MERS-CoV Confirmation among 6,873 suspected persons and relevant Epidemiologic and Clinical Features, Saudi Arabia - 2014 to 2019.

BACKGROUND: Of the three lethal coronaviruses, in addition to the ongoing pandemic-causing SARS-CoV 2, Middle East Respiratory Syndrome Coronavirus (MERS-CoV) remains in circulation. Information on MERS-CoV has relied on small sample of patients. We updated the epidemiology, laboratory and clinical characteristics, and survival patterns of MERS-CoV retrospectively with the largest sample of followed patients. METHODS: We conducted a retrospective review of line-listed records of non-random, continuously admitted patients who were suspected (6,873) or confirmed with MERS-CoV (501) admitted to one of the four MERS-CoV referral hospitals in Saudi Arabia, 2014-2019. FINDINGS: Of the 6,873 MERS-CoV suspected persons, the majority were male (56%) and Saudi nationals (83%) and 95% had no known history that increased their risk of exposure to MERS-CoV patients or vectors (95%). More confirmed cases reported history that increased their risk of MERS-CoV infection (41%). Among the suspected, MERS-CoV confirmation (7.4% overall) was independently associated with being male, known transmission link to MERS-CoV patients or vectors, fever, symptoms for 7 days, admission through intensive care unit, and diabetes. Among persons with confirmed MERS-CoV, single symptoms were reported by 20%, 3-symptom combinations (fever, cough and dyspnea) reported by 21% and 2-symptom combinations (fever, cough) reported by 16%. Of the two-thirds (62%) of MERS-CoV confirmed patients who presented with co-morbidity, 32% had 2-"comorbidities (diabetes, hypertension). More than half of the MERS-CoV patents showed abnormal chest X-ray, elevated aspartate aminotransferase, and creatinine kinase. About a quarter of MERS-CoV patients had positive cultures on blood, urine, or respiratory secretions. During an average hospital stay of 18 days (range 11 to 30), 64% developed complications involving liver, lungs, or kidneys. Ventilation requirement (29% of MERS-CoV cases) was independently associated with abnormal chest X-ray, viremia (Ct value <30), elevated creatinine, and prothrombin time. Death (21% overall) was independently associated with older age, dyspnea and abnormal chest X-ray on admission, and low hemoglobulin levels. INTERPRETATIONS: With two-thirds of the symptomatic persons developing multiorgan complications MERS-CoV remains the coronavirus with the highest severity (29%) and case fatality rate (21%) among the three lethal coronaviruses. Metabolic abnormalities appear to be an independent risk factor for sustained MERS-CoV transmission. The poorly understood transmission dynamics and non-specific clinical and laboratory features call for high index of suspicion among respiratory disease experts to help early detection of outbreaks. We reiterate the need for case control studies on transmission. FUNDING: No special funding to declare.

COVID-19 - the role of mass gatherings.

Mass gathering (MG) medicine emerged against the backdrop of the 2009 pandemic H1N1 Public Health Emergency of International Concern (PHEIC) when the Kingdom of Saudi Arabia (KSA) hosted the largest annual mass gathering of over 3 million pilgrims from 180 plus countries. However, the events surrounding the latest threat to global health, the PHEIC COVID-19, may be sufficient to highlight the role of mass gatherings, mass migration, and other forms of dense gatherings of people on the emergence, sustenance, and transmission of novel pathogens. The COVID-19 spread illustrates the role of MGs in exacerbation of the scope of pandemics. Cancellation or suspension of MGs would be critical to pandemic mitigation. It is unlikely that medical countermeasures are available during the early phase of pandemics. Therefore, mitigation of its impact, rather than containment and control becomes a priority during pandemics. As the most systematically studied MG-related respiratory disease data come from KSA, the cancellation of Umrah by the KSA authorities, prior to emergence of cases, provide the best opportunity to develop mathematical models to quantify event cancellations related mitigation of COVID-19 transmission in KSA and to the home countries of pilgrims. COVID-19 has already provided examples of both clearly planned event cancellations such as the Umrah suspension in KSA, and where outbreaks and events were continued.

Intimate Partners Violence against Women during a COVID-19 Lockdown Period: Results of an Online Survey in 7 Provinces of the Democratic Republic of Congo.

Intimate Partners' Violence (IPV) is a public health problem with long-lasting mental and physical health consequences for victims and their families. As evidence has been increasing that COVID-19 lockdown measures may exacerbate IPV, our study sought to describe the magnitude of IPV in women and identify associated determinants. An online survey was conducted in the Democratic Republic of Congo (DRC) from 24 August to 8 September 2020. Of the 4160 respondents, 2002 eligible women were included in the data analysis. Their mean age was 36.3 (SD: 8.2). Most women (65.8%) were younger than 40 years old. Prevalence of any form of IPV was 11.7%. Being in the 30-39 and >50 years' age groups (OR = 0.66, CI: 0.46-0.95; p = 0.026 and OR = 0.23, CI: 0.11-048; p < 0.001, respectively), living in urban setting (OR = 0.63, CI: 0.41-0.99; p = 0.047), and belonging to the middle socioeconomic class (OR = 0.48, CI: 0.29-0.79; p = 0.003) significantly decreased the odds for experiencing IPV. Lower socioeconomic status (OR = 1.84, CI: 1.04-3.24; p = 0.035) and being pregnant (OR = 1.63, CI: 1.16-2.29; p = 0.005) or uncertain of pregnancy status (OR = 2.01, CI: 1.17-3.44; p = 0.011) significantly increased the odds for reporting IPV. Additional qualitative research is needed to identify the underlying reasons and mechanisms of IPV in order to develop and implement prevention interventions.

COVID-19 and Comorbidities: Audit of 2,000 COVID-19 Deaths in India.

BACKGROUND: On September 5, 2020, India reported the second highest COVID-19 cases globally. Given India's unique disease burden including both infectious and chronic diseases, there is a need to study the survival patterns of COVID-19. We aimed to describe the factors associated with COVID-19 deaths in the State of Tamil Nadu that has the highest COVID-19 case burden among the Indian states, and to compare deaths among COVID patients with and without comorbidities. METHODS: We analyzed the first 1000 COVID deaths (1 March to 26 June 2020) and 1000 recent deaths at the time of analysis (1-10 August 2020). We examined data on facility (public vs private), age, gender, duration of illness prior to and/or during hospitalizations, symptoms, comorbidities and cause of death. We used R statistical program to do the analysis. We compared deaths among patients with and without comorbidities using Wilcoxon rank sum test. p < 0.05 was considered significant. RESULTS: First, we found a shorter time interval from onset of symptoms to death in India than that was reported in the USA and China. Second, young adults without comorbidities had shorter survival from the time of onset of symptoms irrespective of their timing of hospitalization. Third, hypothyroidism is a COVID-19 associated co-morbidity. Longitudinal studies are needed to further assess the thyroid-COVID-19 link. CONCLUSION: As COVID-19 infection rates are accelerating rapidly in India, it is crucial to sensitize young adults while protecting the elderly and other vulnerable populations.

COVID-19 in the least developed, fragile, and conflict-affected countries - How can the most vulnerable be protected?

The relentless spread of coronavirus disease 2019 (COVID-19) and its penetration into the least developed, fragile, and conflict-affected countries (LDFCAC) is a certainty. Expansion of the pandemic will be expedited by factors such as an abundance of at-risk populations, inadequate COVID-19 mitigation efforts, sheer inability to comply with community mitigation strategies, and constrained national preparedness. This situation will reduce the benefits achieved through decades of disease control and health promotion measures, and the economic progress made during periods of global development. Without interventions, and as soon as international travel and trade resume, reservoirs of COVID-19 and other vaccine-preventable diseases in LDFCAC will continue 'feeding' developed countries with repeated infection seeds. Assuring LDFCAC equity in access to medical countermeasures, funds to mitigate the pandemic, and a paradigm change in the global development agenda, similar to the post-World War II Marshall Plan for Europe, are urgently needed. We argue for a paradigm change in strategy, including a new global pandemic financing mechanism for COVID-19 and other future pandemics. This approach should assist LDFCAC in gaining access to and membership of a global interdisciplinary pandemic taskforce to enable in-country plans to train, leverage, and maintain essential functioning and also to utilize and enhance surveillance and early detection capabilities. Such a task force will be able to build on and expand research into the management of pandemics, protect vulnerable populations through international laws/treaties, and reinforce and align the development agenda to prevent and mitigate future pandemics. Lifting LDFCAC from COVID-related failure will offer the global community the best economic dividends of the century.

All Hands on Deck: A synchronized whole-of-world approach for COVID-19 mitigation.

The COVID-19 pandemic can no longer be mitigated by a nationwide approach of individual nations alone. Given its scale and accelerating expansion, COVID-19 requires a coordinated and simultaneous Whole- of-World approach that galvanizes clear global leadership and solidarity from all governments of the world. Considering an 'all hands-on deck' concept, we present a comprehensive list of tools and entities responsible for enabling them, as well a conceptual framework to achieve the maximum impact. The list is drawn from pandemic mitigation tools developed in response to past outbreaks including influenza, coronaviruses, and Ebola, and includes tools to minimize transmission in various settings including person-to-person, crowd, funerals, travel, workplace, and events and gatherings including business, social and religious venues. Included are the roles of individuals, communities, government and other sectors such as school systems, health, institutions, and business. While individuals and communities have significant responsibilities to prevent person-to-person transmission, other entities can play a significant role to enable individuals and communities to make use of the tools. Historic and current data indicate the role of political will, whole-of-government approach, and the role of early introduction of mitigation measures. There is also an urgent need to further elucidate the immunologic mechanisms underlying the epidemiological characteristics such as the low disease burden among women, and the role of COVID-19 in inducing Kawasaki-like syndromes in children. Understanding the role of and development of anti-inflammatory strategies based on our understanding of pro-inflammatory cytokines (IL1, IL-6) is also critical. Similarly, the role of oxygen therapy as an anti-inflammatory strategy is evident and access to oxygen therapy should be prioritized to avoid the aggravation of COVID-19 infection. We highlight the need for global solidarity to share both mitigation commodities and infrastructure between countries. Given the global reach of COVID-19 and potential for repeat waves of outbreaks, we call on all countries and communities to act synergistically and emphasize the need for synchronized pan-global mitigation efforts to minimize everyone's risk, to maximize collaboration, and to commit to shared progress.