Association of COVID-19 Infection With Incident Diabetes

Importance

SARS-CoV-2 infection may lead to acute and chronic sequelae. Emerging evidence suggests a higher risk of diabetes after infection, but population-based evidence is still sparse.

Objective

To evaluate the association between COVID-19 infection, including severity of infection, and risk of diabetes.

Design, Setting, and Participants

This population-based cohort study was conducted in British Columbia, Canada, from January 1, 2020, to December 31, 2021, using the British Columbia COVID-19 Cohort, a surveillance platform that integrates COVID-19 data with population-based registries and administrative data sets. Individuals tested for SARS-CoV-2 by real-time reverse transcription-polymerase chain reaction (RT-PCR) were included. Those who tested positive for SARS-CoV-2 (ie, those who were exposed) were matched on sex, age, and collection date of RT-PCR test at a 1:4 ratio to those who tested negative (ie, those who were unexposed). Analysis was conducted January 14, 2022, to January 19, 2023.

Exposure

SARS-CoV-2 infection.

Main Outcomes and Measures

The primary outcome was incident diabetes (insulin dependent or not insulin dependent) identified more than 30 days after the specimen collection date for the SARS-CoV-2 test with a validated algorithm based on medical visits, hospitalization records, chronic disease registry, and prescription drugs for diabetes management. Multivariable Cox proportional hazard modeling was performed to evaluate the association between SARS-CoV-2 infection and diabetes risk. Stratified analyses were performed to assess the interaction of SARS-CoV-2 infection with diabetes risk by sex, age, and vaccination status.

Results

Among 629 935 individuals (median [IQR] age, 32 [25.0-42.0] years; 322 565 females [51.2%]) tested for SARS-CoV-2 in the analytic sample, 125 987 individuals were exposed and 503 948 individuals were unexposed. During the median (IQR) follow-up of 257 (102-356) days, events of incident diabetes were observed among 608 individuals who were exposed (0.5%) and 1864 individuals who were not exposed (0.4%). The incident diabetes rate per 100 000 person-years was significantly higher in the exposed vs nonexposed group (672.2 incidents; 95% CI, 618.7-725.6 incidents vs 508.7 incidents; 95% CI, 485.6-531.8 incidents; P < .001). The risk of incident diabetes was also higher in the exposed group (hazard ratio [HR], 1.17; 95% CI, 1.06-1.28) and among males (adjusted HR, 1.22; 95% CI, 1.06-1.40). The risk of diabetes was higher among people with severe disease vs those without COVID-19, including individuals admitted to the intensive care unit (HR, 3.29; 95% CI, 1.98-5.48) or hospital (HR, 2.42; 95% CI, 1.87-3.15). The fraction of incident diabetes cases attributable to SARS-CoV-2 infection was 3.41% (95% CI, 1.20%-5.61%) overall and 4.75% (95% CI, 1.30%-8.20%) among males.

Conclusions and Relevance

In this cohort study, SARS-CoV-2 infection was associated with a higher risk of diabetes and may have contributed to a 3% to 5% excess burden of diabetes at a population level.

Observed versus expected rates of myocarditis after SARS-CoV-2 vaccination: a population-based cohort study

BACKGROUND

Postmarketing evaluations have linked myocarditis to SARS-CoV-2 mRNA vaccines. We sought to estimate the incidence of myocarditis after mRNA vaccination against SARS-CoV-2, and to compare the incidence with expected rates based on historical background rates in British Columbia.

METHODS

We conducted an observational study using population health administrative data from the BC COVID-19 Cohort from Dec. 15, 2020, to Mar. 10, 2022. The primary exposure was any dose of an mRNA vaccine against SARS-CoV-2. The primary outcome was incidence of hospital admission or emergency department visit for myocarditis or myopericarditis within 7 and 21 days postvaccination, calculated as myocarditis rates per 100 000 mRNA vaccine doses, expected rates of myocarditis cases and observedto-expected ratios. We stratified analyses by age, sex, vaccine type and dose number.

RESULTS

We observed 99 incident cases of myocarditis within 7 days (0.97 cases per 100 000 vaccine doses; observed v. expected ratio 14.81, 95% confidence interval [CI] 10.83-16.55) and 141 cases within 21 days (1.37 cases per 100 000 vaccine doses; observed v. expected ratio 7.03, 95% CI 5.92-8.29) postvaccination. Cases of myocarditis per 100 000 vaccine doses were higher for people aged 12-17 years (2.64, 95% CI 1.54-4.22) and 18-29 years (2.63, 95% CI 1.94-3.50) than for older age groups, for males compared with females (1.64, 95% CI 1.30-2.04 v. 0.35, 95% CI 0.21-0.55), for those receiving a second dose compared with a third dose (1.90, 95% CI 1.50-2.39 v. 0.76, 95% CI 0.45-1.30) and for those who received the mRNA-1273 (Moderna) vaccine compared with the BNT162b2 (Pfizer-BioNTech) vaccine (1.44, 95% CI 1.06-1.91 v. 0.74, 95% CI 0.56-0.98). The highest observed-to-expected ratio was seen after the second dose among males aged 18-29 years who received the mRNA-1273 vaccine (148.32, 95% CI 95.03-220.69).

INTERPRETATION

Although absolute rates of myocarditis were low, vaccine type, age and sex are important factors to consider when strategizing vaccine administration to reduce the risk of postvaccination myocarditis. Our findings support the preferential use of the BNT162b2 vaccine over the mRNA-1273 vaccine for people aged 18-29 years.

Comparative Risk of Myocarditis/Pericarditis Following Second Doses of BNT162b2 and mRNA-1273 Coronavirus Vaccines

BACKGROUND

Postmarketing evaluations have linked myocarditis to COVID-19 mRNA vaccines. However, few population-based analyses have directly compared the safety of the 2 mRNA COVID-19 vaccines.

OBJECTIVES

This study aimed to compare the risk of myocarditis, pericarditis, and myopericarditis between BNT162b2 and mRNA-1273.

METHODS

We used data from the British Columbia COVID-19 Cohort (BCC19C), a population-based cohort study. The exposure was the second dose of an mRNA vaccine. The outcome was diagnosis of myocarditis, pericarditis, or myopericarditis during a hospitalization or an emergency department visit within 21 days of the second vaccination dose. We performed multivariable logistic regression to assess the association between vaccine product and the outcomes of interest.

RESULTS

The rates of myocarditis and pericarditis per million second doses were higher for mRNA-1273 (n = 31, rate 35.6; 95% CI: 24.1-50.5; and n = 20, rate 22.9; 95% CI: 14.0-35.4, respectively) than BNT162b2 (n = 28, rate 12.6; 95% CI: 8.4-18.2 and n = 21, rate 9.4; 95% CI: 5.8-14.4, respectively). mRNA-1273 vs BNT162b2 had significantly higher odds of myocarditis (adjusted OR [aOR]: 2.78; 95% CI: 1.67-4.62), pericarditis (aOR: 2.42; 95% CI: 1.31-4.46) and myopericarditis (aOR: 2.63; 95% CI: 1.76-3.93). The association between mRNA-1273 and myocarditis was stronger for men (aOR: 3.21; 95% CI: 1.77-5.83) and younger age group (18-39 years; aOR: 5.09; 95% CI: 2.68-9.66).

CONCLUSIONS

Myocarditis/pericarditis following mRNA COVID-19 vaccines is rare, but we observed a 2- to 3-fold higher odds among individuals who received mRNA-1273 vs BNT162b2. The rate of myocarditis following mRNA-1273 receipt is highest among younger men (age 18-39 years) and does not seem to be present at older ages. Our findings may have policy implications regarding the choice of vaccine offered.

Redox biology of Leishmania and macrophage targeted nanoparticles for therapy

Intramacrophage parasite ‘Leishmania’ has developed various mechanisms for proficient uptake into macrophages and phagosome regulation to avoid macrophage's oxidative burst induced by peroxide, hydroxyl radical, hypochlorous acid and peroxynitrite production. One major barrier for impairing the accession of old fashioned anti-Leishmanial drugs is intrinsic incapability to pass through cell membranes and limiting their abilities to ultimately destroy intracellular pathogens. Receptor-mediated targeted drug delivery to the macrophages by using nanoparticles emerges as promising strategy to improve therapeutic efficacy of old-fashioned drug. Receptor-mediated targeted nanoparticles can migrate across the cell membrane barriers and release enclosed drug cargo at sites of infection. This review is focusing on Leishmania-macrophage signaling alterations, its association with drug resistance and role of nanoparticles for receptor mediated macrophage targeting.

COVID-19 vaccines and adverse events of special interest: A multinational Global Vaccine Data Network (GVDN) cohort study of 99 million vaccinated individuals

BACKGROUND

The Global COVID Vaccine Safety (GCoVS) Project, established in 2021 under the multinational Global Vaccine Data Network™ (GVDN®), facilitates comprehensive assessment of vaccine safety. This study aimed to evaluate the risk of adverse events of special interest (AESI) following COVID-19 vaccination from 10 sites across eight countries.

METHODS

Using a common protocol, this observational cohort study compared observed with expected rates of 13 selected AESI across neurological, haematological, and cardiac outcomes. Expected rates were obtained by participating sites using pre-COVID-19 vaccination healthcare data stratified by age and sex. Observed rates were reported from the same healthcare datasets since COVID-19 vaccination program rollout. AESI occurring up to 42 days following vaccination with mRNA (BNT162b2 and mRNA-1273) and adenovirus-vector (ChAdOx1) vaccines were included in the primary analysis. Risks were assessed using observed versus expected (OE) ratios with 95 % confidence intervals. Prioritised potential safety signals were those with lower bound of the 95 % confidence interval (LBCI) greater than 1.5.

RESULTS

Participants included 99,068,901 vaccinated individuals. In total, 183,559,462 doses of BNT162b2, 36,178,442 doses of mRNA-1273, and 23,093,399 doses of ChAdOx1 were administered across participating sites in the study period. Risk periods following homologous vaccination schedules contributed 23,168,335 person-years of follow-up. OE ratios with LBCI > 1.5 were observed for Guillain-Barré syndrome (2.49, 95 % CI: 2.15, 2.87) and cerebral venous sinus thrombosis (3.23, 95 % CI: 2.51, 4.09) following the first dose of ChAdOx1 vaccine. Acute disseminated encephalomyelitis showed an OE ratio of 3.78 (95 % CI: 1.52, 7.78) following the first dose of mRNA-1273 vaccine. The OE ratios for myocarditis and pericarditis following BNT162b2, mRNA-1273, and ChAdOx1 were significantly increased with LBCIs > 1.5.

CONCLUSION

This multi-country analysis confirmed pre-established safety signals for myocarditis, pericarditis, Guillain-Barré syndrome, and cerebral venous sinus thrombosis. Other potential safety signals that require further investigation were identified.

Background rates of adverse events of special interest for COVID-19 vaccines: A multinational Global Vaccine Data Network (GVDN) analysis

BACKGROUND

The Global COVID Vaccine Safety (GCoVS) project was established in 2021 under the multinational Global Vaccine Data Network (GVDN) consortium to facilitate the rapid assessment of the safety of newly introduced vaccines. This study analyzed data from GVDN member sites on the background incidence rates of conditions designated as adverse events of special interest (AESI) for COVID-19 vaccine safety monitoring.

METHODS

Eleven GVDN global sites obtained data from national or regional healthcare databases using standardized methods. Incident events of 13 pre-defined AESI were included for a pre-pandemic period (2015-19) and the first pandemic year (2020). Background incidence rates (IR) and 95% confidence intervals (CI) were calculated for inpatient and emergency department encounters, stratified by age and sex, and compared between pre-pandemic and pandemic periods using incidence rate ratios.

RESULTS

An estimated 197 million people contributed 1,189,652,926 person-years of follow-up time. Among inpatients in the pre-pandemic period (2015-19), generalized seizures were the most common neurological AESI (IR ranged from 22.15 [95% CI 19.01-25.65] to 278.82 [278.20-279.44] per 100,000 person-years); acute disseminated encephalomyelitis was the least common (<0.5 per 100,000 person-years at most sites). Pulmonary embolism was the most common thrombotic event (IR 45.34 [95% CI 44.85-45.84] to 93.77 [95% CI 93.46-94.08] per 100,000 person-years). The IR of myocarditis ranged from 1.60 [(95% CI 1.45-1.76) to 7.76 (95% CI 7.46-8.08) per 100,000 person-years. The IR of several AESI varied by site, healthcare setting, age and sex. The IR of some AESI were notably different in 2020 compared to 2015-19.

CONCLUSION

Background incidence of AESIs exhibited some variability across study sites and between pre-pandemic and pandemic periods. These findings will contribute to global vaccine safety surveillance and research.

Geospatial, Clinical, and Social Determinants of Hospital Readmissions

Unnecessary hospital readmissions increase patient burden, decrease health care quality and efficiency, and raise overall costs. This retrospective cohort study sought to identify high-risk patients who may serve as targets for interventions aiming at reducing hospital readmissions. The authors compared geospatial, social demographic, and clinical characteristics of patients with or without a 90-day readmission. Electronic health records of 42 330 adult patients admitted to 2 Midwestern hospitals during 2013 to 2016 were used, and logistic regression was performed to determine risk factors for readmission. The 90-day readmission percentage was 14.9%. Two main groups of patients with significantly higher odds of a 90-day readmission included those with severe conditions, particularly those with a short length of stay at incident admission, and patients with Medicare but younger than age 65. These findings expand knowledge of potential risk factors related to readmissions. Future interventions to reduce hospital readmissions may focus on the aforementioned high-risk patient groups.

Heterogeneity and Risk of Bias in Studies Examining Risk Factors for Severe Illness and Death in COVID-19: A Systematic Review and Meta-Analysis

This systematic review and meta-analysis synthesized the evidence on the impacts of demographics and comorbidities on the clinical outcomes of COVID-19, as well as the sources of the heterogeneity and publication bias of the relevant studies. Two authors independently searched the literature from PubMed, Embase, Cochrane library, and CINAHL on 18 May 2021; removed duplicates; screened the titles, abstracts, and full texts by using criteria; and extracted data from the eligible articles. The variations among the studies were examined by using Cochrane, Q.; I2, and meta-regression. Out of 11,975 articles that were obtained from the databases and screened, 559 studies were abstracted, and then, where appropriate, were analyzed by meta-analysis (n = 542). COVID-19-related severe illness, admission to the ICU, and death were significantly correlated with comorbidities, male sex, and an age older than 60 or 65 years, although high heterogeneity was present in the pooled estimates. The study design, the study country, the sample size, and the year of publication contributed to this. There was publication bias among the studies that compared the odds of COVID-19-related deaths, severe illness, and admission to the ICU on the basis of the comorbidity status. While an older age and chronic diseases were shown to increase the risk of developing severe illness, admission to the ICU, and death among the COVID-19 patients in our analysis, a marked heterogeneity was present when linking the specific risks with the outcomes.

Elevated serum insulin-like growth factor 1 in recurrent aphthous stomatitis

Over 100 million Americans experience recurrent aphthous stomatitis (RAS) at some point in life. To develop targeted drugs for RAS treatment, it is critical to identify its etiology. We determined if serum insulin‐like growth factor 1 (IGF‐1) and related factors are associated with RAS, because both RAS prevalence and IGF‐1 are highest during puberty. We analyzed data from 1,480 Third National Health and Nutrition Examination Survey participants aged 20–40 years. Participants with a history of diabetes or lupus, cotinine levels 6 ng/ml or higher or glycemia 110 mg/dl or higher were excluded. We compared levels of IGF‐1, IGFBP‐3, leptin, and insulin in participants with a positive vs. negative RAS history in the prior 12 months. We used logistic regression in SAS/SUDAAN to account for the complex sampling design. The odds of a positive RAS history were 1.31 times higher for every 100 ng/ml increase in serum IGF‐1. This association persisted after adjustment for age, race/ethnicity, medication intake, body mass index, insulin, leptin, glycemia, and income (adjusted OR = 1.30, 95% CI [1.06, 1.60]; p = 0.013). The odds of a positive RAS history were also higher among non‐Hispanic white compared with non‐Hispanic black participants (adjusted OR = 4.37, 95% CI [3.00, 6.38]). Leptin, IGFBP‐3, and insulin levels did not differ by RAS status. The significantly higher IGF‐1 levels in participants with a positive RAS history compared with controls suggest a possible role of the IGF‐1 pathway in RAS etiology.

Neurocognitive impairment and health-related quality of life among people living with Human Immunodeficiency Virus (HIV)

The association between HIV-associated neurocognitive impairment (NCI) and health-related quality of life (HRQoL) is not well known. We investigated this association among the CNS (Central Nervous System) HIV Antiretroviral Therapy Effects Research (CHARTER) study participants. We performed factor analysis to distinguish physical and mental HRQoL, followed by general linear models. We analyzed 1,340 HIV participants, including 35.6% with NCI, 77.2% males, 70.5% unemployed, and 42.2% with depression. Impaired participants had lower (worse) mental and physical HRQoL mean scores compared to unimpaired participants. NCI was negatively associated with mental HRQoL in crude (mean difference: -4.38; 95% CI: -6.70 to -2.06) and adjusted analysis (-2.56, -4.83 to -0.30). NCI was also negatively associated with physical HRQoL in unadjusted analysis (-4.62, -7.45 to -1.78), though the association weakened in the adjusted analysis (-2.20, -4.81 to 0.40). The association between NCI and HRQoL was confounded mainly by employment and was partially mediated by depression. These findings suggest that future strategies aimed at improving HRQoL among HIV-infected patients with NCI might benefit from concurrent management of depression.

Improving behavioral health workforce supply and needs estimates using active surveillance data

INTRODUCTION

Previous studies show that supply of behavioral health professionals in rural areas is inadequate to meet the need. Measuring shortage using licensure data on psychiatrists is a common approach. Although inexpensive, the licensure data have many limitations. An alternative is to implement an active surveillance system, which uses licensure data in addition to active data collection to obtain timely and detailed information.

METHODS

Nebraska Health Professions Tracking Service (HPTS) data were used to examine differences in workforce supply estimates between the passive (licensure data only) and active (HPTS data) surveillance systems. The impact of these differences on the designation of psychiatric professional shortage areas has been described. Information regarding the number of psychiatrists, advanced practice registered nurses and physician assistants specializing in psychiatry was not available from the licensure database, unlike HPTS.

RESULTS

Using licensure data versus HPTS data to estimate workforce, the counts of professionals actively practicing in psychiatry and behavioral health were overestimated by 24.1-57.1%. Ignoring work status, the workforce was overestimated by 10.0-17.4%. Providers spent 54-78% of time seeing patients. Based on primary practice location, 87% of counties did not have a psychiatrist and 9.6% were at or above the Health Professional Shortage Area designation ratio of psychiatrists to population.

CONCLUSION

Enumeration methods such as ongoing surveillance, in addition to licensure data, curtails the issues and improves identification of shortage areas and future behavioral workforce related planning and implementation strategies.

An assessment of factors associated with neurocognitive decline in people living with HIV

Despite the widespread use of combination antiretroviral therapy (cART), HIV-associated neurocognitive impairment (NCI) remains a health concern. However, limited research has been done to identify factors associated with neurocognitive decline. We assessed risk factors associated with neurocognitive decline in people living with HIV using a definition of decline that is statistically easy to adopt, is based on a commonly used neuropsychological cut-off and may be clinically relevant. Cox proportional hazards modeling was performed using the CNS HIV Antiretroviral Therapy Effects Research (CHARTER) study database. 581 participants were followed for up to 12 years. Neurocognitive decline was defined as the first observed drop in global T-scores of at least 2.67. Lifetime methamphetamine use had the strongest association with neurocognitive decline (adjusted Hazard Ratio; aHR = 1.48; 95% CI = 0.92-2.39) followed by no current antiretroviral medication use (aHR = 1.32; 95% CI = 0.91-1.92). Other risk factors included Hispanic ethnicity, lifetime history of major depressive disorder, lifetime cannabis use, hepatitis-C infection, and difficulty eating, dressing, bathing, or using the toilet. Results indicate that consistent use of ART may be of high significance to preserving neurocognition. Furthermore, Hispanic patients, those with a history of depression and substance use, and those having difficulty in essential activities of daily living may require vigilant follow-up.

A multiprovincial retrospective analysis of the incidence of myocarditis or pericarditis after mRNA vaccination compared to the incidence after SARS-CoV-2 infection

Objective

To compare myocarditis/pericarditis risk after COVID-19 mRNA vaccination versus SARS-CoV-2 infection, and to assess if myocarditis/pericarditis risk varies by vaccine dosing interval.

Methods

In this retrospective cohort study, we used linked databases in Quebec, Ontario, and British Columbia between January 26, 2020, and September 9, 2021. We included individuals aged 12 or above who received an mRNA vaccine as the second dose or were SARS-CoV-2-positive by RT-PCR. The outcome was hospitalization/emergency department visit for myocarditis/pericarditis within 21 days of exposure. We calculated age- and sex-stratified incidence ratios (IRs) of myocarditis/pericarditis following mRNA vaccination versus SARS-CoV-2 infection. We also calculated myocarditis/pericarditis incidence by vaccine type, homologous/heterologous schedule, and dosing interval. We pooled province-specific estimates using meta-analysis.

Results

Following 18,860,817 mRNA vaccinations and 860,335 SARS-CoV-2 infections, we observed 686 and 160 myocarditis/pericarditis cases, respectively. Myocarditis/pericarditis incidence was lower after vaccination than infection (IR [BNT162b2/SARS-CoV-2], 0.14; 95%CI, 0.07-0.29; IR [mRNA-1273/SARS-CoV-2], 0.28; 95%CI, 0.20-0.39). Within the vaccinated cohort, myocarditis/pericarditis incidence was lower with longer dosing intervals; IR (56 or more days/15-30 days) was 0.28 (95%CI, 0.19-0.41) for BNT162b2 and 0.26 (95%CI, 0.18-0.38) for mRNA-1273.

Conclusion

Myocarditis/pericarditis risk was lower after mRNA vaccination than SARS-CoV-2 infection, and with longer intervals between primary vaccine doses.

Healthcare utilization among COVID-19 mRNA vaccine-associated myocarditis cases: a matched retrospective cohort study

OBJECTIVES

We evaluated all-cause healthcare utilization among those with vaccine-associated myocarditis, compared to vaccinees without postvaccination myocarditis.

METHODS

We conducted a retrospective cohort study in individuals aged 12 and older who received COVID-19 mRNA vaccination in British Columbia. Exposure was defined as an ED visit or hospitalization for myocarditis within 21 days postvaccination. The primary outcome was healthcare utilization. Ratios of rate ratios (RRRs) for exposure-associated healthcare utilization were calculated using a difference-in-differences (DiD) analysis.

RESULTS

In the postindex period, the exposed and unexposed groups showed substantial utilization rate difference (RD = 15.30 [95% CI, 14.47-16.13). A 51% overall increase in healthcare utilization was observed over 18 months among exposed individuals (RRR, 1.51 [95%CI, 1.08-2.11]). In the initial six months, healthcare utilization surpassed the 18-month estimate, exhibiting a 125% increase (RRR, 2.25 [95%CI, 1.43-3.52]), while the last 12 months showed no statistically significant change (RRR, 1.03 [95%CI, 0.72-1.47]). An additional 9.1 (95%CI, 8.53-9.71) visits per person were attributed to vaccine-associated myocarditis over 18 months (total excess = 938.26 healthcare visits).

CONCLUSION

The initial surge in healthcare visits postexposure, mainly outpatient follow-ups, followed by a return to baseline rates, indicates a positive prognosis and supports the vaccine's safety profile.

Risk of Major Adverse Cardiovascular Events After SARS-CoV-2 Infection in British Columbia: A Population-Based Study

BACKGROUND

COVID-19 is associated with increased risk of post-acute cardiovascular outcomes. Population-based evidence for long periods of observation is still limited.

METHODS

This population-based cohort study was conducted using data (2020-2021) from the British Columbia COVID-19 Cohort. The exposure of interest was severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, identified through reverse transcription-polymerase chain reaction (RT-PCR) assay. Individuals who tested positive (exposed) on RT-PCR were matched to negative controls (unexposed) on sex, age, and RT-PCR collection date in a 1:4 ratio. Outcomes of interest were incident major adverse cardiovascular events and acute myocardial infarction, identified more than 30 days after RT-PCR collection date. The association between SARS-CoV-2 infection and cardiovascular risk was assessed through multivariable survival models. Population attributable fractions were computed from Cox models.

RESULTS

We included 649,320 individuals: 129,864 exposed and 519,456 unexposed. The median duration of follow-up was 260 days; 1,786 events (0.34%) took place among the unexposed, and 702 (0.54%) in the exposed. The risk of major adverse cardiovascular events was higher in the exposed (adjusted hazard ratio [aHR] 1.34; 95% confidence interval [CI], 1.22-1.46), with greater risk observed in those who were hospitalized (aHR 3.81; 95% CI, 3.12-4.65) or required intensive care unit admission (aHR 6.25; 95% CI, 4.59-8.52) compared with the unexposed group. The fraction of cardiovascular events attributable to SARS-CoV-2 was 7.04% (95% CI, 4.67-9.41%). Comparable results were observed for acute myocardial infarction.

CONCLUSIONS

SARS-CoV-2 infection was associated with higher cardiovascular risk, with graded increase across the acute COVID-19 severity, contributing to 7% of incident major adverse cardiovascular events. These findings suggest that long-term monitoring of cardiovascular risk is required in COVID-19 survivors.

Understanding the accountability issues of the immunization workforce for the Expanded Program on Immunization (EPI) in Balochistan: An exploratory study

Background

Among all provinces of Pakistan, immunization coverage is poorest in Balochistan. There is no provincial immunization policy for Balochistan including a lack of human resource management policy. Maladministration and lack of accountability leading to health workforce demotivation and poor performance can be a crucial reason behind an inefficient and ineffective immunization program in Balochistan. The objective of this study was to better understand the accountability issues of EPI workforce at provincial and district level leading to poor program performance and to identify governance strategies for management of inefficiency, demotivation and absenteeism.

Methods

An exploratory qualitative study was carried out to explore issues related to human resource (HR) accountability within immunization program of Balochistan for developing strategies to improve performance of the program. Five districts were selected using purposive sampling based on the comparative poor and good routine immunization coverages and Human Development Index (HDI). Interviews were conducted with EPI Staff and District Health Officers (DHOs) in each district including provincial EPI Staff. A semi-structured and open-ended questionnaire was used. Thematic analysis was used to analyze the qualitative data.

Results

Major barriers to HR accountability included lack of a written HR policy, proper service structure including promotions and benefits and understanding of accurate job description coupled with inadequate HR development budget and activities. Most important demotivating factors were inadequate number of vaccinators, deficient budget with delayed wage and salary disbursements resulting in poor immunization coverage and a lack of appreciation/feedback from senior management for the frontline workers. Key challenge for vaccinators was poor community orientation and mobilization. Although, the participants proposed some solutions based on their perspective, none were elaborate or precise.

Conclusions

Adaptation of National Immunization Policy tailored to the provincial context and proper implementation is much needed. Review of current allocations of vaccinators and need based relocation along with recruitment of new vaccinators with clear job description and terms of reference is desirable. Review of current incentive structure is required. Finally, trust building between community and the vaccination program and social mobilization about the benefits of vaccinations through community influential is vital.

Low-Level Groundwater Atrazine in High Atrazine Usage Nebraska Counties: Likely Effects of Excessive Groundwater Abstraction

Recent studies observed a correlation between estrogen-related cancers and groundwater atrazine in eastern Nebraska counties. However, the mechanisms of human exposure to atrazine are unclear because low groundwater atrazine concentration was observed in counties with high cancer incidence despite having the highest atrazine usage. We studied groundwater atrazine fate in high atrazine usage Nebraska counties. Data were collected from Quality Assessed Agrichemical Contaminant Nebraska Groundwater, Parameter-Elevation Regressions on Independent Slopes Model (PRISM), and water use databases. Descriptive statistics and cluster analysis were performed. Domestic wells (59%) were the predominant well type. Groundwater atrazine was affected by well depth. Clusters consisting of wells with low atrazine were characterized by excessive groundwater abstraction, reduced precipitation, high population, discharge areas, and metropolitan counties. Hence, low groundwater atrazine may be due to excessive groundwater abstraction accompanied by atrazine. Human exposure to atrazine in abstracted groundwater may be higher than the estimated amount in groundwater.

Development of a Nomogram-Based Tool to Predict Neurocognitive Impairment Among HIV-positive Charter Participants

Background:

Despite the widespread use of combination antiretroviral therapy (cART), HIV-associated neurocognitive impairment (NCI) persists in people living with HIV (PLWH). Studies have generated inconsistent results regarding etiological factors for NCI in PLWH. Furthermore, a user-friendly and readily available predictive tool is desirable in clinical practice to screen PLWH for NCI.

Objective:

This study aimed to identify factors associated with NCI using a large and diverse sample of PLWH and build a nomogram based on demographic, clinical, and behavioral variables.

Methods:

We performed Bayesian network analysis using a supervised learning technique with the Markov Blanket (MB) algorithm. Logistic regression was also conducted to obtain the adjusted regression coefficients to construct the nomogram.

Results:

Among 1,307 participants, 21.6% were neurocognitively impaired. During the MB analysis, age provided the highest amount of mutual information (0.0333). Logistic regression also showed that old age (>50 vs. ≤50 years) had the strongest association (OR=2.77, 95% CI=1.99-3.85) with NCI. The highest possible points on the nomogram were 626, translated to a nomogram-predicted probability of NCI to be approximately 0.95. The receiver operating characteristic (ROC) curve's concordance index was 0.75, and the nomogram's calibration plot exhibited an excellent agreement between observed and predicted probabilities.

Conclusion:

The nomogram used variables that can be easily measured in clinical settings and, thus, easy to implement within a clinic or web-interface platform. The nomogram may help clinicians screen for patients with a high probability of having NCI and thus needing a comprehensive neurocognitive assessment for early diagnosis and appropriate management.

Cohort profile: the British Columbia COVID-19 Cohort (BCC19C)-a dynamic, linked population-based cohort

Purpose

The British Columbia COVID-19 Cohort (BCC19C) was developed from an innovative, dynamic surveillance platform and is accessed/analyzed through a cloud-based environment. The platform integrates recently developed provincial COVID-19 datasets (refreshed daily) with existing administrative holdings and provincial registries (refreshed weekly/monthly). The platform/cohort were established to inform the COVID-19 response in near "real-time" and to answer more in-depth epidemiologic questions.

Participants

The surveillance platform facilitates the creation of large, up-to-date analytic cohorts of people accessing COVID-19 related services and their linked medical histories. The program of work focused on creating/analyzing these cohorts is referred to as the BCC19C. The administrative/registry datasets integrated within the platform are not specific to COVID-19 and allow for selection of "control" individuals who have not accessed COVID-19 services.

Findings to date

The platform has vastly broadened the range of COVID-19 analyses possible, and outputs from BCC19C analyses have been used to create dashboards, support routine reporting and contribute to the peer-reviewed literature. Published manuscripts (total of 15 as of July, 2023) have appeared in high-profile publications, generated significant media attention and informed policy and programming. In this paper, we conducted an analysis to identify sociodemographic and health characteristics associated with receiving SARS-CoV-2 laboratory testing, testing positive, and being fully vaccinated. Other published analyses have compared the relative clinical severity of different variants of concern; quantified the high "real-world" effectiveness of vaccines in addition to the higher risk of myocarditis among younger males following a 2nd dose of an mRNA vaccine; developed and validated an algorithm for identifying long-COVID patients in administrative data; identified a higher rate of diabetes and healthcare utilization among people with long-COVID; and measured the impact of the pandemic on mental health, among other analyses.

Future plans

While the global COVID-19 health emergency has ended, our program of work remains robust. We plan to integrate additional datasets into the surveillance platform to further improve and expand covariate measurement and scope of analyses. Our analyses continue to focus on retrospective studies of various aspects of the COVID-19 pandemic, as well as prospective assessment of post-acute COVID-19 conditions and other impacts of the pandemic.