Preparing for compounding crises: Staff shortages and cyber-attack vulnerability in the era of COVID-19

In 2020, while the USA was experiencing suc-cessive waves of COVID-19, Universal Health Services experienced a major cyber attack that crippled electronic systems in over 200 hospitals, including a major academic medical centre that was playing a key regional role in COVID-19 care and clinical trials. This paper discusses the impact of the attack on clinical operations, infor-matics, research and teaching, contextualising the case study within more wide-scale trends driving the rise in cyber attacks on health-care systems. The compounding relationships between COVID-19, healthcare workforce depletion and cyber-security vulnerabilities form the framework of the discussion and action plan. Commitments to institutional best prac-tices, large-scale investments in infrastructure, and above all increasing support for the crit-ical human actors carrying out the work, are urgently needed to secure the healthcare system against these destabilising threats. Within this context, this paper argues that information security in the healthcare sector must be reimagined and integrated with greater support for the needs of frontline healthcare workers. © Henry Stewart Publications, 1749–9216.

A phase 3 study to evaluate the efficacy and safety of reparixin in severe COVID-19 pneumonia

Introduction: The clinical progression of severe coronavirus disease 2019 (COVID-19) is associated with uncontrolled activation of inflammatory cytokines that results in excessive tissue injury, among which is interleukin-8 (IL-8). Aim(s): To assess the efficacy and safety of reparixin, an inhibitor of IL-8 receptors, as add-on therapy to the standard of care for severe COVID-19 pneumonia. Method(s): This was a Phase 3, multicenter, randomized, placebo-controlled study in hospitalized adult patients with COVID-19 requiring oxygen support and/or noninvasive ventilation. From February to July 2021, patients were randomized 2:1 to oral reparixin or placebo in addition to the standard of care for up to 21 days or until hospital discharge. The primary endpoint was the proportion of patients alive and free of respiratory failure. This study was funded by Dompe Farmaceutici SpA (ClinicalTrials.gov: NCT04878055). Result(s): Of the 278 randomized patients, 185 patients in the reparixin group and 94 patients in the placebo group were included in the primary intention-to-treat analysis. The proportion of patients alive and free of respiratory failure at day 28 was greater in the reparixin group but not statistically significant (n=152 (89.4%) vs. n=71 (85.5%), OR: 1.63, 95% CI: 0.75 - 3.51, p= 0.2). While time to recovery was not different between groups, patients who received reparixin had a lower intensive care unit admission rate. Reparixin was well-tolerated. Conclusion(s): This trial did not meet the primary efficacy endpoint due to the low mortality in both arms, yet reparixin showed a promising trend towards limiting disease progression. A confirmatory Phase 3 study is currently underway.

Juneau, Alaska's Successful Response to COVID-19: A Case Study of Adaptive Leadership in a Complex System

Juneau, Alaska, kept COVID-19 deaths lower than in other similar jurisdictions. We argue that adaptive leadership—the early decisions and actions of Juneau's leaders, effective communications, and emergent new collaborative structures—in the context of municipal ownership of key assets enabled Juneau's success. The result of 61 interviews and follow-up research, this case study contributes a better understanding of which institutional design, communication, and collaborative factors mattered in responding to the pandemic. Adaptive leadership provides a better explanation for Juneau's success than alternatives that focus on its isolation, home-rule status, and socio-economic structure.

EVALUATING THE EFFECTS OF SOCIAL DETERMINANTS OF HEALTH ON COVID-19 SEVERITY AT DIAGNOSIS, AND ANXIETY, DEPRESSION AND QUALITY OF LIFE OUTCOMES ≥ 6 MONTHS AFTER DIAGNOSIS

BACKGROUND: COVID-19 continues to be an ongoing problem worldwide, especially for those who are disproportionately affected due to their social determinants of health, as they are often at a socioeconomic disadvantage. We are primarily interested in evaluating how education level, income, race, ethnicity, and obesity are correlated with acute COVID-19 severity, and anxiety, depression, and quality of life ≥ 6 months post-infection. Specifically, obesity (BMI > 30), has been previously identified as a risk factor for COVID- 19 regarding severity and mortality. We found it imperative to further investigate these demographic variables, as they are vital in understanding how social determinants of health are impacting COVID-19 outcomes. Insights from this study can assist with identifying gaps in care for those with poor social determinants of health, as well as help shape care for those who have been disproportionately affected. METHODS: We examined records of COVID-19 patients through the COVID-19 Recovery Clinic at George Washington University in Washington, D.C. that has been collecting data on patient short and long-term COVID-19 outcomes in various domains along with demographic information since November 2020. Using RStudio with calculations of descriptive data, odds ratios, and p-values using Fisher's exact test, we assessed education level, income, race, ethnicity, and obesity and looked at how they correlated with COVID-19 severity at diagnosis, presence of anxiety, depression and quality of life ≥ 6 months after acute infection. RESULTS: From our sample (n=150), we found African Americans had greater acute COVID-19 severity (OR=7.56, 95% CI 2.22, 25.68, p=0.0015) relative to white individuals. We also found that obesity was associated with higher levels of acute COVID-19 severity (OR=4.89, 95% CI 1.36, 17.60, p=0.022).Additionally, during acute COVID-19 infection, 7/32 (21.9%) obese patients compared to 9/112 (8.0%) non-obese patients were hospitalized (OR=3.79, 95%CI=1.23, 11.68, p=0.03).No significant association was found between anxiety, depression, quality of life or COVID- 19 severity and persistent symptoms. CONCLUSIONS: We observed associations between the African American race and more severe acute COVID-19 infection. Further, in the acute phase, we observed that obese patients were more likely than non-obsese patients to have more severe infection and be hospitalized. These findings highlight preexisting gaps in healthcare outcomes regarding social determinants of health. It is essential to analyze many of the potential longer-term effects of COVID-19 infection, as they remain poorly understood. We conclude that larger studies are necessary to better understand the effects of social determinants of health on both short and long-term outcomes of COVID-19.

RISK FACTORS ASSOCIATED WITH THE CLINICAL OUTCOMES OF ACUTE AND POST-ACUTE COVID-19 IN ADULT PATIENTS

BACKGROUND: During the COVID-19 pandemic, most attention has been focused on the acute phase of the disease, but lingering symptoms from the postacute sequelae of COVID-19 (PASC) merit concern. The George Washington University COVID-19 Recovery Clinic is documenting these presentations to better understand PASC and its precipitating factors. The group implemented definitions for six phenotype categories: pulmonary, cardiac, connective tissue, vascular, central nervous system (CNS), and other. This research seeks to identify pre-existing factors that could affect disease severity, understand their effect on PASC symptoms at 6-15 months post-infection, and determine associations between patient history and PASC phenotypes. METHODS: An IRB-approved, retrospective cohort study was performed from charts of adult patients with persistent symptoms after acute COVID-19. Data were ed from clinical history prior to COVID-19 diagnosis, during acute COVID-19, and during the post-acute phase, including laboratory results and responses from mental health assessment tools. PASC phenotypes were determined clinically and hospitalization was used as a proxy for disease severity. Descriptive statistics, unadjusted odds ratios, and significance tests (Fisher's exact test, Chi-square test, and Mann-Whitney U test) were calculated using RStudio (4.1.1). RESULTS: Study participants with persistent symptoms at 6-15 months postinfection (n=116) had a mean age of 45.16 (SD 13.23), of which 70% were female, 60% were Caucasian, 12% were African-American, 9% were Asian, and 3% were Hispanic/Latino. When including all patients who had persistent symptoms at 1-15 months post-infection, those with obesity (BMI ≥30) or type 2 diabetes were much more likely to undergo a severe acute phase of COVID19 (OR 12.75;95% CI 1.91-84.95;p=0.02;n=61 and OR 34.67;95% CI 4.43-271.46;p<0.001;n=61 respectively). At 6-15 months post-infection, those suffering from a pulmonary PASC phenotype were more likely to have smoked (OR 3.27;95% CI 1.18-9.11;p=0.02;n=91). At the same period, those presenting with at least one CNS phenotype had a significantly higher level of C-reactive protein (CRP) than those without a CNS phenotype presentation (Mean 3.70 mg/L, SD 5.19 vs. Mean 1.26 mg/L, SD 2.36;p=0.009;n=53). Additionally, acute phase severity was not significantly associated with the presence of PASC. CONCLUSIONS: Our research further demonstrates the increased risk of severe acute COVID-19 among patients with obesity and type 2 diabetes. Furthermore, we show that those with a smoking history were more likely to continue to have pulmonary symptoms of COVID-19 at 6-15 months postinfection. Additionally, our study suggests that there may be a relationship between CRP and persistent CNS symptoms. A better understanding of these associations can help predict the full burden of COVID-19 and improve clinical guidance.