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Majumder MAA, Khatib AA, Alhassan T, Razzaque MS. Potential Impact of COVID-19 on Medical Career Aspirations of Prospective Students. ADVANCES IN MEDICAL EDUCATION AND PRACTICE 2024; 15:737-742. [PMID: 39099683 PMCID: PMC11296364 DOI: 10.2147/amep.s457473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Accepted: 07/11/2024] [Indexed: 08/06/2024]
Abstract
This article describes the evolving landscape of medical education in the wake of the COVID-19 pandemic, emphasizing the renewed importance of public health, mental well-being, and career choices among medical students. The pandemic has prompted a significant shift in medical student's career aspirations, highlighting the need for mental health support mechanisms within the medical education framework. Medical students' career choices are influenced directly and indirectly by the challenges and experiences of the pandemic era, which are discussed in this article under four key themes: traditional values, global health interests and disparities, developing trends, and digital healthcare. There is an urgent need to adjust medical training to the new reality and share the future directions of the medical education landscape by embracing diverse career paths in medicine, integrating technology into medical training, adapting to the changing context of medicine, and strengthening collaboration and communication. The pandemic underscores the importance of evidence-based patient care, necessitating the preparation of tomorrow's doctors to address the emerging healthcare challenges with resilience, adaptability, and a comprehensive understanding of both local and global health challenges.
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Affiliation(s)
| | | | - Taha Alhassan
- Department of Medical Education, School of Medicine, University of Texas (UTRGV), Edinburg, Texas, USA
| | - Mohammed S Razzaque
- Lake Erie College of Osteopathic Medicine, Erie, Pennsylvania, USA
- Department of Medical Education, School of Medicine, University of Texas (UTRGV), Edinburg, Texas, USA
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Pan J, Villalan AK, Ni G, Wu R, Sui S, Wu X, Wang X. Assessing eco-geographic influences on COVID-19 transmission: a global analysis. Sci Rep 2024; 14:11728. [PMID: 38777817 PMCID: PMC11111805 DOI: 10.1038/s41598-024-62300-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Accepted: 05/15/2024] [Indexed: 05/25/2024] Open
Abstract
COVID-19 has been massively transmitted for almost 3 years, and its multiple variants have caused serious health problems and an economic crisis. Our goal was to identify the influencing factors that reduce the threshold of disease transmission and to analyze the epidemiological patterns of COVID-19. This study served as an early assessment of the epidemiological characteristics of COVID-19 using the MaxEnt species distribution algorithm using the maximum entropy model. The transmission of COVID-19 was evaluated based on human factors and environmental variables, including climate, terrain and vegetation, along with COVID-19 daily confirmed case location data. The results of the SDM model indicate that population density was the major factor influencing the spread of COVID-19. Altitude, land cover and climatic factor showed low impact. We identified a set of practical, high-resolution, multi-factor-based maximum entropy ecological niche risk prediction systems to assess the transmission risk of the COVID-19 epidemic globally. This study provided a comprehensive analysis of various factors influencing the transmission of COVID-19, incorporating both human and environmental variables. These findings emphasize the role of different types of influencing variables in disease transmission, which could have implications for global health regulations and preparedness strategies for future outbreaks.
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Affiliation(s)
- Jing Pan
- Key Laboratory for Wildlife Diseases and Bio-Security Management of Heilongjiang Province, Heilongjiang Province, Harbin, 150040, People's Republic of China
- College of Wildlife and Protected Area, Northeast Forestry University, Heilongjiang Province, Harbin, 150040, People's Republic of China
| | - Arivizhivendhan Kannan Villalan
- Key Laboratory for Wildlife Diseases and Bio-Security Management of Heilongjiang Province, Heilongjiang Province, Harbin, 150040, People's Republic of China
- College of Wildlife and Protected Area, Northeast Forestry University, Heilongjiang Province, Harbin, 150040, People's Republic of China
| | - Guanying Ni
- HaiXi Animal Disease Control Center, Qinghai Province, Delingha, 817099, People's Republic of China
| | - Renna Wu
- HaiXi Animal Disease Control Center, Qinghai Province, Delingha, 817099, People's Republic of China
| | - ShiFeng Sui
- Zhaoyuan Forest Resources Monitoring and Protection Service Center, Shandong Province, Zhaoyuan, 265400, People's Republic of China
| | - Xiaodong Wu
- China Animal Health and Epidemiology Center, Shandong Province, Qingdao, 266032, People's Republic of China.
| | - XiaoLong Wang
- Key Laboratory for Wildlife Diseases and Bio-Security Management of Heilongjiang Province, Heilongjiang Province, Harbin, 150040, People's Republic of China.
- College of Wildlife and Protected Area, Northeast Forestry University, Heilongjiang Province, Harbin, 150040, People's Republic of China.
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Marini M, Demichelis A, Menicagli D, Mancini G, Panizza F, Bilancini E, Cevolani G. I want to be safe: understanding the main drivers behind vaccination choice throughout the pandemic. BMC Public Health 2024; 24:1111. [PMID: 38649925 PMCID: PMC11036553 DOI: 10.1186/s12889-024-18511-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 04/03/2024] [Indexed: 04/25/2024] Open
Abstract
BACKGROUND Despite being a major advancement in modern medicine, vaccines face widespread hesitancy and refusal, posing challenges to immunization campaigns. The COVID-19 pandemic accentuated vaccine hesitancy, emphasizing the pivotal role of beliefs in efficacy and safety on vaccine acceptance rates. This study explores the influence of efficacy and safety perceptions on vaccine uptake in Italy during the pandemic. METHODS We administered a 70-item questionnaire to a representative sample of 600 Italian speakers. Participants were tasked with assessing the perceived effectiveness and safety of each vaccine dose, along with providing reasons influencing their vaccination choices. Additionally, we conducted an experimental manipulation, exploring the effects of four framing messages that emphasized safety and/or efficacy on participants' willingness to receive a hypothetical fourth vaccine dose. Furthermore, participants were asked about their level of trust in the scientific community and public authorities, as well as their use of different information channels for obtaining COVID-19-related information. RESULTS Our study reveals a dynamic shift in vaccine efficacy and safety perceptions throughout the COVID-19 pandemic, potentially influencing vaccination compliance. Initially perceived as more effective than safe, this assessment reversed by the time of the third dose. Beliefs regarding safety, rather than efficacy, played a significant role in anticipating future vaccinations (e.g., the booster dose). Safety-focused messages positively affected vaccination intent, while efficacy-focused messages showed limited impact. We also observed a changing trend in reasons for vaccination, with a decline in infection-related reasons and an increase in social related ones. Furthermore, trust dynamics evolved differently for public authorities and the scientific community. CONCLUSIONS Vaccine perception is a dynamic process shaped by evolving factors like efficacy and safety perceptions, trust levels, and individual motivations. Our study sheds light on the complex dynamics that underlie the perception of vaccine safety and efficacy, and their impact on willingness to vaccinate. We discuss these results in light of bounded rationality, loss aversion and classic utility theory.
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Affiliation(s)
- Marco Marini
- IMT School for Advanced Studies Lucca, Lucca, Italy.
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Majumder MAA, Bharatha A, Kumar S, Chatterjee M, Gupta S, Harewood H, Singh K, Johnson WMS, Rajasundaram A, Dutta SB, Prasad SV, Rahman S, Kabir R, Parsa AD, Gaur U, Rabbi AMF, Krishnamurthy K, Mohammad S, Chode V, Haque M, Campbell MH. Self-reported side effects of COVID-19 vaccines among health professions students in India. PeerJ 2024; 12:e17083. [PMID: 38590705 PMCID: PMC11000642 DOI: 10.7717/peerj.17083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 02/19/2024] [Indexed: 04/10/2024] Open
Abstract
Studies focusing on the safety and common side effects of vaccines play a crucial role in enhancing public acceptance of vaccination. Research is scarce regarding the usage of COVID-19 vaccines and the side effects experienced by health professions students in India and other countries. This study aimed to document self-reported side effects associated with COVID-19 vaccination among medical and dental students of six medical and dental colleges and teaching hospitals in four states (Tamil Nadu, Madhya Pradesh, Gujarat, and West Bengal) of India. A cross-sectional survey using purposive sampling of medical and dental students was conducted from 26 April to 26 May 2021. Data was collected using a Google Forms questionnaire capturing information regarding receiving COVID-19 vaccines, side effects and symptoms, onset and duration of symptoms, use of treatment to alleviate symptoms, awareness of haematologic risks associated with vaccination, and side effects from previous (non-COVID-19) vaccinations. The majority (94.5%) of participants received both doses of the Covishield/AstraZeneca COVID-19 vaccine. Among participants (n = 492), 45.3% (n = 223) reported one or more side effects. The most frequently reported side effects were soreness of the injected arm (80.3%), tiredness (78.5%), fever (71.3%), headache (64.1%), and hypersomnia (58.7%). The two most common severe symptoms were fever (14.8%) and headache (13%). Most side effects appeared on the day of vaccination: soreness of the injection site (57%), fever (43.1%), and tiredness (42.6%). Most reported symptoms persisted for one to three days-soreness of the injection site (53%), fever (47.1%), and headache (42.6%). Logistic regression showed that women were almost 85% less likely to report side effects. The study's findings corroborate the safety of the Covishield/AstraZeneca vaccine's first dose, evidenced by the relatively minor and transient nature of the side effects. However, the study underscores the necessity for ongoing research to assess the long-term impacts of COVID-19 vaccines, especially in the context of booster doses, thereby contributing to the global understanding of vaccine safety and efficacy.
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Affiliation(s)
- Md Anwarul Azim Majumder
- Faculty of Medical Sciences, The University of the West Indies, Cave Hill Campus, Bridgetown, Barbados
- Public Health Foundation of Bangladesh, Dhaka, Bangladesh
| | - Ambadasu Bharatha
- Faculty of Medical Sciences, The University of the West Indies, Cave Hill Campus, Bridgetown, Barbados
| | | | - Madhuri Chatterjee
- Shri Ramkrishna Institute of Medical Science, Durgapur, West Bengal, India
| | - Subir Gupta
- Faculty of Medical Sciences, The University of the West Indies, Cave Hill Campus, Bridgetown, Barbados
| | - Heather Harewood
- Faculty of Medical Sciences, The University of the West Indies, Cave Hill Campus, Bridgetown, Barbados
| | - Keerti Singh
- Faculty of Medical Sciences, The University of the West Indies, Cave Hill Campus, Bridgetown, Barbados
| | - WMS Johnson
- Sree Balaji Medical College and Hospital, Chennai, Tamil Nadu, India
| | | | - Sudeshna Banerjee Dutta
- Department of Medical Surgical Nursing (Critical care nursing), Shri Anand Institute of Nursing, Rajkot, Gujarat, India
| | | | - Sayeeda Rahman
- American University of Integrative Sciences (AUIS), Bridgetown, Barbados
| | - Russell Kabir
- Anglia Ruskin University, Chelmsford, Essex, United Kingdom
| | | | - Uma Gaur
- Faculty of Medical Sciences, The University of the West Indies, Cave Hill Campus, Bridgetown, Barbados
| | | | - Kandamaran Krishnamurthy
- Faculty of Medical Sciences, The University of the West Indies, Cave Hill Campus, Bridgetown, Barbados
| | - Shegufta Mohammad
- Health Education Department, Empower Me First College, Geneva, Switzerland
| | | | - Mainul Haque
- National Defence University of Malaysia, Kuala Lumpur, Malaysia
| | - Michael H. Campbell
- Faculty of Medical Sciences, The University of the West Indies, Cave Hill Campus, Bridgetown, Barbados
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Razzaque MS. Can adverse cardiac events of the COVID-19 vaccine exacerbate preexisting diseases? Expert Rev Anti Infect Ther 2024; 22:131-137. [PMID: 38284355 DOI: 10.1080/14787210.2024.2311837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 01/25/2024] [Indexed: 01/30/2024]
Abstract
INTRODUCTION SARS-CoV-2 infection and COVID-19 vaccination can both lead to serious cardiac conditions such as myocarditis, arrhythmia, acute myocardial infarction, and coagulopathy. Further studies are needed to better understand the risks and benefits of COVID-19 vaccination, and to determine the best course of action for individuals with preexisting heart conditions. AREAS COVERED The current knowledge and challenges in understanding vaccine-associated heart issues concerning the COVID-19 pandemic are briefly summarized, highlighting similar cardiac conditions caused by either SARS-CoV-2 infection or COVID-19 vaccination and the potential clinical impacts. EXPERT OPINION The short-term risks of severe cardiovascular side effects following COVID-19 vaccination are relatively low. However, further studies are needed to determine whether adverse vaccination events outweigh the long-term benefits in specific groups of individuals. Since cardiac inflammation, blood pressure dysregulation, coagulopathy, acute myocardial infarction, or arrhythmia could be the consequences of either SARS-CoV-2 infection or COVID-19 vaccination, clinical questions should be asked whether the COVID-19 vaccine worsens the condition in persons with preexisting heart diseases. It is important to carefully assess the potential risks and benefits of COVID-19 vaccination, especially for individuals with preexisting heart conditions, and to continue monitoring and studying the long-term effects of vaccination on cardiovascular health.
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Affiliation(s)
- Mohammed S Razzaque
- Professor of Pathology, Lake Erie College of Osteopathic Medicine, Erie, PA, USA
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Shin SY, Kim JH, Kim JH, Kwon H, Park C, Choi DH, Cho SM, Shin JE. Effect of COVID-19 infection and vaccination on SARS-CoV-2 antibody titer change following ovarian stimulation: Prospective analysis of IVF outcomes. Medicine (Baltimore) 2024; 103:e37349. [PMID: 38489720 PMCID: PMC10939662 DOI: 10.1097/md.0000000000037349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 12/28/2023] [Accepted: 02/02/2024] [Indexed: 03/17/2024] Open
Abstract
The coronavirus disease 2019 (COVID-19) outbreak caused by SARS-CoV-2 (severe acute respiratory syndrome coronavirus-2) has affected various medical fields worldwide. However, relatively few studies have examined the impact of COVID-19 infection and vaccination on in vitro fertilization (IVF) outcomes and changes in SARS-CoV-2 antibody concentration in follicular fluid (FF). A total of 45 women were prospectively recruited and assigned to 3 groups: uninfected and non-vaccinated control group (Control group), infected group (COVID + group), and vaccinated group (Vaccination group). Serum and follicular fluid (FF) estradiol, progesterone, and SARS-CoV-2 antibody concentrations were measured. There were no statistical differences in the total number of retrieved oocytes (P = .291), mature oocytes (P = .416), and good-quality embryos (P = .694) among the 3 groups. In the vaccination group, BNT162b2 exhibited a significantly lower trigger-day serum estradiol/MII oocyte level (110.6 pg/mL) than other vaccines (289.5 pg/mL) (P = .006). No statistical differences in serum (P = .687) and FF (P = .108) SARS-CoV-2 antibody changes were noted among the 3 groups. Only FF antibody changes exhibited statistically significant differences between the BNT162b2 and other vaccine subgroups (P = .047). COVID-19 infection and vaccination do not affect IVF outcomes. However, the effect of BNT162b2 on steroidogenesis of the mature oocyte and FF SARS-CoV2 antibody titer should be further investigated.
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Affiliation(s)
- So Yeon Shin
- Department of Obstetrics and Gynecology, CHA Fertility Center Bundang, Gyeonggi-do, Korea
| | - Jee Hyun Kim
- Department of Obstetrics and Gynecology, CHA Fertility Center Bundang, Gyeonggi-do, Korea
| | - Ji Hyang Kim
- Department of Obstetrics and Gynecology, CHA Fertility Center Bundang, Gyeonggi-do, Korea
| | - Hwang Kwon
- Department of Obstetrics and Gynecology, CHA Fertility Center Bundang, Gyeonggi-do, Korea
| | - Chan Park
- Department of Obstetrics and Gynecology, CHA Fertility Center Bundang, Gyeonggi-do, Korea
| | - Dong Hee Choi
- Department of Obstetrics and Gynecology, CHA Fertility Center Bundang, Gyeonggi-do, Korea
| | - Sun-mi Cho
- Department of Laboratory Medicine, CHA Bundang Medical Center, CHA University, Gyeonggi-do, Korea
| | - Ji Eun Shin
- Department of Obstetrics and Gynecology, CHA Fertility Center Bundang, Gyeonggi-do, Korea
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Seree-aphinan C, Rattanakaemakorn P, Suchonwanit P, Thadanipon K, Ratanapokasatit Y, Yongpisarn T, Malathum K, Simaroj P, Setthaudom C, Lohjai O, Tanrattanakorn S, Chanprapaph K. Immunogenicity of Intradermal Versus Intramuscular BNT162b2 COVID-19 Booster Vaccine in Patients with Immune-Mediated Dermatologic Diseases: A Non-Inferiority Randomized Controlled Trial. Vaccines (Basel) 2024; 12:73. [PMID: 38250886 PMCID: PMC10819288 DOI: 10.3390/vaccines12010073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 01/04/2024] [Accepted: 01/05/2024] [Indexed: 01/23/2024] Open
Abstract
The intradermal route has emerged as a dose-sparing alternative during the coronavirus disease 2019 (COVID-19) pandemic. Despite its efficacy in healthy populations, its immunogenicity has not been tested in immune-mediated dermatologic disease (IMDD) patients. This assessor-blinded, randomized-controlled, non-inferiority trial recruited patients with two representative IMDDs (i.e., psoriasis and autoimmune bullous diseases) to vaccinate with fractionated-dose intradermal (fID) or standard intramuscular (sIM) BNT162b2 vaccines as a fourth booster dose under block randomization stratified by age, sex, and their skin diseases. Post-vaccination SARS-CoV-2-specific IgG and interferon-γ responses measured 4 and 12 weeks post-intervention were serological surrogates used for demonstrating treatment effects. Mean differences in log-normalized outcome estimates were calculated with multivariable linear regression adjusting for their baseline values, systemic immunosuppressants used, and prior COVID-19 vaccination history. The non-inferiority margin was set for fID to retain >80% immunogenicity of sIM. With 109 participants included, 53 received fID (all entered an intention-to-treat analysis). The fID demonstrated non-inferiority to sIM in humoral (mean outcome estimates of sIM: 3.3, ΔfID-sIM [mean, 95%CI]: -0.1, -0.3 to 0.0) and cellular (mean outcome estimates of sIM: 3.2, ΔfID-sIM [mean, 95%CI]: 0.1, -0.2 to 0.3) immunogenicity outcomes. Two psoriasis patients from the fID arm (3.8%) developed injection-site Koebner's phenomenon. Fewer fID recipients experienced post-vaccination fever (fID vs. sIM: 1.9% vs. 12.5%, p = 0.027). The overall incidence of disease flare-ups was low without a statistically significant difference between groups. The intradermal BNT162b2 vaccine is a viable booster option for IMDD patients troubled by post-vaccination fever; its role in mitigating the risk of flare-ups remains unclear.
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Affiliation(s)
- Chutima Seree-aphinan
- Department of Medicine, Division of Dermatology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand; (C.S.-a.); (P.R.); (P.S.); (Y.R.); (T.Y.); (S.T.)
- Department of Internal Medicine, Division of Dermatology, Faculty of Medicine, Prince of Songkla University, Songkhla 90110, Thailand
| | - Ploysyne Rattanakaemakorn
- Department of Medicine, Division of Dermatology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand; (C.S.-a.); (P.R.); (P.S.); (Y.R.); (T.Y.); (S.T.)
| | - Poonkiat Suchonwanit
- Department of Medicine, Division of Dermatology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand; (C.S.-a.); (P.R.); (P.S.); (Y.R.); (T.Y.); (S.T.)
| | - Kunlawat Thadanipon
- Department of Medicine, Division of Dermatology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand; (C.S.-a.); (P.R.); (P.S.); (Y.R.); (T.Y.); (S.T.)
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
| | - Yanisa Ratanapokasatit
- Department of Medicine, Division of Dermatology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand; (C.S.-a.); (P.R.); (P.S.); (Y.R.); (T.Y.); (S.T.)
| | - Tanat Yongpisarn
- Department of Medicine, Division of Dermatology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand; (C.S.-a.); (P.R.); (P.S.); (Y.R.); (T.Y.); (S.T.)
| | - Kumthorn Malathum
- Department of Medicine, Division of Infectious Diseases, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand;
| | - Pornchai Simaroj
- Department of Ophthalmology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand;
| | - Chavachol Setthaudom
- Immunology Laboratory, Department of Pathology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand; (C.S.); (O.L.)
| | - Onchuma Lohjai
- Immunology Laboratory, Department of Pathology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand; (C.S.); (O.L.)
| | - Somsak Tanrattanakorn
- Department of Medicine, Division of Dermatology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand; (C.S.-a.); (P.R.); (P.S.); (Y.R.); (T.Y.); (S.T.)
| | - Kumutnart Chanprapaph
- Department of Medicine, Division of Dermatology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand; (C.S.-a.); (P.R.); (P.S.); (Y.R.); (T.Y.); (S.T.)
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Mead MN, Seneff S, Wolfinger R, Rose J, Denhaerynck K, Kirsch S, McCullough PA. COVID-19 mRNA Vaccines: Lessons Learned from the Registrational Trials and Global Vaccination Campaign. Cureus 2024; 16:e52876. [PMID: 38274635 PMCID: PMC10810638 DOI: 10.7759/cureus.52876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/24/2024] [Indexed: 01/27/2024] Open
Abstract
Our understanding of COVID-19 vaccinations and their impact on health and mortality has evolved substantially since the first vaccine rollouts. Published reports from the original randomized phase 3 trials concluded that the COVID-19 mRNA vaccines could greatly reduce COVID-19 symptoms. In the interim, problems with the methods, execution, and reporting of these pivotal trials have emerged. Re-analysis of the Pfizer trial data identified statistically significant increases in serious adverse events (SAEs) in the vaccine group. Numerous SAEs were identified following the Emergency Use Authorization (EUA), including death, cancer, cardiac events, and various autoimmune, hematological, reproductive, and neurological disorders. Furthermore, these products never underwent adequate safety and toxicological testing in accordance with previously established scientific standards. Among the other major topics addressed in this narrative review are the published analyses of serious harms to humans, quality control issues and process-related impurities, mechanisms underlying adverse events (AEs), the immunologic basis for vaccine inefficacy, and concerning mortality trends based on the registrational trial data. The risk-benefit imbalance substantiated by the evidence to date contraindicates further booster injections and suggests that, at a minimum, the mRNA injections should be removed from the childhood immunization program until proper safety and toxicological studies are conducted. Federal agency approval of the COVID-19 mRNA vaccines on a blanket-coverage population-wide basis had no support from an honest assessment of all relevant registrational data and commensurate consideration of risks versus benefits. Given the extensive, well-documented SAEs and unacceptably high harm-to-reward ratio, we urge governments to endorse a global moratorium on the modified mRNA products until all relevant questions pertaining to causality, residual DNA, and aberrant protein production are answered.
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Affiliation(s)
- M Nathaniel Mead
- Biology and Nutritional Epidemiology, Independent Research, Copper Hill, USA
| | - Stephanie Seneff
- Computer Science and Artificial Intelligence Laboratory, Massachusetts Institute of Technology, Cambridge, USA
| | - Russ Wolfinger
- Biostatistics and Epidemiology, Independent Research, Research Triangle Park, USA
| | - Jessica Rose
- Immunology and Public Health Research, Independent Research, Ottawa, CAN
| | - Kris Denhaerynck
- Epidemiology and Biostatistics, Independent Research, Basel, CHE
| | - Steve Kirsch
- Data Science, Independent Research, Los Angeles, USA
| | - Peter A McCullough
- Cardiology, Epidemiology, and Public Health, McCullough Foundation, Dallas, USA
- Cardiology, Epidemiology, and Public Health, Truth for Health Foundation, Tucson, USA
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Rouvinski A, Friedman A, Kirillov S, Attal JH, Kumari S, Fahoum J, Wiener R, Magen S, Plotkin Y, Chemtob D, Bercovier H. Antibody response in elderly vaccinated four times with an mRNA anti-COVID-19 vaccine. Sci Rep 2023; 13:14165. [PMID: 37644113 PMCID: PMC10465611 DOI: 10.1038/s41598-023-41399-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Accepted: 08/25/2023] [Indexed: 08/31/2023] Open
Abstract
The humoral response after the fourth dose of a mRNA vaccine against COVID-19 has not been adequately described in elderly recipients, particularly those not exposed previously to SARS-CoV-2. Serum anti-RBD IgG levels (Abbott SARS-CoV-2 IgG II Quant assay) and neutralizing capacities (spike SARS-CoV-2 pseudovirus Wuhan and Omicron BA.1 variant) were measured after the third and fourth doses of a COVID-19 mRNA vaccine among 46 elderly residents (median age 85 years [IQR 81; 89]) of an assisted living facility. Among participants never infected by SARS-CoV-2, the mean serum IgG levels against RBD (2025 BAU/ml), 99 days after the fourth vaccine, was as high as 76 days after the third vaccine (1987 BAU/ml), and significantly higher (p = 0.030) when the latter were corrected for elapsed time. Neutralizing antibody levels against the historical Wuhan strain were significantly higher (Mean 1046 vs 1573; p = 0.002) and broader (against Omicron) (Mean 170 vs 375; p = 0.018), following the fourth vaccine. The six individuals with an Omicron breakthrough infection mounted strong immune responses for anti-RBD and neutralizing antibodies against the Omicron variant indicating that the fourth vaccine dose did not prevent a specific adaptation of the immune response. These findings point out the value of continued vaccine boosting in the elderly population.
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Affiliation(s)
- Alexander Rouvinski
- Department of Microbiology and Molecular Genetics, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.
| | - Ahuva Friedman
- Department of Microbiology and Molecular Genetics, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Saveliy Kirillov
- Department of Microbiology and Molecular Genetics, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- Department of General Biology and Genomics, L.N. Gumilyov Eurasian National University, Astana, Kazakhstan
| | - Jordan Hannink Attal
- Braun School of Public Health and Community Medicine, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- Department of Tuberculosis and AIDS, State of Israel Ministry of Health, Jerusalem, Israel
| | - Sujata Kumari
- Department of Microbiology and Molecular Genetics, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- Department of Biochemistry and Molecular Biology, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Jamal Fahoum
- Department of Biochemistry and Molecular Biology, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Reuven Wiener
- Department of Biochemistry and Molecular Biology, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Sophie Magen
- Department of Clinical Biochemistry, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Yevgeni Plotkin
- Department of Anesthesiology, Critical Care and Pain Medicine, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Daniel Chemtob
- Braun School of Public Health and Community Medicine, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- Department of Tuberculosis and AIDS, State of Israel Ministry of Health, Jerusalem, Israel
| | - Herve Bercovier
- Department of Microbiology and Molecular Genetics, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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Scholkmann F, May CA. COVID-19, post-acute COVID-19 syndrome (PACS, "long COVID") and post-COVID-19 vaccination syndrome (PCVS, "post-COVIDvac-syndrome"): Similarities and differences. Pathol Res Pract 2023; 246:154497. [PMID: 37192595 DOI: 10.1016/j.prp.2023.154497] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 04/25/2023] [Accepted: 05/01/2023] [Indexed: 05/18/2023]
Abstract
Worldwide there have been over 760 million confirmed coronavirus disease 2019 (COVID-19) cases, and over 13 billion COVID-19 vaccine doses have been administered as of April 2023, according to the World Health Organization. An infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can lead to an acute disease, i.e. COVID-19, but also to a post-acute COVID-19 syndrome (PACS, "long COVID"). Currently, the side effects of COVID-19 vaccines are increasingly being noted and studied. Here, we summarise the currently available indications and discuss our conclusions that (i) these side effects have specific similarities and differences to acute COVID-19 and PACS, that (ii) a new term should be used to refer to these side effects (post-COVID-19 vaccination syndrome, PCVS, colloquially "post-COVIDvac-syndrome"), and that (iii) there is a need to distinguish between acute COVID-19 vaccination syndrome (ACVS) and post-acute COVID-19 vaccination syndrome (PACVS) - in analogy to acute COVID-19 and PACS ("long COVID"). Moreover, we address mixed forms of disease caused by natural SARS-CoV-2 infection and COVID-19 vaccination. We explain why it is important for medical diagnosis, care and research to use the new terms (PCVS, ACVS and PACVS) in order to avoid confusion and misinterpretation of the underlying causes of disease and to enable optimal medical therapy. We do not recommend to use the term "Post-Vac-Syndrome" as it is imprecise. The article also serves to address the current problem of "medical gaslighting" in relation to PACS and PCVS by raising awareness among the medical professionals and supplying appropriate terminology for disease.
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Affiliation(s)
- Felix Scholkmann
- University Hospital Zurich, University of Zurich, 8091 Zurich, Switzerland.
| | - Christian-Albrecht May
- Department of Anatomy, Faculty of Medicine Carl Gustav Carus, TU Dresden, 01307 Dresden, Germany
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11
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Echaide M, Chocarro de Erauso L, Bocanegra A, Blanco E, Kochan G, Escors D. mRNA Vaccines against SARS-CoV-2: Advantages and Caveats. Int J Mol Sci 2023; 24:ijms24065944. [PMID: 36983017 PMCID: PMC10051235 DOI: 10.3390/ijms24065944] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 03/17/2023] [Accepted: 03/18/2023] [Indexed: 03/30/2023] Open
Abstract
The application of BNT162b2 and mRNA-1273 vaccines against SARS-CoV-2 infection has constituted a determinant resource to control the COVID-19 pandemic. Since the beginning of 2021, millions of doses have been administered in several countries of North and South America and Europe. Many studies have confirmed the efficacy of these vaccines in a wide range of ages and in vulnerable groups of people against COVID-19. Nevertheless, the emergence and selection of new variants have led to a progressive decay in vaccine efficacy. Pfizer-BioNTech and Moderna developed updated bivalent vaccines-Comirnaty and Spikevax-to improve responses against the SARS-CoV-2 Omicron variants. Frequent booster doses with monovalent or bivalent mRNA vaccines, the emergence of some rare but serious adverse events and the activation of T-helper 17 responses suggest the need for improved mRNA vaccine formulations or the use of other types of vaccines. In this review, we discuss the advantages and limitations of mRNA vaccines targeting SARS-CoV-2 focusing on the most recent, related publications.
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Affiliation(s)
- Miriam Echaide
- Oncoimmunology Unit, Instituto de Investigación Sanitaria de Navarra (IdiSNA), Navarrabiomed-Fundación Miguel Servet, Universidad Pública de Navarra (UPNA), Hospital Universitario de Navarra (HUN), 31008 Pamplona, Spain
| | - Luisa Chocarro de Erauso
- Oncoimmunology Unit, Instituto de Investigación Sanitaria de Navarra (IdiSNA), Navarrabiomed-Fundación Miguel Servet, Universidad Pública de Navarra (UPNA), Hospital Universitario de Navarra (HUN), 31008 Pamplona, Spain
| | - Ana Bocanegra
- Oncoimmunology Unit, Instituto de Investigación Sanitaria de Navarra (IdiSNA), Navarrabiomed-Fundación Miguel Servet, Universidad Pública de Navarra (UPNA), Hospital Universitario de Navarra (HUN), 31008 Pamplona, Spain
| | - Ester Blanco
- Oncoimmunology Unit, Instituto de Investigación Sanitaria de Navarra (IdiSNA), Navarrabiomed-Fundación Miguel Servet, Universidad Pública de Navarra (UPNA), Hospital Universitario de Navarra (HUN), 31008 Pamplona, Spain
| | - Grazyna Kochan
- Oncoimmunology Unit, Instituto de Investigación Sanitaria de Navarra (IdiSNA), Navarrabiomed-Fundación Miguel Servet, Universidad Pública de Navarra (UPNA), Hospital Universitario de Navarra (HUN), 31008 Pamplona, Spain
| | - David Escors
- Oncoimmunology Unit, Instituto de Investigación Sanitaria de Navarra (IdiSNA), Navarrabiomed-Fundación Miguel Servet, Universidad Pública de Navarra (UPNA), Hospital Universitario de Navarra (HUN), 31008 Pamplona, Spain
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12
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Torres P, Sancho-Saldaña A, Gil Sánchez A, Peralta S, Solana MJ, Bakkioui S, González-Mingot C, Quibus L, Ruiz-Fernández E, San Pedro-Murillo E, Brieva L. A prospective study of cellular immune response to booster COVID-19 vaccination in multiple sclerosis patients treated with a broad spectrum of disease-modifying therapies. J Neurol 2023; 270:2380-2391. [PMID: 36933032 PMCID: PMC10024306 DOI: 10.1007/s00415-023-11575-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 01/12/2023] [Accepted: 01/13/2023] [Indexed: 03/19/2023]
Abstract
BACKGROUND Most people with Multiple Sclerosis (pwMS) are subjected to immunomodulatory disease-modifying treatments (DMTs). As a result, immune responses to COVID-19 vaccinations could be compromised. There are few data on cellular immune responses to the use of COVID-19 vaccine boosters in pwMS under a broad spectrum of DMTs. METHODS In this prospective study, we analysed cellular immune responses to SARS-CoV-2 mRNA booster vaccinations in 159 pwMS with DMT, including: ocrelizumab, rituximab, fingolimod, alemtuzumab, dimethyl fumarate, glatiramer acetate, teriflunomide, natalizumab and cladribine. RESULTS DMTs, and particularly fingolimod, interact with cellular responses to COVID-19 vaccination. One booster dose does not increase cellular immunity any more than two doses, except in the cases of natalizumab and cladribine. SARS-CoV-2 infection combined with two doses of vaccine resulted in a greater cellular immune response, but this was not observed after supplementary booster jabs. Ocrelizumab-treated pwMS who had previously received fingolimod did not develop cellular immunity, even after receiving a booster. The time after MS diagnosis and disability status negatively correlated with cellular immunity in ocrelizumab-treated pwMS in a booster dose cohort. CONCLUSIONS After two doses of SARS-CoV-2 vaccination, a high response yield was achieved, except in patients who had received fingolimod. The effects of fingolimod on cellular immunity persisted for more than 2 years after a change to ocrelizumab (which, in contrast, conserved cellular immunity). Our results confirmed the need to find alternative protective measures for fingolimod-treated people and to consider the possible failure to provide protection against SARS-CoV-2 when switching from fingolimod to ocrelizumab.
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Affiliation(s)
- Pascual Torres
- Metabolic Pathophysiology Research Group, Department of Experimental Medicine, University of Lleida (UdL)-IRBLleida, 25198, Lleida, Spain
- Neuroimmunology Group, Department of Medicine, University of Lleida (UdL)-IRBLleida, 25198, Lleida, Spain
| | - Agustín Sancho-Saldaña
- Neuroimmunology Group, Department of Medicine, University of Lleida (UdL)-IRBLleida, 25198, Lleida, Spain
- Department of Neurology, Hospital Universitari Arnau de Vilanova, 25198, Lleida, Spain
| | - Anna Gil Sánchez
- Neuroimmunology Group, Department of Medicine, University of Lleida (UdL)-IRBLleida, 25198, Lleida, Spain
| | - Silvia Peralta
- Neuroimmunology Group, Department of Medicine, University of Lleida (UdL)-IRBLleida, 25198, Lleida, Spain
- Department of Neurology, Hospital Universitari Arnau de Vilanova, 25198, Lleida, Spain
| | - Maria José Solana
- Neuroimmunology Group, Department of Medicine, University of Lleida (UdL)-IRBLleida, 25198, Lleida, Spain
- Department of Neurology, Hospital Universitari Arnau de Vilanova, 25198, Lleida, Spain
| | - Sofian Bakkioui
- Neuroimmunology Group, Department of Medicine, University of Lleida (UdL)-IRBLleida, 25198, Lleida, Spain
| | - Cristina González-Mingot
- Neuroimmunology Group, Department of Medicine, University of Lleida (UdL)-IRBLleida, 25198, Lleida, Spain
- Department of Neurology, Hospital Universitari Arnau de Vilanova, 25198, Lleida, Spain
| | - Laura Quibus
- Neuroimmunology Group, Department of Medicine, University of Lleida (UdL)-IRBLleida, 25198, Lleida, Spain
- Department of Neurology, Hospital Universitari Arnau de Vilanova, 25198, Lleida, Spain
| | - Emilio Ruiz-Fernández
- Department of Neurology, Hospital Universitari Arnau de Vilanova, 25198, Lleida, Spain
| | | | - Luis Brieva
- Neuroimmunology Group, Department of Medicine, University of Lleida (UdL)-IRBLleida, 25198, Lleida, Spain.
- Department of Neurology, Hospital Universitari Arnau de Vilanova, 25198, Lleida, Spain.
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13
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Almendro-Vázquez P, Laguna-Goya R, Paz-Artal E. Defending against SARS-CoV-2: The T cell perspective. Front Immunol 2023; 14:1107803. [PMID: 36776863 PMCID: PMC9911802 DOI: 10.3389/fimmu.2023.1107803] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 01/16/2023] [Indexed: 01/28/2023] Open
Abstract
SARS-CoV-2-specific T cell response has been proven essential for viral clearance, COVID-19 outcome and long-term memory. Impaired early T cell-driven immunity leads to a severe form of the disease associated with lymphopenia, hyperinflammation and imbalanced humoral response. Analyses of acute SARS-CoV-2 infection have revealed that mild COVID-19 course is characterized by an early induction of specific T cells within the first 7 days of symptoms, coordinately followed by antibody production for an effective control of viral infection. In contrast, patients who do not develop an early specific cellular response and initiate a humoral immune response with subsequent production of high levels of antibodies, develop severe symptoms. Yet, delayed and persistent bystander CD8+ T cell activation has been also reported in hospitalized patients and could be a driver of lung pathology. Literature supports that long-term maintenance of T cell response appears more stable than antibody titters. Up to date, virus-specific T cell memory has been detected 22 months post-symptom onset, with a predominant IL-2 memory response compared to IFN-γ. Furthermore, T cell responses are conserved against the emerging variants of concern (VoCs) while these variants are mostly able to evade humoral responses. This could be partly explained by the high HLA polymorphism whereby the viral epitope repertoire recognized could differ among individuals, greatly decreasing the likelihood of immune escape. Current COVID-19-vaccination has been shown to elicit Th1-driven spike-specific T cell response, as does natural infection, which provides substantial protection against severe COVID-19 and death. In addition, mucosal vaccination has been reported to induce strong adaptive responses both locally and systemically and to protect against VoCs in animal models. The optimization of vaccine formulations by including a variety of viral regions, innovative adjuvants or diverse administration routes could result in a desirable enhanced cellular response and memory, and help to prevent breakthrough infections. In summary, the increasing evidence highlights the relevance of monitoring SARS-CoV-2-specific cellular immune response, and not only antibody levels, as a correlate for protection after infection and/or vaccination. Moreover, it may help to better identify target populations that could benefit most from booster doses and to personalize vaccination strategies.
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Affiliation(s)
- Patricia Almendro-Vázquez
- Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - Rocío Laguna-Goya
- Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- Department of Immunology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Estela Paz-Artal
- Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- Department of Immunology, Hospital Universitario 12 de Octubre, Madrid, Spain
- Department of Immunology, Ophthalmology and ENT, Complutense University School of Medicine, Madrid, Spain
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14
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Majumder MAA, Singh K, Johnson WMS, Rajasundaram A, Gupta S, Gaur U, Kumar S, Chatterjee M, Fazle Rabbi AM, Sangishetti VP, Rahman S, Campbell MH, Harewood H, Bharatha A, Krishnamurthy K, Kabir R, Parsa AD, Mohammmad S, Haque M, Razzaque MS. Evaluation of Short-Term Side Effects Following the First Dose of COVID-19 Vaccines Among Physicians and Dentists: A Cross-Sectional Study from India. J Multidiscip Healthc 2023; 16:161-174. [PMID: 36700174 PMCID: PMC9869700 DOI: 10.2147/jmdh.s390364] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 01/10/2023] [Indexed: 01/20/2023] Open
Abstract
Background Efficacy and safety are fundamental for the development of successful COVID-19 vaccines. Vaccine-associated side effects influence vaccine hesitancy. This study investigated the prevalence, severity, and onset of side effects following the first dose of COVID-19 vaccines among physicians and dentists working in various healthcare settings across India. Methods A cross-sectional survey collected self-report data from April to June 2021 on side effects following the first dose of the vaccine. An online validated questionnaire using the Google Docs® platform was circulated via email and social media platforms. Results More than 40% of participants experienced at least one side effect after the first dose of vaccination; the most common were mild and resolved within three days after vaccination. More than 91% of respondents received the Covishield (AstraZeneca) vaccine; the most prevalent adverse effects were soreness of the injected arm (78.9%), tiredness (71.1%), and fever (54.9%). Logistic regression showed that women were almost 60% less likely to report side effects. Conclusion Findings supported the safety of the first dose of the COVID-19 vaccine based on relatively few self-limiting side effects, mainly soreness of the injected arm and tiredness. Further research is needed to determine the long-term safety of COVID-19 vaccines, especially after booster doses.
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Affiliation(s)
- Md Anwarul Azim Majumder
- Public Health Foundation of Bangladesh, Dhaka, Bangladesh,Faculty of Medical Sciences, The University of the West Indies, Bridgetown, Barbados
| | - Keerti Singh
- Faculty of Medical Sciences, The University of the West Indies, Bridgetown, Barbados
| | - W M S Johnson
- Department of Anatomy, Sree Balaji Medical College and Hospital, Chennai, Tamil Nadu, India,Correspondence: WMS Johnson, Sree Balaji Medical College and Hospital, Chennai, Tamil Nadu, India, Email ;
| | - Archana Rajasundaram
- Department of Anatomy, Sree Balaji Medical College and Hospital, Chennai, Tamil Nadu, India
| | - Subir Gupta
- Faculty of Medical Sciences, The University of the West Indies, Bridgetown, Barbados
| | - Uma Gaur
- Faculty of Medical Sciences, The University of the West Indies, Bridgetown, Barbados
| | - Santosh Kumar
- Karnavati School of Dentistry, Karnavati University, Ahmedabad, Gujarat, India
| | - Madhuri Chatterjee
- Department of Pharmacology, Shri Ramkrishna Institute of Medical Science, Durgapur, West Bengal, India
| | | | | | - Sayeeda Rahman
- School of Medicine, American University of Integrative Sciences (AUIS), Bridgetown, Barbados
| | - Michael H Campbell
- Faculty of Medical Sciences, The University of the West Indies, Bridgetown, Barbados
| | - Heather Harewood
- Faculty of Medical Sciences, The University of the West Indies, Bridgetown, Barbados
| | - Ambadasu Bharatha
- Faculty of Medical Sciences, The University of the West Indies, Bridgetown, Barbados
| | | | - Russell Kabir
- Faculty of Health, Education, Medicine and Social Care, Anglia Ruskin University, Chelmsford, Essex, UK
| | - Ali Davod Parsa
- Faculty of Health, Education, Medicine and Social Care, Anglia Ruskin University, Chelmsford, Essex, UK
| | | | - Mainul Haque
- Faculty of Medicine and Defence Health, Universiti Pertahanan Nasional Malaysia (National Defence University of Malaysia), Kuala Lumpur, 57000, Malaysia,Mainul Haque, Faculty of Medicine and Defence Health, National Defence University of Malaysia, Kuala Lumpur, Malaysia, Email ;
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