Sex- and Gender-specific Observations and Implications for COVID-19

Sex-specific disparities in COVID-19 outcomes

Objectives

Sex-specific disparities in morbidity and mortality of COVID-19 illness are not well understood. Neutralizing antibodies (Ab) may protect against severe COVID-19 illness. We investigated the association of sex with disease progression and SARS-CoV-2 Ab response.

Methods

In this exploratory analysis of the phase 3, multicenter, randomized, placebo-controlled Convalescent Plasma in Outpatients (C3PO) trial, we examined whether sex was associated with progression to severe illness, defined as a composite of all-cause hospitalization, emergency/urgent care visit, or death within 15 days from study enrollment. Patients had a positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) test, symptom onset within 7 days, stable condition for emergency department discharge, and were either ≥50 years old or had at least one high-risk feature for disease progression. Patients received blinded convalescent plasma or placebo in a 1:1 fashion and were evaluated on days 15 and 30 after infusion. Blood samples were collected on day 0 (pre-/post-infusion), 15, and 30 to measure Ab levels with the Broad Institute using the Plaque Reduction Neutralization Test assay.

Results

Of 511 patients enrolled (median age 54 [Iinterquartile range 41-62] years, 46% male, 66% white, 20% black, 3.5% Asian), disease progression occurred in 36.7% of males and 25.9% of females (unadjusted risk difference 10.8%, 95% confidence interval [CI], 2.8-18.8%). Sex-disparities did not persist when adjusted for treatment group, age, viremic status, symptom onset, and tobacco use (adjusted risk difference 5.6%, 95% confidence interval [CI], -2.2% to 13.4%), but were present in the subgroup presenting 3 or more days after symptom onset (adjusted risk difference 12.6%, 95% CI, 3.4% to 21.9%). Mean baseline Ab levels (log scale) available for 367 patients were similar between sexes (difference 0.19 log units, 95% CI, -0.08 to 0.46). The log-scale mean increase from baseline to day 15 after adjusting for treatment assignment and baseline levels was larger in males than females (3.26 vs. 2.67). A similar difference was noted when the groups were subdivided by outcome.

Conclusions

Progression of COVID-19 was similar in males and females when adjusted for age, tobacco use, and viremia status in this study. However, in the cohort presenting 3 or more days after symptom onset, COVID-19 outcomes were worse in males than females. Neutralizing Ab levels increased more in males but did not correlate with sex differences in outcomes.

Genomic Surveillance Reveals the Rapid Expansion of the XBB Lineage among Circulating SARS-CoV-2 Omicron Lineages in Southeastern Wisconsin, USA

SARS-CoV-2 caused a life-threatening COVID-19 pandemic outbreak worldwide. The Southeastern Region of Wisconsin, USA (SERW) includes large urban Milwaukee and six suburban counties, namely Kenosha, Ozaukee, Racine, Walworth, Washington and Waukesha. Due to the lack of detailed SARS-CoV-2 genomic surveillance in the suburban populations of the SERW, whole-genome sequencing was employed to investigate circulating SARS-CoV-2 lineages and characterize dominant XBB lineages among this SERW population from November 2021 to April 2023. For an unbiased data analysis, we combined our 6709 SARS-CoV-2 sequences with 1520 sequences from the same geographical region submitted by other laboratories. Our study shows that SARS-CoV-2 genomes were distributed into 357 lineages/sublineages belonging to 13 clades, of which 88.8% were from Omicron. We document dominant sublineages XBB.1.5 and surging XBB.1.16 and XBB.1.9.1 with a few additional functional mutations in Spike, which are known to contribute to higher viral reproduction, enhanced transmission and immune evasion. Mutational profile assessment of XBB.1.5 Spike identifies 38 defining mutations with high prevalence occurring in 49.8-99.6% of the sequences studied, of which 32 mutations were in three functional domains. Phylogenetic and genetic relatedness between XBB.1.5 sequences reveal potential virus transmission occurring within households and within and between Southeastern Wisconsin counties. A comprehensive phylogeny of XBB.1.5 with global sub-dataset sequences confirms the wide spread of genetically similar SARS-CoV-2 strains within the same geographical area. Altogether, this study identified proportions of circulating Omicron variants and genetic characterization of XBB.1.5 in the SERW population, which helped state and national public health agencies to make compelling mitigation efforts to reduce COVID-19 transmission in the communities and monitor emerging lineages for their impact on diagnostics, treatments and vaccines.

Infections and Autoimmunity-The Immune System and Vitamin D: A Systematic Review

Both 25-autoimmunity and(25(OH)D: calcifediol) and its active form, 1,25-dihydroxyvitamin D (1,25(OH)2D: calcitriol), play critical roles in protecting humans from invasive pathogens, reducing risks of autoimmunity, and maintaining health. Conversely, low 25(OH)D status increases susceptibility to infections and developing autoimmunity. This systematic review examines vitamin D's mechanisms and effects on enhancing innate and acquired immunity against microbes and preventing autoimmunity. The study evaluated the quality of evidence regarding biology, physiology, and aspects of human health on vitamin D related to infections and autoimmunity in peer-reviewed journal articles published in English. The search and analyses followed PRISMA guidelines. Data strongly suggested that maintaining serum 25(OH)D concentrations of more than 50 ng/mL is associated with significant risk reduction from viral and bacterial infections, sepsis, and autoimmunity. Most adequately powered, well-designed, randomized controlled trials with sufficient duration supported substantial benefits of vitamin D. Virtually all studies that failed to conclude benefits or were ambiguous had major study design errors. Treatment of vitamin D deficiency costs less than 0.01% of the cost of investigation of worsening comorbidities associated with hypovitaminosis D. Despite cost-benefits, the prevalence of vitamin D deficiency remains high worldwide. This was clear among those who died from COVID-19 in 2020/21-most had severe vitamin D deficiency. Yet, the lack of direction from health agencies and insurance companies on using vitamin D as an adjunct therapy is astonishing. Data confirmed that keeping an individual's serum 25(OH)D concentrations above 50 ng/mL (125 nmol/L) (and above 40 ng/mL in the population) reduces risks from community outbreaks, sepsis, and autoimmune disorders. Maintaining such concentrations in 97.5% of people is achievable through daily safe sun exposure (except in countries far from the equator during winter) or taking between 5000 and 8000 IU vitamin D supplements daily (average dose, for non-obese adults, ~70 to 90 IU/kg body weight). Those with gastrointestinal malabsorption, obesity, or on medications that increase the catabolism of vitamin D and a few other specific disorders require much higher intake. This systematic review evaluates non-classical actions of vitamin D, with particular emphasis on infection and autoimmunity related to the immune system.

Characteristics of re-admitted adult patients infected with severe acute respiratory syndrome Coronavirus 2 After initial hospitalization at King Salman Armed Forces Hospital, Tabuk, Saudi Arabia

OBJECTIVES

To describe the clinical characteristics and possible risk factors associated with re-hospitalization within 30 days of discharge among hospitalized adult patients with confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection.

METHODS

This is a retrospective cohort study conducted at King Salman Armed Forces Hospital (KSAFH), Tabuk, Saudi Arabia over the period between March to November 2020. The study was conducted over 237 patients who had confirmed SARS-CoV-2 and fulfilled the study inclusion criteria (at least 14 years old, with subsequently discharged alive from the hospital) were included.

RESULTS

The commonest presenting symptoms were cough, fever, and dyspnea. The most frequent reported comorbid diseases were diabetes mellitus and hypertension. Half of cases were regarded as severe cases whereas 14.8% were critical cases. The rate of readmission was 5.9%. Older patients were more likely to be readmitted compared to younger patients. Regarding clinical characteristics, critically ill patients were more likely to be readmitted than less severe cases. Patients with unilateral lung shadow in chest x-ray, and those with positive history of Intensive care unit (ICU) admission were more likely to be readmitted compared to their peers. Regarding medical history, the only factor significantly associated with readmission were history of cerebrovascular accident (CVA), as 22.2% of those with CVA history compared to only 1.5% of those without CVA history were more likely to be readmitted. Among laboratory findings, high lymphocytic count (>3 per microliter) was significantly associate with likelihood for readmission.

CONCLUSION

Readmission rate or patients hospitalization initially for Covid-19 was comparable to rates reported by most of other similar international studies. Further longitudinal larger multicentric study is warranted to have clearer image of the situation.

COVID-19 and Policy-Induced Inequalities: Exploring How Social and Economic Exclusions Impact 'Temporary' Migrant Men's Health and Wellbeing in Australia

The Australian government swiftly put in place a number of economic relief measures and policies to support people during the COVID-19 crisis. However, the government's COVID-19 response policies excluded people with 'temporary' migrant status living in the country and encouraged people holding temporary visas who lost jobs and could no longer afford to support themselves to 'go home'. This paper draws upon sub-citizenship theory to explore how Australia's immigration and COVID-19 response policies are likely to impact the health and wellbeing of 'temporary' migrant men and their families. Through focusing on Australia's policy approach towards 'temporary' migrants and the social, health, and human rights implications among men with temporary migrant status during the pandemic, this paper contributes to emerging literature that considers the intersectional implications of immigration and COVID-19 response policies as they pertain to people with precarious migration status. Applying sub-citizenship theory to analyse how Australia's COVID-19 response policies intersect with 'temporary' migration schemes offers a useful way to think about and unearth how structural, and often legislated, exclusions can affect the health and wellbeing of marginalised groups.

Associations of Combustible Cigarette, Electronic Cigarette, and Dual Use With COVID Infection and Severity in the U.S.: A Cross-sectional Analysis of the 2021 National Health Information Survey

Given the potential respiratory health risks, the association of COVID infection and the use of combustible cigarettes, electronic nicotine delivery systems (ENDS), and concurrent dual use is a priority for public health. Many published reports have not accounted for known covarying factors. This study sought to calculate adjusted odds ratios for self-reported COVID infection and disease severity as a function of smoking and ENDS use, while accounting for factors known to influence COVID infection and disease severity (i.e., age, sex, race and ethnicity, socioeconomic status and educational attainment, rural or urban environment, self-reported diabetes, COPD, coronary heart disease, and obesity status). Data from the 2021 U.S. National Health Interview Survey, a cross-sectional questionnaire design, were used to calculate both unadjusted and adjusted odds ratios for self-reported COVID infection and severity of symptoms. Results indicate that combustible cigarette use is associated with a lower likelihood of self-reported COVID infection relative to non-use of tobacco products (AOR = .64; 95% CI [.55, .74]), whereas ENDS use is associated with a higher likelihood of self-reported COVID infection (AOR = 1.30; 95% CI [1.04, 1.63]). There was no significant difference in COVID infection among dual users (ENDS and combustible use) when compared with non-users. Adjusting for covarying factors did not substantially change the results. There were no significant differences in COVID disease severity between those of varying smoking status. Future research should examine the relationship between smoking status and COVID infection and disease severity utilizing longitudinal study designs and non-self-report measures of smoking status (e.g., the biomarker cotinine), COVID infection (e.g., positive tests), and disease severity (e.g., hospitalizations, ventilator assistance, mortality, and ongoing symptoms of long COVID).

Physiological Basis for Using Vitamin D to Improve Health

Vitamin D is essential for life-its sufficiency improves metabolism, hormonal release, immune functions, and maintaining health. Vitamin D deficiency increases the vulnerability and severity of type 2 diabetes, metabolic syndrome, cancer, obesity, and infections. The active enzyme that generates vitamin D [calcitriol: 1,25(OH)₂D], CYP27B1 (1α-hydoxylase), and its receptors (VDRs) are distributed ubiquitously in cells. Once calcitriol binds with VDRs, the complexes are translocated to the nucleus and interact with responsive elements, up- or down-regulating the expression of over 1200 genes and modulating metabolic and physiological functions. Administration of vitamin D₃ or correct metabolites at proper doses and frequency for longer periods would achieve the intended benefits. While various tissues have different thresholds for 25(OH)D concentrations, levels above 50 ng/mL are necessary to mitigate conditions such as infections/sepsis, cancer, and reduce premature deaths. Cholecalciferol (D₃) (not its metabolites) should be used to correct vitamin D deficiency and raise serum 25(OH)D to the target concentration. In contrast, calcifediol [25(OH)D] raises serum 25(OH)D concentrations rapidly and is the agent of choice in emergencies such as infections, for those who are in ICUs, and for insufficient hepatic 25-hydroxylase (CYP2R1) activity. In contrast, calcitriol is necessary to maintain serum-ionized calcium concentration in persons with advanced renal failure and hypoparathyroidism. Calcitriol is, however, ineffective in most other conditions, including infections, and as vitamin D replacement therapy. Considering the high costs and higher incidence of adverse effects due to narrow therapeutic margins (ED50), 1α-vitamin D analogs, such as 1α-(OH)D and 1,25(OH)₂D, should not be used for other conditions. Calcifediol analogs cost 20 times more than D₃-thus, they are not indicated as a routine vitamin D supplement for hypovitaminosis D, osteoporosis, or renal failure. Healthcare workers should resist accepting inappropriate promotions, such as calcifediol for chronic renal failure and calcitriol for osteoporosis or infections-there is no physiological rationale for doing so. Maintaining the population's vitamin D sufficiency (above 40 ng/mL) with vitamin D₃ supplements and/or daily sun exposure is the most cost-effective way to reduce chronic diseases and sepsis, overcome viral epidemics and pandemics, and reduce healthcare costs. Furthermore, vitamin D sufficiency improves overall health (hence reducing absenteeism), reduces the severity of chronic diseases such as metabolic and cardiovascular diseases and cancer, decreases all-cause mortality, and minimizes infection-related complications such as sepsis and COVID-19-related hospitalizations and deaths. Properly using vitamin D is the most cost-effective way to reduce chronic illnesses and healthcare costs: thus, it should be a part of routine clinical care.

Sex-differences in COVID-19 diagnosis, risk factors and disease comorbidities: A large US-based cohort study

Introduction

Morbidity and mortality from COVID-19 are higher among men, however, underlying pathways remain controversial. We aim to investigate sex-gender differences in COVID-19 in a large US-based cohort, namely COVID-19 Research Database. More specifically, the objectives are to explore the socio-economic characteristics of COVID-19 male and female patients and to examine potential sex differences in lifestyle factors and disease comorbidities among diagnosed patients.

Methods

This is a retrospective cohort study contrasting male vs. female patients with test-confirmed COVID-19. The study used Healthjump electronic medical records (e.g., demographics, encounters, medical history, and vitals) extracted from January 2020 to December 2021 (N = 62,310).

Results

Significant sociodemographic and comorbidity differences were observed between males and females (p < 0.05). For example, a significantly higher proportion of males (vs. females) were aged ≥70-year-old (17.04 vs. 15.01%) and smokers (11.04 vs. 9.24%, p < 0.0001). In addition, multiple logistic regression showed that hypertension and diabetes were significantly more frequent in males [adjusted odds ratio (ORa) = 66.19 and ORa = 22.90].

Conclusions

Understanding the differences in outcomes between male and female patients will inform gender equity responsive approach to COVID-19 and enhance the effectiveness of clinical practice, health policy and interventions.

Dengue Fever Responses in Dhaka City, Bangladesh: A Cross-Sectional Survey

Objectives: This study intends to evaluate the Dhaka city residents’ individual views toward DF.

Methods: A cross-sectional survey used google forms for collecting data. Python and RStudio were used for data management and analysis. Kruskal-Wallis or Mann-Whitney U test and logistic regression models were performed, where appropriate.

Results: In total 1008 individuals participated in a pre-tested KAP survey. More than 20% reported being affected by DF before the survey, where they rated their current places as being moderately safe (43%). In terms of DF control, 65% had good knowledge, and 68% reported good practice, whereas they demonstrated an overall good attitude. The increased knowledge of individuals could contribute to behavioral changes regarding DF. Female residents demonstrated better DF attitudes (OR: 0.69; p &lt; 0.05) and practices (OR: 0.66; p &lt; 0.01) compared to male residents. Mixed unit residents had poor KAP levels. Educational attainment can also play an essential role in enhancing the attitude level.

Conclusion: Overall, dengue surveillance activities with sufficient campaigns are required for behavioral change in Dhaka city. This information could be integrated into other DF-affected countries’ strategies against dengue outbreaks.

Prevalence of Post-Traumatic Stress Disorder (PTSD) in University Students during the COVID-19 Pandemic: A Meta-Analysis Attending SDG 3 and 4 of the 2030 Agenda

Background: Most universities around the world have been heavily affected by the COVID-19 pandemic, as declared by the World Health Organization (WHO) in March 2020. Many students were isolated at home and underwent a forced transition from face-to-face learning to e-learning, at least in the first few months. The subsequent months and years were typically characterised by a slow return to normal learning under COVID-19 protocols and restrictions. A potential consequence of the lockdowns, social restrictions and changes to learning is the development of PTSD (post-traumatic stress disorder) in university students, affecting their health and well-being (SDG3) and quality of education (SDG4). Materials and Methods: Medline was searched through PubMed for studies on the prevalence of PTSD in university students from 1 December 2019 to 31 December 2021. The pooled prevalence of PTSD was calculated with random-effects models. Results: A total of six studies were included, across which the prevalence of PTSD among university students was 23%. Meta-regression showed that the prevalence of PTSD was significantly higher with older age, but independent of the percentage of women in a study or its methodological quality. Conclusions: Our results suggest that students suffer from PTSD at a moderate rate. Measures are needed to address the mental health issues of university students that have arisen during COVID-19 all around the world.

Conflicto trabajo-familia de mujeres en situación de teletrabajo a partir de la contingencia sanitaria por COVID-19 en Chile

Objetivo. El presente artículo expone las características que ha tenido la interacción entre el trabajo pagado y no pagado para las mujeres chilenas que, a partir de la crisis sanitaria por COVID-19, han debido comenzar a desempeñar sus empleos desde sus hogares. Metodología. Se trabajó con un cuestionario mixto online (N=1137) aplicado entre abril y junio de 2020. Se analizan las respuestas a un cuestionario likert y se profundiza en el análisis de las preguntas abiertas del mismo. Resultados. Las participantes tienen una percepción negativa del teletrabajo en pandemia, evidenciando conflictos en la relación trabajo/familia, sobrecarga de tiempos y uso desbalanceado de espacios, escasa corresponsabilidad familiar y laboral. Finalmente, es posible reconocer variados recursos narrativos de resistencia a la construcción patriarcal de los roles de género y reconocimiento de la situación vivida como un asunto que afecta a una gran cantidad de mujeres en Chile. Conclusiones. Nuestros resultados dan cuenta de la existencia de un conflicto que ha afectado la interacción entre la vida laboral y familiar de las mujeres, quienes han debido enfrentarse a un escenario de implementación de medidas de aislamiento social y al inicio de una modalidad de teletrabajo caracterizada por su improvisación, lo que las ha obligado afrontar la crisis mediante el despliegue de recursos propios, capacidades de autoorganización y aprendizajes individuales, con fuertes costos para su salud mental.

Sex, gender, and the opioid epidemic: Crucial implications for acute care

INTRODUCTION

The opioid epidemic continues to escalate in the United States, exacerbated significantly by the COVID-19 pandemic. Necessary steps in acute care medicine to expand efforts to combat this epidemic involve increased emergency department engagement of patients with opioid use disorder (OUD) and an incorporation of evolving sex- and gender-based factors that affect this disease presentation and management course.

METHODS & AIMS

An ever-increasing amount of peer-reviewed, evidence-based literature has shed light on the important biologic and sociocultural variables, specifically sex and gender, which impact OUD trajectory and outcomes. As a collaborative effort of the Sex and Gender in Emergency Medicine (SGEM) Interest Group, a community within the Society for Academic Emergency Medicine (SAEM), we sought to consider, review, and summarize clinically pertinent information as a comprehensive introduction to this topic for the emergency medicine (EM) clinician and educator.

RESULTS

A selected overview of current evidence-based data and publications, to include current epidemiologic trends, opioid-based physiology and pathophysiology, as well as opioid use disorder management and outcomes, through a sex- and gender-based lens, was reviewed and included in this summary. Also discussed are implications and recommendations for EM educators seeking insight and resources for continuing, graduate, and/or undergraduate education on this topic.

CONCLUSION

Incorporation of emerging sex- and gender-specific scientific knowledge into clinical context represents a critical link to effective management of the OUD patient in the ED. Similarly, integration of this information into EM education represents an essential step for both sex- and gender-based medicine and opioid-specific training.

Neurological symptoms associated with SARS-CoV-2 infection in a tertiary hospital in Bogota, Colombia

Introduction

SARS-CoV-2 infection is an emerging disease that represents a threat to life globally, with more than 179 million confirmed cases and 3 million deaths. In Colombia, where almost 5 million infections and approximately 127 thousand deaths have been reported, it presents a wide variety of neurological manifestations that range from mild to severe symptoms.

Objective

This study describes the characteristics of neurological manifestations in patients with COVID-19 in the period March-September 2020 at a tertiary hospital in Bogota.

Methods

We performed a cross-sectional descriptive study. We selected patients by non-probability sampling, including all patients attended by the neurology service at our hospital. We included all patients with infection confirmed by RT-PCR test and neurological disease confirmed by tomography, study of cerebrospinal fluid, and clinical manifestations reported in the medical history. We excluded epileptic patients who presented seizures as the only clinical manifestation.

Results

In a total of 58 patients, the mean age was 58 years, with 60.3% of patients being men; 65.5% were alert at admission. The main neurological symptom was brain ischaemia, in 36.2%, followed by seizures, in 25.9%. Arterial hypertension was observed in 58.6%. We observed no alterations in the cerebrospinal fluid; the mean hospital stay was 35 days, and 41.4% of patients died.

Conclusions

SARS-CoV-2 infection not only affects the respiratory system, but can also cause a range of neurological manifestations ranging from mild symptoms such as headache, dysgeusia, and anosmia to severe complications such as seizures, brain ischaemia/haemorrhage, encephalopathy, or death.

A cross-sectional study of COVID-19-related knowledge, risk perceptions, and preventive practices among pharmacy students in Bangladesh

OBJECTIVES

The coronavirus disease 2019 pandemic is a threat to public health that impacts the life of frontline pharmacists as they are more susceptible to getting infected by the coronavirus. This study aimed to assess the knowledge, risk perceptions, and preventive practices associated with coronavirus disease 2019 among pharmacy students of Bangladesh to evaluate their preparedness as future frontline workers against the ongoing pandemic.

METHODS

An online-based cross-sectional study was conducted among pharmacy undergraduate students of Bangladesh during the early months of the pandemic in April 2020. Respondents voluntarily submitted an online questionnaire regarding sociodemographics, knowledge, risk perceptions, and preventive practices related to coronavirus disease 2019.

RESULTS

A total of 418 participants submitted their responses, and we included 395 responses for final analysis. The mean age of the participants was 20.65 years. The study revealed that out of 395 pharmacy students, 68 (17.2%) had high levels of knowledge, 210 (53.2%) possessed high risk perceptions regarding coronavirus disease 2019, and 165 (41.7%) were adopting high levels of preventive practices. Average scores for knowledge, risk perceptions, and preventive practices were 5.7, 8.4, and 8.2 out of 10. Chi-square test and logistic regression analyses showed that having high knowledge levels was associated with high risk perceptions regarding coronavirus disease 2019. Similarly, higher risk perceptions were associated with having high knowledge and preventive measures, while higher preventive measures were associated with female gender, low monthly family income, and having high risk perceptions.

CONCLUSION

We found moderate knowledge, risk perceptions, and preventive practices related to coronavirus disease 2019 among the undergraduate pharmacy students. We recommend awareness-building discussions or seminars focusing on pharmacy students. In addition, the upgradation of the existing curriculum may help future pharmacists.

On the interplay of regional mobility, social connectedness and the spread of COVID-19 in Germany

Since the primary mode of respiratory virus transmission is person-to-person interaction, we are required to reconsider physical interaction patterns to mitigate the number of people infected with COVID-19. While research has shown that non-pharmaceutical interventions (NPI) had an evident impact on national mobility patterns, we investigate the relative regional mobility behaviour to assess the effect of human movement on the spread of COVID-19. In particular, we explore the impact of human mobility and social connectivity derived from Facebook activities on the weekly rate of new infections in Germany between 3 March and 22 June 2020. Our results confirm that reduced social activity lowers the infection rate, accounting for regional and temporal patterns. The extent of social distancing, quantified by the percentage of people staying put within a federal administrative district, has an overall negative effect on the incidence of infections. Additionally, our results show spatial infection patterns based on geographical as well as social distances.

How Can I Get COVID?: Understanding Differences in American Heterosexual and Sexual Minority Men’s Risk Perception

Men are more vulnerable to COVID-19 infections compared to women, but their risk perceptions around COVID-19 are persistently lower. Further, men often engage in less health promotion behavior because self-care in this capacity is seen as weak or less masculine. This combination has consequences for mortality; thus, a better understanding of men’s COVID-19 cognitions and individual difference factors is critical. In a web-based survey conducted during the beginning stages of the pandemic in the U.S., we collected risk perceptions of various sexual and non-sexual behaviors from heterosexual (n = 137) and gay/bisexual men (n = 108). There were no significant sexual orientation differences for perceptions of COVID-19 risk from routine activities or in overall risk estimates. However, gay/bisexual men did report engaging in more precautionary behavior while socializing (i.e., masking, social distancing) and reported higher risk perceptions than did heterosexual men for nearly all intimate and sexual activities. A more nuanced understanding of cognitions around COVID-19 is needed to better understand motivation for—and especially motivation against—pursuing vaccinations and continuing precautionary behavior.

Roles of steroid receptors in the lung and COVID-19

COVID-19 symptoms and mortality are largely due to its devastating effects in the lungs. The disease is caused by the SARS (Severe Acute Respiratory Syndrome)-CoV-2 coronavirus, which requires host cell proteins such as ACE2 (angiotensin-converting enzyme 2) and TMPRSS2 (transmembrane serine protease 2) for infection of lung epithelia. The expression and function of the steroid hormone receptor family is important in many aspects that impact on COVID-19 effects in the lung - notably lung development and function, the immune system, and expression of TMPRSS2 and ACE2. This review provides a brief summary of current knowledge on the roles of the steroid hormone receptors [androgen receptor (AR), glucocorticoid receptor (GR), progesterone receptor (PR), mineralocorticoid receptor (MR) and oestrogen receptor (ER)] in the lung, their effects on host cell proteins that facilitate SARS-CoV-2 uptake, and provides a snapshot of current clinical trials investigating the use of steroid receptor (SR) ligands to treat COVID-19.

Identification of the most vulnerable populations in the psychosocial sphere: a cross-sectional study conducted in Catalonia during the strict lockdown imposed against the COVID-19 pandemic

DESIGN AND OBJECTIVES

A cross-sectional study to evaluate the impact of COVID-19 on the psychosocial sphere in both the general population and healthcare workers (HCWs).

METHODS

The study was conducted in Catalonia (Spain) during the first wave of the COVID-19 pandemic when strict lockdown was in force. The study population included all people aged over 16 years who consented to participate in the study and completed the survey, in this case a 74-question questionnaire shared via social media using snowball sampling. A total of 56 656 completed survey questionnaires were obtained between 3 and 19 April 2020.The primary and secondary outcome measures included descriptive statistics for the non-psychological questions and the psychological impact of the pandemic, such as depression, anxiety, stress and post-traumatic stress disorder question scores.

RESULTS

A n early and markedly negative impact on family finances, fear of working with COVID-19 patients and ethical issues related to COVID-19 care among HCWs was observed. A total of seven target groups at higher risk of impaired mental health and which may therefore benefit from an intervention were identified, namely women, subjects aged less than 42 years, people with a care burden, socioeconomically deprived groups, people with unskilled or unqualified jobs, patients with COVID-19 and HCWs working with patients with COVID-19.

CONCLUSIONS

Active implementation of specific strategies to increase resilience and to prepare an adequate organisational response should be encouraged for the seven groups identified as high risk and susceptible to benefit from an intervention.

TRIAL REGISTRATION NUMBER

NCT04378452.

Sex and Gender in COVID-19 Vaccine Research: Substantial Evidence Gaps Remain

Since the start of the COVID-19 pandemic there has been a global call for sex/gender-disaggregated data to be made available, which has uncovered important findings about COVID-19 testing, incidence, severity, hospitalisations, and deaths. This mini review scopes the evidence base for efficacy, effectiveness, and safety of COVID-19 vaccines from both experimental and observational research, and asks whether (1) women and men were equally recruited and represented in vaccine research, (2) the outcomes of studies were presented or analysed by sex and/or gender, and (3) there is evidence of sex and/or gender differences in outcomes. Following a PubMed search, 41 articles were eligible for inclusion, including seven randomised controlled trials (RCTs), 11 cohort studies, eight cross-sectional surveys, eight routine surveillance studies, and seven case series. Overall, the RCTs contained equal representation of women and men; however, the observational studies contained a higher percentage of women. Of 10 studies with efficacy data, only three (30%) presented sex/gender-disaggregated results. Safety data was included in 35 studies and only 12 (34%) of these presented data by sex/gender. For those that did present disaggregated data, overall, the majority of participants reporting adverse events were women. There is a paucity of reporting and analysis of COVID-19 vaccine data by sex/gender. Research should be designed in a gender-sensitive way to present and, where possible analyse, data by sex/gender to ensure that there is a robust and specific evidence base of efficacy and safety data to assist in building public confidence and promote high vaccine coverage.

A quantifiable framework for ‘Covid-19 exposure’ to support the Vaccine prioritization and resource allocation for resource-constraint societies

As the pandemic COVID-19 has severely affected the entire world, it became the utmost necessity of careful prioritization and utilization of limited medical resources, especially for the resource-constraint societies. This requirement along with the asymptomatic nature of COVID-19 in a significant proportion of the population, has prompted the need for a risk assessment tool-kit that can provide a rational behind prioritization and allocation of limited available medical resources. The purpose of this study is to compose a scientific-rationale-based ‘COVID-19-Self-Assessment-Test’ (C19SAT) framework, which helps develop a basis for measuring the risk of COVID-19 exposure with self-assessment. The study comprises of two major parts- (1) identification of key components of the C19SAT framework by studying various guidelines (WHO & CDC) and relevant literature, and (2) quantification of those components by assigning weight through the analysis of survey results and opinions from medical physicians and experts. A C19SAT framework is developed to measure the risk of covid-19 exposure, comprising a set of identified components (12 parameters and their corresponding attributes) and their corresponding weights. As the scientific rationale behind such assessment framework has not been reported to date in case of available mobile applications and web-based toolkit, the present study brings the novelty and reports the construction of such a framework. The study opens up untouched research and discussion on the composition of the COVID-19 exposure-measurement framework, which can help in vaccine prioritization and resource allocation. Further studies can be carried out on refining the framework for better understanding and effectiveness towards urban health governance.

The association of metabolic syndrome and COVID-19 deterioration

BACKGROUND AND AIMS

To evaluate the prevalence and prognostic value of metabolic syndrome (MetS) in patients admitted for coronavirus disease 2019 (COVID-19).

METHODS AND RESULTS

In this monocentric cohort retrospective study, we consecutively included all adult patients admitted to COVID-19 units between April 9 and May 29, 2020 and between February 1 and March 26, 2021. MetS was defined when at least three of the following components were met: android obesity, high HbA1c, hypertension, hypertriglyceridemia, and low HDL cholesterol. COVID-19 deterioration was defined as the need for nasal oxygen flow ≥6 L/min within 28 days after admission. We included 155 patients (55.5% men, mean age 61.7 years old, mean body mass index 29.8 kg/m²). Fifty-six patients (36.1%) had COVID-19 deterioration. MetS was present in 126 patients (81.3%) and was associated with COVID-19 deterioration (no-MetS vs MetS: 13.7% and 41.2%, respectively, p < 0.01). Logistic regression taking into account MetS, age, gender, ethnicity, period of inclusion, and Charlson Index showed that COVID-19 deterioration was 5.3 times more likely in MetS patients (95% confidence interval 1.3-20.2) than no-MetS patients.

CONCLUSIONS

Over 81.3% of patients hospitalized in COVID-19 units had MetS. This syndrome appears to be an independent risk factor of COVID-19 deterioration.

The Molecular Basis of Gender Variations in Mortality Rates Associated With the Novel Coronavirus (COVID-19) Outbreak

Since the outbreak of the novel coronavirus disease (COVID-19) at the end of 2019, the clinical presentation of the disease showed a great heterogeneity with a diverse impact among different subpopulations. Emerging evidence from different parts of the world showed that male patients usually had a longer disease course as well as worse outcome compared to female patients. A better understanding of the molecular mechanisms behind this difference might be a fundamental step for more effective and personalized response to this disease outbreak. For that reason, here we investigate the molecular basis of gender variations in mortality rates related to COVID-19 infection. To achieve this, we used publicly available lung transcriptomic data from 141 females and compare it to 286 male lung tissues. After excluding Y specific genes, our results showed a shortlist of 73 genes that are differentially expressed between the two groups. Further analysis using pathway enrichment analysis revealed downregulation of a group of genes that are involved in the regulation of hydrolase activity including (CHM, DDX3X, FGFR3, SFRP2, and NLRP2) in males lungs compared to females. This pathway is believed to be essential for immune response and antimicrobial activity in the lung tissues. In contrast, our results showed an increased upregulation of angiotensin II receptor type 1 (AGTR1), a member of the renin-angiotensin system (RAS) that plays a role in angiotensin-converting enzyme 2 (ACE2) activity modulation in male lungs compared to females. Finally, our results showed a differential expression of genes involved in the immune response including the NLRP2 and PTGDR2 in lung tissues of both genders, further supporting the notion of the sex-based immunological differences. Taken together, our results provide an initial evidence of the molecular mechanisms that might be involved in the differential outcomes observed in both genders during the COVID-19 outbreak. This maybe essential for the discovery of new targets and more precise therapeutic options to treat COVID-19 patients from different clinical and epidemiological characteristics with the aim of improving their outcome.

The effect of the COVID-19 pandemic on community mental health: A psychometric and prevalence study in Turkey

BACKGROUND

COVID-19, which is characterised by life-threatening symptoms, difficulty in breathing, and pneumonia symptoms and requires global emergency intervention, may cause psychological problems such as phobia, fear and anxiety. This study aims to examine the psychometric properties of the Fear of COVID-19 Scale (FCV-19S) in Turkish people and to determine the level of fear of COVID-19 among Turkish people.

METHODS

The research was carried out between March and April 2020. A Personal Information Form and the FCV-19S were used to collect the research data. In the validity and reliability stage, 84 people were contacted randomly for data collection. After the validity and reliability analyses of the scale, a total of 431 Turkish people volunteered to participate in the study and answered the questions in the online questionnaire form using a convenience and snowball sampling method. Confirmatory factor analysis, item-total correlation and Cronbach's alpha coefficient were calculated for psychometric evaluation. Bivariate analysis was applied to determine the level of fear of COVID-19.

RESULTS

Cronbach's alpha coefficient was 0.89, which is stated to have high reliability. FCV-19S scores of participants were determined to be 21.47 ± 6.28. FCV-19S scores of females were determined as 20.48 ± 6.33 and FCV-19S scores of males were determined as 19.78 ± 7.34 according to the bivariate analysis (p < .05). Age, marital status, having children and living alone or with others, tobacco use and anxiety about going to the hospital during the pandemic did not affect on fear of COVID-19 (p > .05). Particularly being female, the presence of chronic disease requiring long-term medication and rarely taking protective measures recommended by the Ministry of Health and having a chronic disease had a significant effect on higher levels of fear of COVID-19 (p < .05).

CONCLUSION

The FCV-19S is a valid and reliable tool for determining the fear of COVID-19. It was found that the fear level of COVID-19 infection was high in Turkish people.

Exploring the Interrelationship between COVID-19 Phobia, Work–Family Conflict, Family–Work Conflict, and Life Satisfaction among School Administrators for Advancing Sustainable Management

This study aims to investigate the relationships between the COVID-19 phobia experienced by school administrators and their work–family conflict, family–work conflict, and life satisfaction. This descriptive research, designed according to the relational survey model, was conducted with the participation of 356 school administrators. The study data were collected through online questionnaires, and then t-test, ANOVA, correlation analysis, and simple linear regression analysis were employed for the statistical analyses. The results revealed that female school administrators experienced greater levels of COVID-19 phobia than their male peers and that COVID-19 phobia is felt more intensely in the psychological and social sub-dimensions. However, female school administrators’ life satisfaction levels were significantly higher than those of male school administrators. In the current study, it was determined that school administrators in the younger age group experienced greater levels of COVID-19 phobia and family–work/work–family conflict than their peers from other age groups. The results of this study revealed a positive and moderate relationship between school administrators’ COVID-19 phobia and their levels of both work–family and family–work conflict. The findings of the study offer significant implications for policy makers in education, showing the importance of developing strategies that will reduce the effects of the pandemic for a more sustainable and efficient employee performance.

Sex and age bias viral burden and interferon responses during SARS-CoV-2 infection in ferrets

SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2) hospitalizations and deaths disportionally affect males and older ages. Here we investigated the impact of male sex and age comparing sex-matched or age-matched ferrets infected with SARS-CoV-2. Differences in temperature regulation was identified for male ferrets which was accompanied by prolonged viral replication in the upper respiratory tract after infection. Gene expression analysis of the nasal turbinates indicated that 1-year-old female ferrets had significant increases in interferon response genes post infection which were delayed in males. These results provide insight into COVID-19 and suggests that older males may play a role in viral transmission due to decreased antiviral responses.

Differential perceptions regarding personal protective equipment use during the COVID-19 pandemic by NHS healthcare professionals based on ethnicity, sex and professional experience

Objectives

To capture perceptions regarding personal protective equipment (PPE) among healthcare professionals during the COVID-19 pandemic, including staff subgroups at high risk for severe COVID-19, such as black and minority ethnic (BAME) groups.

Design

Electronically distributed survey with semi-quantitative analysis. Survey distributed at a major academic NHS tertiary referral centre in the West Midlands with a diverse medical workforce to medically qualified staff who completed COVID-19 redeployment training. (N=121; 47% female; 49% of BAME background; 26% international medical graduates).

Results

All demographic groups reported overall good awareness of when and how to use PPE during COVID-19 pandemic. Statistically significant differences in the perceptions regarding PPE use during COVID-19 were noted between BAME vs non-BAME staff, international vs UK medical graduates, and male vs female participants, as well as between professionals at different stages of their career. The differences related to perceptions around availability, degree of protection provided, perceived inconvenience, ability to raise concerns about availability, confidence in sharing underlying health conditions with managers and the impact of full PPE in emergency situations causing delay patient care.

Conclusions

Amongst medically qualified staff, significant differences exist in the perceptions relating to the, availability and effectiveness of PPE during the COVID-19 pandemic depending on country of training, ethnic background and sex.

GAFREC Study Approval

Study ID GF0392.

Gender Differences in the Presentation and Outcomes of Hospitalized Patients With COVID-19

Gender-related differences in COVID-19 clinical presentation, disease progression, and mortality have not been adequately explored. We analyzed the clinical profile, presentation, treatments, and outcomes of patients according to gender in the HOPE-COVID-19 International Registry. Among 2,798 enrolled patients, 1,111 were women (39.7%). Male patients had a higher prevalence of cardiovascular risk factors and more comorbidities at baseline. After propensity score matching, 876 men and 876 women were selected. Male patients more often reported fever, whereas female patients more often reported vomiting, diarrhea, and hyposmia/anosmia. Laboratory tests in men presented alterations consistent with a more severe COVID-19 infection (eg, significantly higher C-reactive protein, troponin, transaminases, lymphocytopenia, thrombocytopenia, and ferritin). Systemic inflammatory response syndrome, bilateral pneumonia, respiratory insufficiency, and renal failure were significantly more frequent in men. Men more often required pronation, corticosteroids, and tocilizumab administration. A significantly higher 30-day mortality was observed in men vs women (23.4% vs 19.2%; P = .039). Trial Numbers: NCT04334291/EUPAS34399.

Preliminary Evidence from a Cross-sectional Study on Epidemiology and Early Transmission Dynamics of COVID-19 in Karnataka State of India

Introduction Coronavirus disease 2019 (COVID-19) is an emerging infection and quickly disseminated around the world. This article studies the epidemiology and early transmission dynamics of COVID-19 in Karnataka, which would be useful for effective epidemic management and policy formulation.

Materials and Methods All COVID-19 cases reported in the state of Karnataka, India, till June 12, 2020, are included in the study. The epidemiology and transmission dynamics of COVID-19 in Karnataka is studied through descriptive statistical analysis.

Results The findings illustrate a gender-, age-, and region-based disparity in the susceptibility and fatality. There appears to be a male preponderance in the susceptibility, but a female preponderance in fatality. It is also found that the adults are more susceptible to the infection, while the elderly have the risk of high fatality. Further, infected individuals in the region with urbanization have a higher risk of fatality than other regions. The study shows that the chances of recovery for females are lower than males, and further, the chances of recovery are positively related to the age of the infected person. The chances of recovery are higher if the infected individual is younger and they diminish if the individual is older. The study also explores that the chances of recovery are affected by the patient’s geographical location. It is also noted that individuals who returned from foreign travel have better chances of recovery than the locally transmitted individuals.

Conclusion Though the risk of susceptibility to COVID-19 infection is equal to all, the burden of getting infected and the burden of fatality is unequally distributed among different demographic categories. To manage the contagious spread of epidemic, to reduce fatality, and to increase the chances of recovery, targeted policy actions are suggested to benefit the vulnerable demographic categories.

COVID-19 and periodontitis: reflecting on a possible association

Recent studies have demonstrated a relationship between the severe clinical course of COVID-19 and other chronic diseases such as: cardiovascular disease, hypertension, diabetes mellitus, obesity and chronic renal disease. It may be possible to extend this association to a common and chronic oral disease in adults: periodontitis. Alternatively, the latter could be simply related to the systemic chronic diseases cited above, as already observed in the non-COVID-19 literature. In order to provide an overview and their opinion, the authors in this perspective article will report and discuss the most recent references of interest relating to COVID-19 and periodontitis pathophysiology. Within such a narrative review, the authors will hypothesize that the association between chronic periodontitis and COVID-19 could exist via two pathways: a direct link, through the ACEII and CD147 receptors used by the virus to infect the cells, which would occur in greater numbers in cases of periodontitis (thereby favoring a SARS-CoV-2 infection); and/or an indirect pathway involving the overexpression of inflammatory molecules, especially IL-6 and IL-17. An expression of the latter has been found to play a role in periodontitis, in addition to severe cases of COVID-19, although it is still unclear if it plays a direct role in the worsening of the clinical course.

Sex-Based Differences in COVID-19 Outcomes

Background: Smaller studies suggest lower morbidity and mortality associated with coronavirus disease 2019 (COVID-19) in women. Our aim is to assess the impact of female sex on outcomes in a large cohort of patients hospitalized with COVID-19. Materials and Methods: This is a retrospective observational cohort study of 10,630 adult patients hospitalized with a confirmed COVID-19 polymerase chain reaction between March 1, 2020 and April 27, 2020, with follow-up conducted through June 4, 2020. Logistic regression was used to examine the relationship between sex and the primary outcomes, including length of stay, admission to intensive care unit (ICU), need for mechanical ventilation, pressor requirement, and all-cause mortality as well as major adverse events and in-hospital COVID-19 treatments. Results: In the multivariable analysis, women had 27% lower odds of in-hospital mortality (odds ratio [OR] = 0.73, 95% confidence interval [CI] 0.66-0.81; p < 0.001), 24% lower odds of ICU admission (OR = 0.76, 95% CI 0.69-0.84; p < 0.001), 26% lower odds of mechanical ventilation (OR = 0.74, 95% CI 0.66-0.82; p < 0.001), and 25% lower odds of vasopressor requirement (OR = 0.75, 95% CI 0.67-0.84; p < 0.001). Women had 34% less odds of having acute cardiac injury (OR = 0.66, 95% CI 0.59-0.74; p < 0.001; n = 7,289), 16% less odds of acute kidney injury (OR = 0.84, 95% CI 0.76-0.92; p < 0.001; n = 9,840), and 27% less odds of venous thromboembolism (OR = 0.73, 95% CI 0.56-0.96; p < 0.02; c-statistic 0.85, n = 9,407). Conclusions: Female sex is associated with lower odds of in-hospital outcomes, major adverse events, and all-cause mortality. There may be protective mechanisms inherent to female sex, which explain differences in COVID-19 outcomes.

Sex differences in clinical characteristics and risk factors for disease severity of hospitalized patients with COVID-19

Recent studies reported sex differences in patients with coronavirus disease‐2019 (COVID‐19). We aim to analyze sex differences in clinical characteristics and risk factors for disease severity of hospitalized patients with COVID‐19 in Beijing. All adults (185 cases) diagnosed with COVID‐19 and admitted to Beijing Ditan Hospital, Capital Medical University were included in samples. The median age of all patients was 41 years. The mean body mass index (BMI) of males was relatively higher compared to females (p < 0.001). The proportion of male patients with coronary heart disease (CHD), nonalcoholic fatty liver disease (NAFLD), history of smoking and drinking was higher than females. Male patients developed more clinical symptoms, obtained more abnormal laboratory test results, while they were less aware of care‐seeking than female patients. There were no significant differences in clinical complications and outcomes between two groups. Age (odds ratio [OR]: 1.082; 95% confidence interval [CI]: 1.034–1.132; p = 0.001) and BMI (OR: 1.237; 95% CI: 1.041–1.47; p = 0.016) were considered risk factors for refractory pneumonia in multivariate regression analysis. The findings of the current study showed that SARS‐CoV‐2 was more likely to affect older males with comorbidities. Further researches into factors underlying obesity and disease severity may provide mechanistic insight into COVID‐19 development.

Global Sex Disparity of COVID-19: A Descriptive Review of Sex Hormones and Consideration for the Potential Therapeutic Use of Hormone Replacement Therapy in Older Adults

The 2019-2020 SARS-related coronavirus-2 (SARS-CoV-2) pandemic has brought unprecedented challenges to healthcare sectors around the world. As of November 2020, there have been over 64 million confirmed cases and approaching 2 million deaths globally. Despite the large number of positive cases, there are very limited established standards of care and therapeutic options available. To date, there is still no Food and Drug Administration (FDA) approved vaccine for COVID-19, although there are several options in various clinical trial stages. Herein, we have performed a global review evaluating the roles of age and sex on COVID-19 hospitalizations, ICU admissions, deaths in hospitals, and deaths in nursing homes. We have identified a trend in which elderly and male patients are significantly affected by adverse outcomes. There is evidence suggesting that sex hormone levels can influence immune system function against SARS-CoV-2 infection, thus reducing the adverse effects of COVID-19. Since older adults have lower levels of these sex hormones, we therefore speculate, within rational scientific context, that sex steroids, such as estrogen and progesterone, needs further consideration for use as alternative therapeutic option for treating COVID-19 elderly patients. To our knowledge, this is the first comprehensive article evaluating the significance of sex hormones in COVID-19 outcomes in older adults.

Numerical analysis of factors, pace and intensity of the corona virus (COVID-19) epidemic in Poland

This article focuses on a statistical analysis of the corona virus disease 2019 (COVID-19) data that appeared until November 31, 2020 in Poland. The studied database, expressed in terms of both population and air pollution (particulate) indicators, is provided mainly by the Airly company, the Central Statistical Office (GUS) and the Rogalski project. The particular measured factors, which underwent standardization, were assessed for mutual dependency by means of a Pearson correlation coefficient and analysed by a linear regression. Based on the presented models, our results indicate that air quality (air pollution level) is the most important factor in the context of enabling COVID-19 case load increase in Poland.

Gender Differences in Psychological and Behavioral Responses of Infected and Uninfected Health-Care Workers During the Early COVID-19 Outbreak

Objective: Understanding gender differences in responses of health-care workers (HCWs) to COVID-19 outbreak is an effective way to promote customized supports. Methods: During February 2020, 103 HCWs infected with COVID-19 (64 females and 39 males) and 535 uninfected HCWs (383 females and 152 males) were recruited in a cross-sectional study. Level of attention, six emotional status, and self-evaluation of eight protective measures were recorded. Multivariable Firth's logistic regressions were applied to explored independent effect of gender. Results: During early outbreak, female HCWs were more likely to give greater attention, adjusted OR:1.92 (95%CI 1.14-3.23) in total HCWs. Higher proportion of anxiety was observed in female HCWs, adjusted OR:3.14 (95%CI 1.98-4.99) for total HCWs, 4.32(95%CI 1.32-14.15) for infected HCWs and 2.97 (1.78, 4.95) for uninfected HCWs. Proportion of pessimism, fear, full of fighting spirit, and optimism were low, and no gender differences were observed. During a later outbreak, a majority of HCWs reported being very familiar with eight protective measures. After training, a proportion of high self-evaluation in hand hygiene, wearing gloves, and surgical masks increased independently in female HCWs, and adjusted ORs were 3.07 (95% CI 1.57-5.99), 2.37 (95% CI 1.26-4.49), and 1.92 (95% CI 1.02-3.62), respectively. Infection status amplified gender difference in anxiety, hand hygiene, and glove wearing. Conclusion: Female HCWs perceived the outbreak seriously, effective emotional and psychological well-ness should be targeted at female HCWs preferentially, and male HCWs should be encouraged to express their feelings and be further trained.

Sex Differences on Clinical Characteristics, Severity, and Mortality in Adult Patients With COVID-19: A Multicentre Retrospective Study

Background: Coronavirus disease-2019 (COVID-19) epidemic is spreading globally. Sex differences in the severity and mortality of COVID-19 emerged. This study aims to describe the impact of sex on outcomes in COVOD-19 with a special focus on the effect of estrogen.

Methods: We performed a retrospective cohort study which included 413 patients (230 males and 183 females) with COVID-19 from three designated hospitals in China with a follow up time from January 31, 2020, to April 17, 2020. Women over 55 were considered as postmenopausal patients according to the previous epidemiological data from China. The interaction between age and sex on in-hospital mortality was determined through Cox regression analysis. In addition, multivariate Cox regression models were performed to explore risk factors associated with in-hospital mortality of COVID-19.

Results: Age and sex had significant interaction for the in-hospital mortality (P < 0.001). Multivariate Cox regression showed that age (HR 1.041, 95% CI 1.009–1.073, P = 0.012), male sex (HR 2.033, 95% CI 1.007–2.098, P = 0.010), the interaction between age and sex (HR 1.118, 95% CI 1.003–1.232, P = 0.018), and comorbidities (HR 9.845, 95% CI 2.280–42.520, P = 0.002) were independently associated with in-hospital mortality of COVID-19 patients. In this multicentre study, female experienced a lower fatality for COVID-19 than male (4.4 vs. 10.0%, P = 0.031). Interestingly, stratification by age group revealed no difference in-hospital mortality was noted in women under 55 compared with women over 55 (3.8 vs. 5.2%, P = 0.144), as well as in women under 55 compared with the same age men (3.8 vs. 4.0%, P = 0.918). However, there was significantly difference in women over 55 with men of the same age group (5.2 vs. 21.0%, P = 0.007). Compared with male patients, female patients had higher lymphocyte (P < 0.001) and high-density lipoprotein (P < 0.001), lower high sensitive c reaction protein level (P < 0.001), and lower incidence rate of acute cardiac injury (6.6 vs. 13.5%, P = 0.022).

Conclusion: Male sex is an independent risk factor for COVID-19 in-hospital mortality. Although female mortality in COVID-19 is lower than male, it might not be directly related to the effect of estrogen. Further study is warranted to identify the sex difference in COVID-19 and mechanisms involved.

Acute Respiratory Distress in Aged, SARS-CoV-2-Infected African Green Monkeys but Not Rhesus Macaques

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) induces a wide range of disease severity, ranging from asymptomatic infection to a life-threating illness, particularly in the elderly population and individuals with comorbid conditions. Among individuals with serious coronavirus 2019 (COVID-19) disease, acute respiratory distress syndrome (ARDS) is a common and often fatal presentation. Animal models of SARS-CoV-2 infection that manifest severe disease are needed to investigate the pathogenesis of COVID-19-induced ARDS and evaluate therapeutic strategies. We report two cases of ARDS in two aged African green monkeys (AGMs) infected with SARS-CoV-2 that had pathological lesions and disease similar to severe COVID-19 in humans. We also report a comparatively mild COVID-19 phenotype characterized by minor clinical, radiographic, and histopathologic changes in the two surviving, aged AGMs and four rhesus macaques (RMs) infected with SARS-CoV-2. Notable increases in circulating cytokines were observed in three of four infected, aged AGMs but not in infected RMs. All the AGMs had increased levels of plasma IL-6 compared with baseline, a predictive marker and presumptive therapeutic target in humans infected with SARS-CoV-2. Together, our results indicate that both RMs and AGMs are capable of modeling SARS-CoV-2 infection and suggest that aged AGMs may be useful for modeling severe disease manifestations, including ARDS.

Male sex and age biases viral burden, viral shedding, and type 1 and 2 interferon responses during SARS-CoV-2 infection in ferrets

SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2) hospitalizations and deaths disportionally affect males and the elderly. Here we investigated the impact of male sex and age by infecting adult male, aged male, and adult female ferrets with SARS-CoV-2. Aged male ferrets had a decrease in temperature which was accompanied by prolonged viral replication with increased pathology in the upper respiratory tract after infection. Transcriptome analysis of the nasal turbinates and lungs indicated that female ferrets had significant increases in interferon response genes (OASL, MX1, ISG15, etc.) on day 2 post infection which was delayed in aged males. In addition, genes associated with taste and smell such as RTP1, CHGA, and CHGA1 at later time points were upregulated in males but not in females. These results provide insight into COVID-19 and suggests that older males may play a role in viral transmission due to decreased antiviral responses.

Is COVID-19 Gender-sensitive?

While clinical characteristics exhibit that susceptibility to COVID-19 infection is equally likely between males and females, clinical outcomes show that males experience both a higher severity and fatality for COVID-19 infection than females. This review examines the evidence for these sex and gender differences and aims to illustrate possible mechanisms behind such sensitivity. Successful entry of SARS-CoV-2 into the body is dependent on the angiotensin-converting enzyme 2 (ACE2) receptor and the transmembrane protease serine 2 (TMPRSS2). Thus, sex-based differences in the expression of the ACE2 receptor and TMPRSS2 may explain the disparities in COVID-19 severity and fatality. Furthermore, these disparities may also be attributed to sex-based difference in immunological responses. Finally, the differences in clinical outcomes of COVID-19 infections between men and women may be due to gendered differences in behaviors, such as smoking, and prevalence to comorbidities. An understanding of the sex and gender sensitivities of COVID-19 infection is a necessary component towards the creation of effective treatment options and therapies for the virus. Graphical abstract.

Mortality risk of COVID-19 in elderly males with comorbidities: a multi-country study

The COVID-19 pandemic causes severe morbidity and mortality. This multi-country study aimed to explore risk factors that drive mortality in COVID-19 patients who received neither dexamethasone nor remdesivir. We analyzed a cohort of 568 survivors and 507 non-survivors from China, European regions, and North America. Elderly males ≥70 years accounted for only 25% of survivors, but this rate was significantly higher in non-survivors from China (55%), European regions (63%), and North America (47%). Compared with survivors, non-survivors had more incidences of comorbidities such as cerebrovascular disease and chronic obstructive pulmonary disease (COPD, p-values<0.05). Survival analyses revealed age, male gender, shortness of breath, cerebrovascular disease, and COPD as mortality-associated factors. Survival time from symptom onset was significantly shorter in elderly versus young patients (median: 29 versus 62 days), males versus females (median: 46 versus 59 days), and patients with versus without comorbidities (mean: 41 versus 61 days). Mortality risk was higher in elderly males with comorbidities than in young females without comorbidities (p-value<0.01). Elderly male survivors with comorbidities also had longer hospital stays than other survivors (25 versus 18.5 days, p-value<0.01). Overall, the high mortality risk in elderly males with COVID-19-associated comorbidities supports early prevention and critical care for elderly populations.

Taming the cytokine storm: repurposing montelukast for the attenuation and prophylaxis of severe COVID-19 symptoms

As a result of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections, a clinical complication can arise that is characterized by a hyperinflammatory cytokine profile, often termed a 'cytokine storm'. A protein complex (nuclear factor kappa-light-chain-enhancer of activated B cells; NF-κB) is intricately involved in regulating inflammation and the immune response following viral infections, with a reduction in cytokine production often observed following a decrease in NF-κB activity. An approved asthma drug, montelukast, has been found to modulate the activity of NF-κB, and result in a corresponding decrease in proinflammatory mediators. Herein, we hypothesize that repurposing montelukast to suppress NF-κB activation will result in an attenuation of proinflammatory mediators and a decrease in cytokine production, thereby leading to a reduction in symptom severity and to improved clinical outcomes in patients with Coronavirus 2019 (COVID-19).

Effect of sex hormones on coronavirus disease 2019: an analysis of 5,061 laboratory-confirmed cases in South Korea

OBJECTIVE

To evaluate the effect of female sex hormones on the clinical outcomes of coronavirus disease 2019 patients using national claims data.

METHODS

This retrospective cohort study used the Health Insurance Review and Assessment data of 5,061 adult patients with laboratory-confirmed coronavirus disease 2019 in South Korea from January 20 to April 8, 2020. To evaluate the effect of hormone therapy on clinical outcomes among women, subgroup analyses using age-matched case-control data were performed.

RESULTS

Coronavirus disease 2019 was most prevalent in women in the 20-39 years age group (1,250 [44.14%]). Men were more likely to receive oxygen therapy (144 [6.46%] vs 131 [4.63%], P = 0.004), be admitted to the intensive care unit (60 [2.69%] vs 53 [1.87%], P = 0.049), and have a longer length of stay after admission to the intensive care unit (19.70 ± 11.80 vs 14.75 ± 9.23, P = 0.016). However, there was no significant difference in the mortality rate (men vs women: 42 [1.88%] vs 42 [1.48%], P = 0.267). In the multivariable Cox analysis, older age and underlying comorbidities, but not sex, were independent risk factors for mortality. Hormone therapy was not significantly associated with clinical outcomes.

CONCLUSIONS

This study, using nationwide data, suggests that female sex hormones are not associated with the morbidity and clinical outcomes of coronavirus disease 2019 in South Korea.

Lesson learned from China regarding use of personal protective equipment

BACKGROUND

In Wuhan, China, in December 2019, the novel coronavirus was detected. The virus causing COVID-19 was related to a coronavirus named severe acute respiratory syndrome coronavirus (SARS-CoV). The virus caused an epidemic in China and was quickly contained in 2003. Although coming from the same family of viruses and sharing certain transmissibility factors, the local health institutions in China had no experience with this new virus, subsequently named SARS-CoV-2.

METHODS

Based on their prior experience with the 2003 SARS epidemic, health authorities in China recognized the need for personal protective equipment (PPE). Existing PPE and protocols were limited and reflected early experience with SARS; however, as additional PPE supplies became available, designated COVID-19 hospitals in Hubei Province adopted the World Health Organization guidelines for Ebola to create a protocol specific for treating patients with COVID-19.

RESULTS

This article describes the PPE and protocol for its safe and effective deployment and the implementation of designated hospital units for COVID-19 patients. To date, only 2 nurses working in China who contracted SARS-CoV-2 have died from COVID-19 in the early period of the epidemic (February 11 and 14, 2020).

CONCLUSIONS

The lessons learned by health care workers in China are shared in the hope of preventing future occupational exposure.