summarize the current knowledge on the neurovascular complications arising post-SARS-CoV-2 vaccination. We conducted an extensive literature review, focusing on clinical studies and case reports to identify reported neurovascular events, such as ischemic stroke, cerebral sinus venous thrombosis, intracerebral hemorrhage, pituitary apoplexy and primary CNS angiitis Despite the relative rarity of these events, their impact on affected individuals underscores the importance of ongoing surveillance, early detection, and management strategies. We aim to provide healthcare professionals with the latest evidence on neurovascular adverse effects, facilitating informed decision-making in the context of SARS-CoV-2 vaccination programs. Furthermore, we highlight areas requiring further research to understand the pathophysiology of these adverse events better and to develop targeted prevention and treatment strategies.

Predictive potential of SARS-CoV-2 RNA concentration in wastewater to assess the dynamics of COVID-19 clinical outcomes and infections

Coronavirus disease 2019 - caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) -, has triggered a worldwide pandemic resulting in 665 million infections and over 6.5 million deaths as of December 15, 2022. The development of different epidemiological tools have helped predict new outbreaks and assess the behavior of clinical variables in different health contexts. In this study, we aimed to monitor concentrations of SARS-CoV-2 in wastewater as a tool to predict the progression of clinical variables during Waves 3, 5, and 6 of the pandemic in the Spanish city of Xátiva from September 2020 to March 2022. We estimated SARS-CoV-2 RNA concentrations in 195 wastewater samples using the RT-PCR Diagnostic Panel validated by the Center for Disease Control and Prevention. We also compared the trends of several clinical variables (14-day cumulative incidence, positive cases, hospital cases and stays, critical cases and stays, primary care visits, and deaths) for each study wave against wastewater SARS-CoV-2 RNA concentrations using Pearson's product-moment correlations, a two-sided Mann-Whitney U test, and a cross-correlation analysis. We found strong correlations between SARS-CoV-2 concentrations with 14-day cumulative incidence and positive cases over time. Wastewater RNA concentrations showed strong correlations with these variables one and two weeks in advance. There were significant correlations with hospitalizations and critical care during Wave 3 and Wave 6; cross-correlations were stronger for hospitalization stays one week before during Wave 6. No association between vaccination percentages and wastewater viral concentrations was observed. Our findings support wastewater SARS-CoV-2 concentrations as a potential surveillance tool to anticipate infection and epidemiological data such as 14-day cumulative incidence, hospitalizations, and critical care stays. Public health authorities could use this epidemiological tool on a similar population as an aid for health care decision-making during an epidemic outbreak.

A population-based assessment of avoidable hospitalizations and resource use of non-vaccinated patients with COVID-19

OBJECTIVE

The coronavirus disease 2019 (COVID-19) pandemic has precipitated a prolonged public health crisis. Numerous public health protections were widely implemented. The availability of effective and safe vaccines for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) presented an opportunity to resolve this crisis; however, vaccine uptake was slow and inconsistent. This study evaluated the potential for preventable hospitalizations and avoidable resource use among eligible non-vaccinated persons hospitalized for COVID-19 had these persons been vaccinated.

METHODS

This was a retrospective, population-based cohort study. The population-at-risk were persons aged ≥ 12 years in Alberta (mid-year 2021 population ~ 4.4 million). The primary exposure was vaccination status. The primary outcome was hospitalization with confirmed SARS-CoV-2, and secondary outcomes included avoidable hospitalizations, avoidable hospital bed-days, and the potential cost avoidance related to COVID-19. The study inception period was 27 September 2021 to 25 January 2022. Data on COVID-19 hospitalizations, vaccination status, health services, and costs were obtained from the Government of Alberta and from the Discharge Abstract Database.

RESULTS

Hospitalizations occurred in 3835, 1907, and 481 persons who were non-vaccinated, fully vaccinated, and boosted (risk of hospitalization/100,000 population: 886, 92, and 43), respectively. For non-vaccinated persons compared with fully vaccinated and boosted persons, the risk ratios (95%CI) of hospitalization were 9.7 (7.9-11.8) and 20.6 (17.9-23.6), respectively. For non-vaccinated persons, estimates of avoidable hospitalizations and bed-days used were 3439 and 36,331 if fully vaccinated and 3764 and 40,185 if boosted. Estimates of cost avoidance for non-vaccinated persons were $101.46 million if fully vaccinated and $110.24 million if boosted.

CONCLUSION

Eligible non-vaccinated persons with COVID-19 had tenfold and 21-fold higher risks of hospitalization relative to whether they had been fully vaccinated or boosted, resulting in considerable avoidable hospital bed-days and costs.

The Impact of Vaccination on COVID-19 Burden of Disease in the Adult and Elderly Population: A Systematic Review of Italian Evidence

COVID-19 is a major global health threat, with millions of confirmed cases and deaths worldwide. Containment and mitigation strategies, including vaccination, have been implemented to reduce transmission and protect the population. We conducted two systematic reviews to collect nonrandomized studies investigating the effects of vaccination on COVID-19-related complications and deaths in the Italian population. We considered studies conducted in Italian settings and written in English that contained data on the effects of vaccination on COVID-19-related mortality and complications. We excluded studies that pertained to the pediatric population. In total, we included 10 unique studies in our two systematic reviews. The results showed that fully vaccinated individuals had a lower risk of death, severe symptoms, and hospitalization compared to unvaccinated individuals. The review also looked at the impact of vaccination on post-COVID-19 syndrome, the effectiveness of booster doses in older individuals, and nationwide adverse events. Our work highlights the crucial role that vaccination campaigns have played in reducing the burden of COVID-19 disease in the Italian adult population, positively impacting the pandemic trajectory in Italy.

The COVID-19 Pandemic and Health and Care Workers: Findings From a Systematic Review and Meta-Analysis (2020-2021)

Objectives: The COVID-19 pandemic has greatly impacted health and care workers (HCW) globally, whom are considered at greater risk of infection and death. This study aims to document emerging evidence on disease prevalence, clinical outcomes, and vaccination rates of HCWs. Methods: Three databases were surveyed resulting on 108 final articles between July-December 2020 (period 1) and January-June 2021 (period 2). Results: Amongst the overall 980,000 HCWs identified, in period 1, the estimates were 6.1% (95% CI, 4.1-8.8) for the PCR positivity rate. Regarding outcomes, the hospitalization prevalence was 1.6% (95% CI, 0.7-3.9), and mortality rate of 0.3% (95% CI, 0.1-0.8). In period 2, the PCR positivity rate was 8.1% (95% CI, 4.6-13.8). Analysis of outcomes revealed a hospitalization rate of 0.7% (95% CI 0.3-1.8), and average mortality rate of 0.3% (95% CI 0.1-0.9). Our analysis indicated a HCW vaccination rate of 59.0% (95% CI, 39.4-76.1). Conclusion: Studies from the latter half of 2020 to the first half of 2021 showed a slight increasing trend in PCR positivity among HCW, along with improved clinical outcomes in the 1-year period of exposure. These results correlate well with the improving uptake of COVID-19 vaccination globally.

The COVID-19 Pandemic Between Bio-Ethics, Bio-Law and Bio-Politics: A Case Study on The Italian Experience of The DuPre Commission

The aim of this qualitative study was to consider the question of whether the Italian political management of the pandemic respected the European bio-ethical and bio-juridical approaches in light of the principles of autonomy, dignity, integrity and vulnerability. As no specific consolidated literature exists on the subject, the Italian situation was taken into consideration, specifically the work of a spontaneous commission (DuPre) that collected the reflections of academics and researchers interested in discussing political decisions for the management of the emergency, which was the coronavirus disease (COVID-19) pandemic. The analysis took into account the contributions of scholars during two conferences (without proceedings), which were transcribed and examined. From the texts processed with a thematic analysis, three main themes emerged: ‘pandemic as a state of exception, sovereignty and crisis of democracy’, ‘the value of doubt and refutation’ and ‘elimination of informed consent between persuasion and blackmail’. In this paper, the final bio-political considerations on the European approach and the management of the COVID-19 pandemic in Italy are presented.

Management of the Medico-Legal Dispute of Healthcare-Related SARS-CoV-2 Infections: Evaluation Criteria and Case Study in a Large University Hospital in Northwest Italy from 2020 to 2021

Healthcare-related SARS-CoV-2 infection is an issue of particular concern during the pandemic. It has important repercussions on the National Health System, which represents a source of medical-legal health disputes. In the healthcare context, there are reports of negative screening at hospital admission (via nasopharyngeal swabs) and subsequent diagnosis of SARS-CoV-2 infection during hospitalization. Such cases cannot be considered a priori of healthcare-related infections but require extensive in-depth evaluation. In this study, we propose an empirical classification to frame cases of SARS-CoV-2 infection diagnosed in the hospital (first negative admission swab, with subsequent positive test during hospitalization). The classification is based on five categories: nosocomial, probably nosocomial, indeterminate, probably community, and community cases. We analyzed patients who died after testing positive for SARS-CoV-2 during hospitalization (with initial negative screening) in the largest hospital in Northwest Italy from February 2020 to 31 December 2021. A total of 383 cases were tracked and are listed as follows: 41 cases (11%) were classified as nosocomial (i.e., 3.2% of COVID-19 deaths). In contrast, 71 cases (19%) were classified as probably nosocomial, 69 (18%) were indeterminate (i.e., the clinical, radiological, and laboratory characteristics did not provide information on the genesis of the infection), 166 (43%) were classified as probably community cases, and 36 (9%) were defined as community cases. Deceased patients with nosocomial SARS-CoV-2 infection constituted the following: 3.23% (41/1266) with respect to the total number of COVID-19 deaths, 1.1% (41/3789) with respect to those who entered the hospital with a negative swab and 0.82% (41/4672) with respect to the total of deaths from any cause of death. In this paper we discuss the topic and issues of nosocomial COVID-19 in hospitalized patients and address the medicolegal implications.

COVID-19 hospitalizations and patients' age at admission: The neglected importance of data variability for containment policies

Introduction

An excess in the daily fluctuation of COVID-19 in hospital admissions could cause uncertainty and delays in the implementation of care interventions. This study aims to characterize a possible source of extravariability in the number of hospitalizations for COVID-19 by considering age at admission as a potential explanatory factor. Age at hospitalization provides a clear idea of the epidemiological impact of the disease, as the elderly population is more at risk of severe COVID-19 outcomes. Administrative data for the Veneto region, Northern Italy from February 1, 2020, to November 20, 2021, were considered.

Methods

An inferential approach based on quasi-likelihood estimates through the generalized estimation equation (GEE) Poisson link function was used to quantify the overdispersion. The daily variation in the number of hospitalizations in the Veneto region that lagged at 3, 7, 10, and 15 days was associated with the number of news items retrieved from Global Database of Events, Language, and Tone (GDELT) regarding containment interventions to determine whether the magnitude of the past variation in daily hospitalizations could impact the number of preventive policies.

Results

This study demonstrated a significant increase in the pattern of hospitalizations for COVID-19 in Veneto beginning in December 2020. Age at admission affected the excess variability in the number of admissions. This effect increased as age increased. Specifically, the dispersion was significantly lower in people under 30 years of age. From an epidemiological point of view, controlling the overdispersion of hospitalizations and the variables characterizing this phenomenon is crucial. In this context, the policies should prevent the spread of the virus in particular in the elderly, as the uncontrolled diffusion in this age group would result in an extra variability in daily hospitalizations.

Discussion

This study demonstrated that the overdispersion, together with the increase in hospitalizations, results in a lagged inflation of the containment policies. However, all these interventions represent strategies designed to contain a mechanism that has already been triggered. Further efforts should be directed toward preventive policies aimed at protecting the most fragile subjects, such as the elderly. Therefore, it is essential to implement containment strategies before the occurrence of potentially out-of-control situations, resulting in congestion in hospitals and health services.

Avoidable intensive care unit resource use and costs of unvaccinated patients with COVID-19: a historical population-based cohort study

PURPOSE

SARS-CoV-2 vaccines have been proven effective at preventing poor outcomes from COVID-19; however, voluntary vaccination rates have been suboptimal. We assessed the potential avoidable intensive care unit (ICU) resource use and associated costs had unvaccinated or partially vaccinated patients hospitalized with COVID-19 been fully vaccinated.

METHODS

We conducted a retrospective, population-based cohort study of persons aged 12 yr or greater in Alberta (2021 population ~ 4.4 million) admitted to any ICU with COVID-19 from 6 September 2021 to 4 January 2022. We used publicly available aggregate data on COVID-19 infections, vaccination status, and health services use. Intensive care unit admissions, bed-days, lengths of stay, and costs were estimated for patients with COVID-19 and stratified by vaccination status.

RESULTS

In total, 1,053 patients admitted to the ICU with COVID-19 were unvaccinated, 42 were partially vaccinated, and 173 were fully vaccinated (cumulative incidence 230.6, 30.8, and 5.5 patients/100,000 population, respectively). Cumulative incidence rate ratios of ICU admission were 42.2 (95% confidence interval [CI], 39.7 to 44.9) for unvaccinated patients and 5.6 (95% CI, 4.1 to 7.6) for partially vaccinated patients when compared with fully vaccinated patients. During the study period, 1,028 avoidable ICU admissions and 13,015 bed-days were recorded for unvaccinated patients and the total avoidable costs were CAD 61.3 million. The largest opportunity to avoid ICU bed-days and costs was in unvaccinated patients aged 50 to 69 yr.

CONCLUSIONS

Unvaccinated patients with COVID-19 had substantially greater rates of ICU admissions, ICU bed-days, and ICU-related costs than vaccinated patients did. This increased resource use would have been potentially avoidable had these unvaccinated patients been vaccinated against SARS-CoV-2.

Autoimmune mucocutaneous blistering diseases after SARS-Cov-2 vaccination: A Case report of Pemphigus Vulgaris and a literature review

BACKGROUND

Cases of severe autoimmune blistering diseases (AIBDs) have recently been reported in association with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination.

AIMS

To describe a report of oropharyngeal Pemphigus Vulgaris (OPV) triggered by the mRNABNT162b2 vaccine (Comirnaty®/ Pfizer/ BioNTech) and to analyze the clinical and immunological characteristics of the AIBDs cases reported following the SARS-CoV-2 vaccination.

METHODS

The clinical and immunological features of our case of OPV were documented. A review of the literature was conducted and only cases of AIBDs arising after the SARS-CoV-2 vaccination were included.

CASE REPORT

A 60-year old female patients developed oropharyngeal and nasal bullous lesions seven days after the administration of a second dose of the mRNABNT162b2 vaccine (Comirnaty®/ Pfizer/BioNtech). According to the histology and direct immunofluorescence findings showing the presence of supra-basal blister and intercellular staining of IgG antibodies and the presence of a high level of anti-Dsg-3 antibodies (80 U/ml; normal < 7 U/ml) in the serum of the patients, a diagnosis of oropharyngeal Pemphigus Vulgaris was made.

REVIEW

A total of 35 AIBDs cases triggered by the SARS-CoV-2 vaccination were found (including our report). 26 (74.3%) were diagnosed as Bullous Pemphigoid, 2 (5.7%) as Linear IgA Bullous Dermatosis, 6 (17.1%) as Pemphigus Vulgaris and 1 (2.9%) as Pemphigus Foliaceus. The mean age of the sample was 72.8 years and there was a predominance of males over females (F:M=1:1.7). In 22 (62.9%) cases, the disease developed after Pfizer vaccine administration, 6 (17.1%) after Moderna, 3 (8.6%) after AstraZeneca, 3 (8.6%) after CoronaVac (one was not specified). All patients were treated with topical and/or systemic corticosteroids, with or without the addition of immunosuppressive drugs, with a good clinical response in every case.

CONCLUSION

Clinicians should be aware of the potential, though rare, occurrence of AIBDs as a possible adverse event after the SARS-CoV-2 vaccination. However, notwithstanding, they should encourage their patients to obtain the vaccination in order to assist the public health systems to overcome the COVID-19 pandemic.