Attitudes among physicians toward vaccine mandates for emerging infectious disease: the case of the COVID-19 vaccine

Objectives: The outbreak of SARS-CoV-2 resulted in a global pandemic. Vaccine mandates were implemented in several countries, including in Taiwan, and often targeted health-care workers in particular. This study investigated attitudes among Taiwanese physicians toward such policies and how ethical beliefs and logic influenced attitudes. Methods: A total of 16 physicians were recruited by using the snowball method from hospitals in northern Taiwan. Data were collected through semi-structured interviews. Results: Physicians tended not to support mandatory vaccination. Five themes emerged: (1) Individual rights, including violation of autonomy and labor rights;(2) vaccine performance, including safety and efficacy;(3) institutional norms, including the degree of relevancy of the policy-issuing unit and the employment relationship between physicians and institutions;(4) social and workplace stigma resulting from coercive policies in different job categories or departments;and (5) professional ethics of physicians. Conclusions: Autonomy and professional ethics among physicians influence attitudes toward vaccine mandates. Vaccine performance, institutional norms, and stigma also influence attitudes toward vaccine mandates and decision-making. Even with high ethical awareness, the study participants tended not to support vaccine mandates. The government should formulate mandatory vaccination policy means for healthcare workers that can be used by hospitals. Each hospital should assess their unique risks and implement policies that best suit their needs. (Taiwan J Public Health. 2023;42(1):75-87)

Reduction of ACE2 serum concentrations by telbivudine in chronic hepatitis B patients.

BACKGROUND: Coronavirus disease 2019, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has wreaked havoc worldwide since December 2019. Currently, no effective medical treatments have been approved. As the epidemic continues to spread, SARS-CoV-2 mutants emerge, some of which become more infectious with increasing vaccine resistance. The main route for SARS-CoV-2 to enter the host cells is by binding of its spike protein to the host receptor, angiotensin-converting enzyme 2 (ACE2). Besides the membrane-bound form of ACE2, the soluble form of ACE2 (sACE2) can also bind SARS-CoV-2 for viral endocytosis. OBJECTIVE: Previously, we found that telbivudine reduced the concentrations of ACE1 in blood. Therefore, we speculated that this drug might also reduce the concentrations of sACE2. METHODS: In this retrospective study, serum samples from 39 hepatitis B patients receiving telbivudine were collected and examined for sACE2 concentrations using an ELISA kit. RESULTS: It was found that the serum concentrations of sACE2 were significantly declined in chronic hepatitis B patients treated by telbivudine. CONCLUSION: Telbivudine treatment reduced sACE2 concentrations, which could potentially reduce the infection risk of SARS-CoV-2.

pcMSC Modulates Immune Dysregulation in Patients With COVID-19-Induced Refractory Acute Lung Injury.

Background and Objectives: The novel coronavirus disease 2019 (COVID-19) has been a pandemic health issue in 30 January 2020. The mortality rate is as high as 50% in critically ill patients. Stem cell therapy is effective for those who are refractory to standard treatments. However, the immune responses that underlie stem cell therapy have not been well reported, particularly, in patients associated with moderate to severe acute respiratory distress syndrome (ARDS). Methods: On Days 0 and 4, an intravenous infusion of 2 × 107 placenta-derived mesenchymal stem cells (pcMSCs) (MatriPlax) were administered to five severe COVID-19 patients refractory to current standard therapies. Peripheral blood inflammatory markers and immune profiles were determined by multi-parameter flow cytometry and studied at Days 0, 4, and 8. Clinical outcomes were also observed. Results: None of the pc-MSC treated patients experienced 28-day mortality compared with the control group and showed a significant improvement in the PaO2/FiO2 ratio, Murray's lung injury scores, reduction in serum ferritin, lactate dehydrogenase (LDH), and C-reactive protein (CRP) levels. The cytokine profiles also showed a reduction in IL-1ß, IFN-γ, IL-2, and IL-6, and an increase in IL-13 and IL-5 type 2 cytokines within 7 days of therapy. Lymphopenia was also significantly improved after 7 days of treatment. Immune cell profiles showed an increase in the proportions of CD4+ T cells (namely, CD4+ naïve T cells and CD4+ memory T cell subtypes), Treg cells, CD19+ B cells (namely, CD19+ naïve B cells, CD27+ switched B cell subtypes) and dendritic cells, and a significant decrease in the proportion of CD14+ monocytes (namely, CD16- classical and CD16+ non-classical subtypes), and plasma/plasmablast cells. No adverse effects were seen at the serial follow-up visits for 2 months after initial therapy. Conclusion: pc-MSCs therapy suppressed hyper-inflammatory states of the innate immune response to COVID-19 infection by increasing Treg cells, decreasing monocytes and plasma/plasmablast cells, and promoting CD4+ T cells and CD19+ B cells toward adaptive immune responses in severely critically ill COVID-19 patients with moderate to severe ARDS, especially those who were refractory to current standard care and immunosuppressive therapies.

Risk assessment of public health emergencies concerned in the mainland of China, September 2021

Objective: To assess the risk of public health emergencies, both the indigenous ones and the imported ones, which might occur in the mainland of China in September 2021.

Exhausting T Cells During HIV Infection May Improve the Prognosis of Patients with COVID-19.

T-cell reduction is an important characteristic of coronavirus disease 2019 (COVID-19), and its immunopathology is a subject of debate. It may be due to the direct effect of the virus on T-cell exhaustion or indirectly due to T cells redistributing to the lungs. HIV/AIDS naturally served as a T-cell exhaustion disease model for recognizing how the immune system works in the course of COVID-19. In this study, we collected the clinical charts, T-lymphocyte analysis, and chest CT of HIV patients with laboratory-confirmed COVID-19 infection who were admitted to Jin Yin-tan Hospital (Wuhan, China). The median age of the 21 patients was 47 years [interquartile range (IQR) = 40-50 years] and the median CD4 T-cell count was 183 cells/µl (IQR = 96-289 cells/µl). Eleven HIV patients were in the non-AIDS stage and 10 were in the AIDS stage. Nine patients received antiretroviral treatment (ART) and 12 patients did not receive any treatment. Compared to the reported mortality rate (nearly 4%-10%) and severity rate (up to 20%-40%) among COVID-19 patients in hospital, a benign duration with 0% severity and mortality rates was shown by 21 HIV/AIDS patients. The severity rates of COVID-19 were comparable between non-AIDS (median CD4 = 287 cells/µl) and AIDS (median CD4 = 97 cells/µl) patients, despite some of the AIDS patients having baseline lung injury stimulated by HIV: 7 patients (33%) were mild (five in the non-AIDS group and two in the AIDS group) and 14 patients (67%) were moderate (six in the non-AIDS group and eight in the AIDS group). More importantly, we found that a reduction in T-cell number positively correlates with the serum levels of interleukin 6 (IL-6) and C-reactive protein (CRP), which is contrary to the reported findings on the immune response of COVID-19 patients (lower CD4 T-cell counts with higher levels of IL-6 and CRP). In HIV/AIDS, a compromised immune system with lower CD4 T-cell counts might waive the clinical symptoms and inflammatory responses, which suggests lymphocyte redistribution as an immunopathology leading to lymphopenia in COVID-19.

Initial Findings From the North American COVID-19 Myocardial Infarction Registry.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has impacted many aspects of ST-segment elevation myocardial infarction (STEMI) care, including timely access to primary percutaneous coronary intervention (PPCI). OBJECTIVES: The goal of the NACMI (North American COVID-19 and STEMI) registry is to describe demographic characteristics, management strategies, and outcomes of COVID-19 patients with STEMI. METHODS: A prospective, ongoing observational registry was created under the guidance of 3 cardiology societies. STEMI patients with confirmed COVID+ (group 1) or suspected (person under investigation [PUI]) (group 2) COVID-19 infection were included. A group of age- and sex-matched STEMI patients (matched to COVID+ patients in a 2:1 ratio) treated in the pre-COVID era (2015 to 2019) serves as the control group for comparison of treatment strategies and outcomes (group 3). The primary outcome was a composite of in-hospital death, stroke, recurrent myocardial infarction, or repeat unplanned revascularization. RESULTS: As of December 6, 2020, 1,185 patients were included in the NACMI registry (230 COVID+ patients, 495 PUIs, and 460 control patients). COVID+ patients were more likely to have minority ethnicity (Hispanic 23%, Black 24%) and had a higher prevalence of diabetes mellitus (46%) (all p < 0.001 relative to PUIs). COVID+ patients were more likely to present with cardiogenic shock (18%) but were less likely to receive invasive angiography (78%) (all p < 0.001 relative to control patients). Among COVID+ patients who received angiography, 71% received PPCI and 20% received medical therapy (both p < 0.001 relative to control patients). The primary outcome occurred in 36% of COVID+ patients, 13% of PUIs, and 5% of control patients (p < 0.001 relative to control patients). CONCLUSIONS: COVID+ patients with STEMI represent a high-risk group of patients with unique demographic and clinical characteristics. PPCI is feasible and remains the predominant reperfusion strategy, supporting current recommendations.

Cooperation or Confrontation? —— Prediction of COVID-19 Pandemic Situation via Deep Learning (preprint)

The COVID-19 pandemic is the most serious catastrophe since the Second World War. To more accurately observe the epidemic under the influence of policies and provide policy adjustments before the official presidential transition in the United States, we use a three-layer superimposed Long-Short-Term-Memory (LSTM) model to predict the epidemic development trend to mid-January, 2021. The proposed model provides more accuracy and stability relative to Susceptible-Exposed-Infective-Recovered (SEIR), modified stacked au-to-encoder, and single-layer LSTM models. The performance effects of the measures in China and five countries with severe epidemics are analysed and summarised. The model shows that the error rate of China, five countries and the world is less than 1.4%. According to forecasts, the epidemic situations in the United States, India, and Brazil, caused by untimely, inappropriate policies, lax regulations and insufficient public cooperation, remain very severe, with cases continuing to increase by tens of thousands. The number of cumulative confirmed cases worldwide will exceed 84.58 million by mid-January, 2021; however, the mortality rate will gradually decrease. Based on analysis of measures (including China’s effective prevention and control policies), we found that there are performed tremendous different efficiency even using same positive policy for different countries because of various cooperation between people and governments. It is essential to maintain self-protection to prevent the epidemic from deterioration or regenerating, especially, wearing mask and maintaining a safe distance.

Reduction in healthcare services during the COVID-19 pandemic in China.

INTRODUCTION: The COVID-19 pandemic caused a healthcare crisis in China and continues to wreak havoc across the world. This paper evaluated COVID-19's impact on national and regional healthcare service utilisation and expenditure in China. METHODS: Using a big data approach, we collected data from 300 million bank card transactions to measure individual healthcare expenditure and utilisation in mainland China. Since the outbreak coincided with the 2020 Chinese Spring Festival holiday, a difference-in-difference (DID) method was employed to compare changes in healthcare utilisation before, during and after the Spring Festival in 2020 and 2019. We also tracked healthcare utilisation before, during and after the outbreak. RESULTS: Healthcare utilisation declined overall, especially during the post-festival period in 2020. Total healthcare expenditure and utilisation declined by 37.8% and 40.8%, respectively, while per capita expenditure increased by 3.3%. In a subgroup analysis, we found that the outbreak had a greater impact on healthcare utilisation in cities at higher risk of COVID-19, with stricter lockdown measures and those located in the western region. The DID results suggest that, compared with low-risk cities, the pandemic induced a 14.8%, 26.4% and 27.5% reduction in total healthcare expenditure in medium-risk and high-risk cities, and in cities located in Hubei province during the post-festival period in 2020 relative to 2019, an 8.6%, 15.9% and 24.4% reduction in utilisation services; and a 7.3% and 18.4% reduction in per capita expenditure in medium-risk and high-risk cities, respectively. By the last week of April 2020, as the outbreak came under control, healthcare utilisation gradually recovered, but only to 79.9%-89.3% of its pre-outbreak levels. CONCLUSION: The COVID-19 pandemic had a significantly negative effect on healthcare utilisation in China, evident by a dramatic decline in healthcare expenditure. While the utilisation level has gradually increased post-outbreak, it has yet to return to normal levels.

Prevalence and associated factors of poor sleep quality among Chinese returning workers during the COVID-19 pandemic.

OBJECTIVES: The 2019 novel coronavirus (COVID-19) pandemic is a severe global crisis which has resulted in many public health problems. This study aimed to investigate the prevalence of poor sleep quality and its related factors among employees who returned to work during the COVID-19 pandemic. METHODS: Our online cross-sectional study included 2,410 participants aged ≥17 years in Deqing and Taizhou, Zhejiang Province, China from 5th to 14th March 2020. The questionnaire covered information on demographic characteristics, health status, workplace, lifestyle, attitude towards COVID-19, assessment of anxiety, depression and sleep quality. The Chinese version of the Pittsburgh Sleep Quality Index (CPSQI) was administered to measure the poor sleep quality. Poor sleep quality was defined as a global PSQI score>5. Factors associated with sleep quality were analyzed by logistic regression models. RESULTS: In sum near half (49.2%) of 2,410 returning workers were females and the average year of subjects was 36.3 ± 9.1 years. The overall prevalence of poor sleep quality was 14.9% (95%CI: 13.5%-16.3%). The average score of PSQI was 3.0 ± 2.5 and average sleep duration was 7.6 ± 1.2 h. Independent related factors of poor sleep quality included age older than 24 years, higher education level, negative attitude towards COVID-19 control measures, anxiety and depression. CONCLUSIONS: Poor sleep quality was common and there was a shorter sleep duration among returning workers during the COVID-19 pandemic. Possible risk factors identified from this study may be of great importance in developing proper intervention for the targeted population to improve the sleep health during the COVID-19 public health emergency.

Spatiotemporal spread pattern of the COVID-19 cases in China (preprint)

COVID-19 is currently spreading widely around the world, causing huge threats on public safety and global society. This study analyzes the spatiotemporal spread pattern of the COVID-19 in China, reveals China’s epicenters of the epidemic through spatial clustering, and delineates the substantial effect of distance to Wuhan on the COVID-19 spread. The results show that the daily new COVID-19 cases mostly occurred in and around Wuhan before March 6, and then moved to the Grand Bay Area (Shenzhen, Hong Kong and Macau). The total COVID-19 cases in China were mainly distributed in the east of the Huhuanyong Line, where the epicenters account for more than 60% of the country’s total on 24 January and 7 February, half on 31 January, and more than 70% from 14 February. The total cases finally stabilized around 84,000, and the inflection point for Wuhan was on 14 February, one week later than those of Hubei (outside Wuhan) and China (outside Hubei). The generalized additive model-based analysis shows that population density and distance to provincial cities significantly associated with the total number of the cases, while distances to prefecture cities and inter-city traffic stations, and population inflow from Wuhan after 24 January, had no strong relationships with the total number of cases. The results and findings should provide valuable insights for understanding the changes in the COVID-19 transmission and controlling the global COVID-19 spread.