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Harvey BJ, McElvaney NG. Sex differences in airway disease: estrogen and airway surface liquid dynamics. Biol Sex Differ 2024; 15:56. [PMID: 39026347 PMCID: PMC11264786 DOI: 10.1186/s13293-024-00633-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 07/03/2024] [Indexed: 07/20/2024] Open
Abstract
Biological sex differences exist for many airway diseases in which females have either worse or better health outcomes. Inflammatory airway diseases such as cystic fibrosis (CF) and asthma display a clear male advantage in post-puberty while a female benefit is observed in asthma during the pre-puberty years. The influence of menstrual cycle stage and pregnancy on the frequency and severity of pulmonary exacerbations in CF and asthma point to a role for sex steroid hormones, particularly estrogen, in underpinning biological sex differences in these diseases. There are many ways by which estrogen may aggravate asthma and CF involving disturbances in airway surface liquid (ASL) dynamics, inappropriate hyper-immune and allergenic responses, as well as exacerbation of pathogen virulence. The deleterious effect of estrogen on pulmonary function in CF and asthma contrasts with the female advantage observed in airway diseases characterised by pulmonary edema such as pneumonia, acute respiratory distress syndrome (ARDS) and COVID-19. Airway surface liquid hypersecretion and alveolar flooding are hallmarks of ARDS and COVID-19, and contribute to the morbidity and mortality of severe forms of these diseases. ASL dynamics encompasses the intrinsic features of the thin lining of fluid covering the airway epithelium which regulate mucociliary clearance (ciliary beat, ASL height, volume, pH, viscosity, mucins, and channel activating proteases) in addition to innate defence mechanisms (pathogen virulence, cytokines, defensins, specialised pro-resolution lipid mediators, and metabolism). Estrogen regulation of ASL dynamics contributing to biological sex differences in CF, asthma and COVID-19 is a major focus of this review.
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Affiliation(s)
- Brian J Harvey
- Faculty of Medicine and Health Sciences, Royal College of Surgeons in Ireland, 126 St Stephens Green, Dublin 2, Ireland.
- Department of Medicine, RCSI ERC, Beaumont Hospital, Dublin 2, Ireland.
| | - Noel G McElvaney
- Faculty of Medicine and Health Sciences, Royal College of Surgeons in Ireland, 126 St Stephens Green, Dublin 2, Ireland
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McElvaney OJ, Cleary B, Fraughen DD, Kelly G, McElvaney OF, Murphy MP, Branagan P, Gunaratnam C, Carroll TP, Goss CH, McElvaney NG. Safety and Reactogenicity of COVID-19 Vaccination in Severe Alpha-1 Antitrypsin Deficiency. CHRONIC OBSTRUCTIVE PULMONARY DISEASES (MIAMI, FLA.) 2024; 11:3-12. [PMID: 37676644 PMCID: PMC10913930 DOI: 10.15326/jcopdf.2023.0432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/31/2023] [Indexed: 09/08/2023]
Abstract
Background Patients with alpha-1 antitrypsin deficiency (AATD) exhibit dysregulated inflammatory responses and a predilection for autoimmunity. While the adverse event (AE) profiles of COVID-19 vaccines in several chronic inflammatory conditions are now available, safety and tolerability data for patients with severe AATD have yet to be described. The feasibility of coadministering vaccines against COVID-19 and influenza in this population is similarly unclear. Methods We conducted a prospective study of 170 patients with Pi*ZZ genotype AATD receiving their initial vaccination series with ChAdOx1 nCoV-19 (AstraZeneca). Patients were monitored clinically for AEs over the week that followed their first and second doses. In parallel, we conducted the same assessments in patients with Pi*MM genotype chronic obstructive pulmonary disease (COPD) (n=160) and Pi*MM individuals without lung disease (n=150). The Pi*ZZ cohort was subsequently followed through 2 consecutive mRNA-based booster vaccines (monovalent and bivalent BNT162b2, Pfizer/BioNTech). To assess the safety of combined vaccination against COVID-19 and influenza, the quadrivalent influenza vaccine was administered to participants attending for their second COVID-19 booster vaccination, either on the same day or following a 1-week interval. Results Pi*ZZ AATD participants did not display increased AEs compared to Pi*MM COPD or Pi*MM non-lung disease controls. Although unexpected and serious vaccine-associated AEs did occur, the majority of AEs experienced across the 3 groups were mild and self-limiting. The AATD demographic at highest risk for AEs (especially systemic and prolonged AEs) was young females. No increase in AE risk was observed in patients with established emphysema, sonographic evidence of liver disease, or in those receiving intravenous augmentation therapy. AE incidence declined sharply following the initial vaccine series. Same-day coadministration of the COVID-19 mRNA bivalent booster vaccine and the annual influenza vaccine did not result in increased AEs compared to sequential vaccines 1 week apart. Conclusions Despite their pro-inflammatory state, patients with severe AATD are not at increased risk of AEs or serious AEs compared to patients with nonhereditary COPD and patients without lung disease. Same-day coadministration of COVID-19 booster vaccines with the annual influenza vaccine is feasible, safe, and well-tolerated in this population.
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Affiliation(s)
- Oliver J. McElvaney
- Department of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
- National Centre for Alpha-1 Antitrypsin Deficiency, Beaumont Hospital, Dublin, Ireland
- Seattle Children’s Research Institute, Seattle, Washington, United States
- Department of Medicine, University of Washington, Seattle, Washington, United States
| | - Brian Cleary
- Department of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Daniel D. Fraughen
- Department of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
- National Centre for Alpha-1 Antitrypsin Deficiency, Beaumont Hospital, Dublin, Ireland
| | | | - Oisin F. McElvaney
- Department of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Mark P. Murphy
- Department of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Peter Branagan
- Department of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
- National Centre for Alpha-1 Antitrypsin Deficiency, Beaumont Hospital, Dublin, Ireland
| | - Cedric Gunaratnam
- Department of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
- National Centre for Alpha-1 Antitrypsin Deficiency, Beaumont Hospital, Dublin, Ireland
| | - Tomás P. Carroll
- Department of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
- Alpha-1 Foundation of Ireland, Dublin, Ireland
| | - Christopher H. Goss
- Seattle Children’s Research Institute, Seattle, Washington, United States
- Department of Medicine, University of Washington, Seattle, Washington, United States
- Department of Pediatrics, University of Washington, Seattle, Washington, United States
| | - Noel G. McElvaney
- Department of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
- National Centre for Alpha-1 Antitrypsin Deficiency, Beaumont Hospital, Dublin, Ireland
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Hay MA, Holm KE, McCathern J, Sandhaus RA, Strange C. Impact of Coronavirus Disease 2019 and Vaccination Attitudes on Alpha-1 Antitrypsin Deficiency. CHRONIC OBSTRUCTIVE PULMONARY DISEASES (MIAMI, FLA.) 2023; 10:335-342. [PMID: 37363861 DOI: 10.15326/jcopdf.2023.0406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/28/2023]
Abstract
Background Individuals with alpha-1 antitrypsin deficiency (AATD)-associated chronic obstructive pulmonary disease (COPD) may be at increased risk of coronavirus disease 2019 (COVID-19) pneumonia since COPD is associated with an increased risk of severe COVID-19 infection. Research Question We hypothesized that the AlphaNet disease management program would lower COVID-19 burdens. We evaluated the prevalence of COVID-19 infection, severe COVID-19, interruptions in augmentation therapy, and intention to vaccinate. Study Design and Methods Data regarding COVID-19 were collected monthly from March 2020 through February 2022. Responses from 8019 individuals were analyzed to evaluate the prevalence and severity of COVID-19 infections, interruptions in AATD care, and the likelihood of vaccination. Results By the end of 2020, 4% of patients reported a positive COVID-19 test. Of those, 35.3% were hospitalized, with 8.6% admitted to the intensive care unit (ICU). By February 2022, the prevalence of COVID-19 infections had increased to 18.6%, with hospitalization rates of 22.1% and ICU admissions at 4.7%. Attitudes about COVID-19 vaccination assessed in December 2020 before the vaccine was widely available suggested 10.3% of patients would definitely not get the vaccine. Notably, 38.2% of those subsequently self-reported receipt of a COVID-19 vaccine. Interpretation The prevalence of COVID-19 infections in patients with AATD was lower than the prevalence in the general U.S. population during 2020, although with a higher hospitalization rate. This health-managed population has a high vaccination intent. Those with an initially low vaccination intent changed their minds over time. We interpret these results as showing that most AlphaNet individuals with AATD had success at navigating the COVID-19 pandemic with lower case rates than the general U.S. population.
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Affiliation(s)
- Margaret A Hay
- Division of Pulmonary and Critical Care Medicine, Medical University of South Carolina, Charleston, South Carolina, United States
| | - Kristen E Holm
- AlphaNet, Inc., Coral Gables, Florida, United States
- Department of Medicine, National Jewish Health, Denver, Colorado, United States
| | | | - Robert A Sandhaus
- AlphaNet, Inc., Coral Gables, Florida, United States
- Department of Medicine, National Jewish Health, Denver, Colorado, United States
| | - Charlie Strange
- Division of Pulmonary and Critical Care Medicine, Medical University of South Carolina, Charleston, South Carolina, United States
- AlphaNet, Inc., Coral Gables, Florida, United States
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