COVID-19 vaccination: public health lessons from a large indoor gathering

COVID-19 transmission rates among vaccinated persons attending large gatherings have not been reported widely. This research was intended to track the potential incidence of COVID-19 among physicians and their families who attended a large in-person gathering in Atlanta in August 2021. After the successful conclusion of a large-scale indoor gathering, we encouraged all attendees to self-report the incidence of COVID-19 illness. In addition, an online questionnaire was disseminated to collect basic information about age, gender, place of residence, vaccination status including the number of doses, type, and date of each dose as well as behavioral and convention factors that would have contributed to the infection rates. Information about current COVID-19 infection status, symptoms, and severity were also collected. We also contacted the attendees through telephone to gather pending information about their COVID-19 status, after attending the meeting. Most attendees were physicians, employees in the healthcare industry or family members of healthcare professionals. Among the 520 participants of the meeting, no COVID-19 illness was reported up to six weeks after attending the convention. As a sub-group analysis, we obtained demographic data from 143 attendees, through an online survey. Among the survey respondents, 43% were over the age of 60 years, 10% over the age of 70 years, 29% and 14% each between 31-45 years and 12-30 years. 53% were women. Almost 99% had received both doses of COVID-19 mRNA vaccine in January and February of 2021. Public health measures including the use of indoor masks, social distancing, and personal hygiene were followed by 76%. None of the convention attendees who responded had any symptoms or tested positive for COVID-19 infection six weeks after leaving the convention. None reported being diagnosed with COVID-19 for at least 30 days before attending the convention. This report confirms the efficacy of COVID-19 mRNA vaccines against protection from COVID-19 illness among participants of large scale indoor gatherings. Our findings support the notion that large-scale events can be successfully conducted among fully vaccinated persons who follow public health guidelines.

A study on breakthrough infections of COVID-19 from an urban healthcare centre in Kerala

Background and Aim: While India's vaccination drive against COVID-19 continues to progress, the number of Breakthrough Infections are also revealing an uptick due to Community spread of COVID-19. There is a dearth of data quantifying the extent of breakthrough infections, defined as infections following two doses of vaccine. We aimed to understand the occurrence of Breakthrough Infections among the public in the City of Thrissur, Kerala, India, during the recent surge of COVID-19 in Kerala. Methods: Patients visiting the Internal Medicine Outpatient Department (OPD) in a private hospital in the City of Thrissur in Kerala, India were selected for the study. Subjects above the age of 18 years presenting to the OPD between August 01, 2021 and September 30, 2021 were surveyed through a short interview on the COVID-19 infection history, symptoms, severity and vaccination status. Results: Of the 56 participants who tested positive for COVID-19, 38 had received both doses of vaccine and all had received their first dose of vaccine. 4 patients had no symptoms, 37 patients reported mild symptoms and nine patients reported moderate to severe symptoms. Conclusion: Our study demonstrates the occurrence and describes the epidemiology of COVID-19 breakthrough infections in a City from the Indian State of Kerala in a real-world setting. We conclude the occurrence of Symptomatic Breakthrough Infections of COVID-19 in patients who had received two doses of the vaccine were mild in the majority of the patients (87%). Further research is required to understand the mechanisms behind these Breakthrough infections.

COVID-19 vaccine hesitancy among medical students: A systematic review

BACKGROUND: Vaccine hesitancy leads to an increase in morbidity, mortality, and health-care burden. Reasons for vaccine hesitancy include anti-vax group statements, misinformation about vaccine side effects, speed of vaccine development, and general disbelief in the existence of viruses like COVID-19. Medical students are future physicians and are key influencers in the uptake of vaccines. Hence, investigating vaccine hesitancy in this population can help to overcome any barrier in vaccine acceptance. METHODS: In this paper, we review five articles on COVID-19 vaccine hesitancy in medical students and consider potential future research. All published papers relevant to the topic were obtained through extensive search using major databases. Inclusion criteria included studies that specifically investigated COVID-19 vaccine hesitancy in medical students published between 2020 and 2021. Exclusion criteria included studies that investigated vaccine hesitancy in health-care professionals, allied health, and viruses apart from COVID-19. A total of 10 studies were found from our search. RESULTS: Based on our exclusion criteria, only five studies were included in our review. The sample size ranged from 168 to 2133 medical students. The percentage of vaccine hesitancy in medical students ranged from 10.6 to 65.1%. Reasons for vaccine hesitancy included concern about serious side effects, vaccine efficacy, misinformation and insufficient information, disbelief in public health experts, financial costs, and belief that they had acquired immunity. CONCLUSION: These results suggest that vaccine hesitancy is an important cause of the incidence and prevalence of COVID-19 cases. Identifying the barriers of vaccine hesitancy in prospective physicians can help increase vaccination uptake in the general public. Further research is necessary to identify the root cause of these barriers. © Shahad A. Hafez et al., 2022;Published by Mary Ann Liebert, Inc. 2022.

Prevalence, risk factors and sources of anxiety among Emergency Department healthcare workers in Pakistan during COVID-19 pandemic: A single center survey

COVID-19 has challenged the mental health of healthcare workers confronting it world-wide. Our study identifies the prevalence and risk of anxiety among emergency healthcare workers confronting COVID-19 in Pakistan. We conducted a cross-sectional survey in an Emergency Department using the Generalized Anxiety Scale (GAD-7), and questions about sources of anxiety. Of 107 participants, 61.7% were frontline workers. The prevalence of anxiety was 50.5%. Nonparametric tests determined that nurses, younger and inexperienced staff, developed significant anxiety. Multivariate ordinal regression determined independent risk factors for developing anxiety were younger age (OR 2.11, 95% CI 0.89-4.99) and frontline placement (OR 1.34, 95% CI 0.33-1.66). Significant sources of stress were fear of infecting family (P = 0.003), lack of social support when the health care providers were themselves unwell (P = 0.02) and feelings of inadequate work performance (P = 0.05). Our study finds that HCWs' anxiety is considerable. Appropriate measures for its alleviation and prevention are required. ©

CHARACTERISTICS ASSOCIATED with POOR COVID-19 OUTCOMES in PEOPLE with PSORIASIS and SPONDYLOARTHRITIS: DATA from the COVID-19 PSOPROTECT and GLOBAL RHEUMATOLOGY ALLIANCE PHYSICIAN-REPORTED REGISTRIES

Background: Some factors associated with severe COVID-19 outcomes have been identifed in patients with psoriasis (PsO) and infammatory/autoimmune rheumatic diseases, namely older age, male sex, comorbidity burden, higher disease activity, and certain medications such as rituximab. However, information about specifcities of patients with PsO, psoriatic arthritis (PsA) and axial spondyloarthritis (axSpA), including disease modifying anti-rheumatic drugs (DMARDs) specifcally licensed for these conditions, such as IL-17 inhibitors (IL-17i), IL-23/IL-12 + 23 inhibitors (IL-23/IL-12 + 23i), and apremilast, is lacking. Objectives: To determine characteristics associated with severe COVID-19 outcomes in people with PsO, PsA and axSpA. Methods: This study was a pooled analysis of data from two physician-reported registries: the Psoriasis Patient Registry for Outcomes, Therapy and Epidemiology of COVID-19 Infection (PsoProtect), comprising patients with PsO/PsA, and the COVID-19 Global Rheumatology Alliance (GRA) registry, comprising patients with PsA/axSpA. Data from the beginning of the pandemic up to 25 October, 2021 were included. An ordinal severity outcome was defned as: 1) not hospitalised, 2) hospitalised without death, and 3) death. A multivariable ordinal logistic regression model was constructed to assess the relationship between COVID-19 severity and demographic characteristics (age, sex, time period of infection), comorbidities (hypertension, other cardiovascular disease [CVD], chronic obstructive lung disease [COPD], asthma, other chronic lung disease, chronic kidney disease, cancer, smoking, obesity, diabetes mellitus [DM]), rheumatic/skin disease (PsO, PsA, axSpA), physician-reported disease activity, and medication exposure (methotrexate, lefunomide, sulfasalazine, TNFi, IL17i, IL-23/IL-12 + 23i, Janus kinase inhibitors (JAKi), apremilast, glucocorticoids [GC] and NSAIDs). Age-adjustment was performed employing four-knot restricted cubic splines. Country-adjustment was performed using random effects. Results: A total of 5008 individuals with PsO (n=921), PsA (n=2263) and axSpA (n=1824) were included. Mean age was 50 years (SD 13.5) and 51.8% were male. Hospitalisation (without death) was observed in 14.6% of cases and 1.8% died. In the multivariable model, the following variables were associated with severe COVID-19 outcomes: older age (Figure 1), male sex (OR 1.53, 95%CI 1.29-1.82), CVD (hypertension alone: 1.26, 1.02-1.56;other CVD alone: 1.89, 1.22-2.94;vs no hypertension and no other CVD), COPD or asthma (1.75, 1.32-2.32), other lung disease (2.56, 1.66-3.97), chronic kidney disease (2.32, 1.50-3.59), obesity and DM (obesity alone: 1.36, 1.07-1.71;DM alone: 1.85, 1.39-2.47;obesity and DM: 1.89, 1.34-2.67;vs no obesity and no DM), higher disease activity and GC intake (remission/low disease activity and GC intake: 1.96, 1.36-2.82;moderate/severe disease activity and no GC intake: 1.35, 1.05-1.72;moderate/severe disease activity and GC intake 2.30, 1.41-3.74;vs remission/low disease activity and no GC intake). Conversely, the following variables were associated with less severe COVID-19 outcomes: time period after 15 June 2020 (16 June 2020-31 December 2020: 0.42, 0.34-0.51;1 January 2021 onwards: 0.52, 0.41-0.67;vs time period until 15 June 2020), a diagnosis of PsO (without arthritis) (0.49, 0.37-0.65;vs PsA), and exposure to TNFi (0.58, 0.45-0.75;vs no DMARDs), IL17i (0.63, 0.45-0.88;vs no DMARDs), IL-23/IL-12 + 23i (0.68, 0.46-0.997;vs no DMARDs) and NSAIDs (0.77, 0.60-0.98;vs no NSAIDs). Conclusion: More severe COVID-19 outcomes in PsO, PsA and axSpA are largely driven by demographic factors (age, sex), comorbidities, and active disease. None of the DMARDs typically used in PsO, PsA and axSpA, were associated with severe COVID-19 outcomes, including IL-17i, IL-23/IL-12 + 23i, JAKi and apremilast.

ANTI-TNF THERAPY for IMMUNE MEDIATED INFLAMMATORY DISEASES MAY BE ASSOCIATED with LOWER ANTIBODY LEVELS and VIRUS NEUTRALIZATION EFFICACY FOLLOWING SARS-COV-2 MRNA VACCINATION

Background: The impact of immunosuppressants on COVID-19 vaccination response and durability in patients with immune-mediated infammatory diseases (IMID) is yet to be fully characterized. Humoral response may be attenuated in these patients especially those on B cell depleting therapy and higher doses of corticosteroids, but data regarding other immunosuppressants are scarce. Objectives: We aimed to investigate antibody and T cell responses and durability to SARS-CoV-2 mRNA vaccines (BNT162b and/or mRNA 1273) in IMID patients on immunomodulatory maintenance therapy other than B-cell depleting therapy and corticosteroids. Methods: This prospective observational cohort study examined the immuno-genicity of SARS-CoV-2 mRNA vaccines in adult patients with IMIDs (psoriatic arthritis, psoriasis, infammatory bowel disease and rheumatoid arthritis) with or without maintenance immunosuppressive therapies (anti-TNF, methotrexate/azathioprine [MTX/AZA], anti-TNF + MTX/AZA, anti IL12/23, anti-IL-17, anti-IL23) compared to healthy controls. Automated ELISA for IgGs to spike trimer, spike receptor binding domain (RBD) and the nucleocapsid (NP) and T-cell release of 9 cytokines (IFNg, IL2, IL4, IL17A, TNF) and cytotoxic molecules (sFasL, GzmA, GzmB, Perforinin) in cell culture supernatants following stimulation with spike or NP peptide arrays were conducted at 4 time points: T1=pre vaccination, T2=me-dian 26 days after dose 1, T3=median 16 days after dose 2 and T4=median 106 days after dose 2. Neutralization assays against four SARS-CoV-2 variants (wild type, delta, beta and gamma) were conducted at T3. Results: We followed 150 subjects: 26 healthy controls and 124 IMID patients: 9 untreated, 44 on anti-TNF, 16 on anti-TNF with MTX/AZA, 10 on anti-IL23, 28 on anti-IL12/23, 9 on anti-IL17, 8 on MTX/AZA (Table 1). Most patients mounted antibody and T cell responses with increases from dose 1 to dose 2 (100% sero-conversion at T3) and some decline by T4, with variability within groups. Antibody levels and neutralization efficacy was lower in anti-TNFgroups (anti-TNF, anti-TNF + MTX/AZA) compared to controls and waned by T4 (Figure 1). T cell responses were not consistently different between groups. Pooled data showed a higher antibody response to mRNA-1273 compared to BNT162b. Conclusion: Following 2 doses of mRNA vaccination there is 100% seroconver-sion in IMID patients on maintenance therapy. Antibody levels and neutralization efficacy in anti-TNF group are lower than controls, and wane substantially by 3 months after dose 2. These fndings highlight the need for third dose in patients undergoing treatment with anti-TNF therapy and continued monitoring of immunity in these patient groups, taking into consideration newer variants and additional vaccine doses.

Are patients with immune mediated inflammatory diseases (imid) more likely to receive COVID-19 tests and test positive for SARS-CoV-2 a matched population-based study

Background: Population-based data about the COVID-19 risk in patients with IMID remain scarce. Objectives: To investigate the cumulative incidence and risk factors for laboratory-confirmed COVID-19 infection and SARS-CoV2 testing in patients with IMID compared with matched non-IMID patients from the general population. Methods: A population-based, matched cohort study was conducted using health administrative data from adults living in Ontario, Canada from January to December 2020. Cohorts for each of the following IMID were assembled: rheumatoid arthritis (RA), psoriasis, psoriatic arthritis, ankylosing spondylitis, systemic autoimmune rheumatic diseases (including lupus, systemic sclerosis, Sjogren's, inflammatory myositis), multiple sclerosis (MS), iritis, inflammatory bowel disease (IBD), polymyalgia rheumatica (PMR) and vasculitis. Each patient was matched with 5 non-IMID comparators based on age, sex, area of residence and living in long term care (LTC). Standardized cumulative rates of testing for SARS-CoV2, and for receiving a positive test between IMID and non-IMID were compared between IMID and non-IMID patients. Multivariable logistic regression analyses assessed sociodemographic factors associated with COVID-19 testing and positivity. Results: A total of 493,499 IMID patients and 2,466,946 non-IMID comparators were assessed. Significantly more IMID patients versus non-IMID were tested for SARS-CoV2 (27.4% vs. 22.7%), while the proportions of those positive for COVID-19 were identical (0.9% of all patients in both groups). Overall, IMID patients were more likely to undergo SARS-CoV2 testing (odds ratio (OR) 1.28, 95% CI 1.27, 1.29), but their overall risk of laboratory-confirmed COVID-19 was not elevated (OR 0.97 (95% CI 0.93, 1)). However, the risk of laboratory-confirmed COVID-19 infection was lower in IBD (OR 0.75), MS (OR 0.77) and psoriasis (OR 0.94) and marginally higher in RA (OR 1.07) and iritis (OR 1.13) compared with non-IMID comparators (Figure 1A). The highest standardized rates of COVID-19 infection were found in vasculitis (115 per 10,000 patients) and iritis (109 per 10,000 patients) (Figure 1B). Risk factors for COVID-19 infection included younger age, living in LTC, multimorbidity, urban living and lower income (Table 1). Conclusion: Patients across all IMID were more likely to be tested for COVID-19 versus non-IMID patients. IMID patients were not at higher risk for testing positive for COVID-19 as an overall group, yet risk varied across disease subgroups.