Adaptive Immunity Dysregulation Is Associated to the Development of Long Covid

Background: The pathogenetic mechanisms behind the development of long- COVID (LC) are largely unknown. Because both plasma SARS-CoV-2 RNAemia and dysregulated immunity have been correlated with COVID-19 severity, we evaluated whether they are associated with LC. Method(s): We consecutively enrolled unvaccinated hospitalized COVID-19 patients during acute-COVID-19 (T0) in March-October 2020 who either developed LC at a follow-up visit 2-3 months from virologic clearance (T1) or did not. LC was defined as persistence >=2 months after recovery of >=1 symptom: anosmia, dysgeusia, fever, gastrointestinal symptoms, dyspnoea, fatigue, musculoskeletal pain, muscle weakness, brain fog. We measured: SARS-CoV-2 RNAemia (RT-qPCR, log10(copies/mL)), magnitude (ELISA, AUC) and functionality (pseudovirus neutralization, ID50;Fc-mediated functions, %ADCC) of SARS-CoV-2-specific antibodies, SARS-CoV-2-specific B and CD4-T-cells (Immunophenotype, AIM and ICS assays). Result(s): We enrolled 48 COVID-19 individuals, 38/48 (79.2%) developed LC (LC+) and 10 did not (LC-). LC+ and LC- had similar co-morbidities and symptoms in the acute phase (Fig.1A), and the majority showed a radiologically documented SARS-CoV-2 pneumonia. The SARS-CoV-2 RNAemia did not differ between groups at both time points. The levels of RBD-specific Abs, as well as their functionality, appeared to increase over time in the LC- group but not in the LC+ (Fig.1B-D). Similarly, a trend towards increased RBD-specific B-cells was observed over time in the LC- group but not in LC+ (Fig.1E). B-cell immunophenotyping showed a significant increase over time of classical memory B cells (MBCs) at the expenses of activated MBCs (Fig.1F-G) as well as an IgA class-switching in the LC- group compared to LC+ (Fig.1H-I). Furthermore, LC+ showed a faster decline of SARS-CoV-2-specific (CD69+CD137+) CD4- TEMRA and CD4-TEM (Fig.1L-M). Finally, IFN-gamma-producing TREG of LC- individuals increased over time (Fig.1N). Conclusion(s): Acutely ill, hospitalized COVID-19 patients developing LC feature a dysregulated SARS-CoV-2-specific humoral as well as B- and T-cell response, in both magnitude and functionality, suggesting a link between dysregulated SARS-CoV-2-specific adaptive immunity and LC development. The fine understanding of the factors contributing to such dysregulation in LC patients is strongly needed, that might further inform targeted therapeutic interventions. (Figure Presented).

HIGH RNAemia ASSOCIATES WITH SKEWED T-CELL RESPONSE IN PLWH HOSPITALIZED FOR COVID-19

Background: Severe COVID-19 outcomes have been reported in people living with HIV (PLWH). High SARS-CoV-2 RNAemia has emerged as a hallmark of severe COVID-19, yet its pathogenic role in the context of COVID-19 in PLWH is currently unknown. We hereby measured SARS-CoV-2 RNAemia and explored its association with T-cell/humoral responses and clinical severity in PLWH. Method(s): Unvaccinated PLWH and age/sex-matched people living without HIV (PLWOH) hospitalized for radiologically-confirmed COVID-19 pneumonia were consecutively enrolled (March 2020-January 2021). We measured: SARS-CoV-2 RNAemia (RT-qPCR);T-cell activation (HLA-DR+CD-38+), cytotoxic T-cells [granzyme-B(GRZB)+perforin(PRF)+], GRZB/PRF production (MFI) by cytotoxic T-cells (flow cytometry);SARS-CoV-2-specific cytokines (IFN-gamma/ TNF-alpha/IL-2/IL-4/IL-17A)-producing T-cells, after SARS-CoV-2 spike peptides challenge (flow cytometry);anti-RBD antibodies (ELISA), Spike-ACE2 binding inhibition (receptor binding inhibition assay). Statistics: Mann-Whitney test and Spearman's correlation. Result(s): 18 PLWH (16 on cART;median CD4 361.5/mL;HIV-RNA< 50 cp/ mL in 15/18) and 18 PLWOH were included at a median of 10 days from symptoms onset (Fig.1A). PLWH had lower PaO2/FiO2 [140 (122-151.5) vs. 207 (156.3-309.3);P=0.0005] and higher SARS-CoV-2 RNAemia (Fig.1B). While humoral responses were comparable between groups ( Fig.1C-D), as was T-cell activation, PLWH showed skewed T-cell responses: higher perforin production by cytotoxic T-cells (Fig.1E);fewer SARS-CoV-2-specific IFN-gamma+ and IL-4+ CD4 T-cells (Fig.1F);lower Th1 tri-functional (IFN-gamma+TNF-alpha+IL-2+) and bi-functional (IFN-gamma+TNF-alpha+) CD4 T-cells (Fig.1G);reduced TNF-alpha+ CD8 T-cells (Fig.1H). Interestingly, SARS-CoV-2 RNAemia correlated negatively with PaO2/FiO2 nadir and SARS-CoV-2-specific T-cells, yet positively with perforin production by cytotoxic T-cells (Fig.1I-M). No correlations between RNAemia and humoral responses were found. Conclusion(s): As compared to HIV-uninfected patients, PLWH hospitalized for COVID-19 pneumonia feature high SARS-CoV-2 RNAemia which is linked to respiratory failure and skewed T-cell responses, with higher perforin production by cytotoxic T-cells, and yet fewer polyfunctional SARS-CoV-2-specific T-cells. Our data suggest a link between HIV-related T-cell dysfunction and poor control over circulating SARS-CoV-2 that may in turn influence COVID-19 severity in PLWH. (Figure Presented).

Analysis of Characteristics and Outcomes of 223 Patients Admitted to Our Unit due to Respiratory Insufficiency Secondary to Pneumonia from SARS-COV2

A total of 223 patients (145 M-78F) admitted for respiratory failure secondary to SARS-COV2 pneumonia from February 2020 to May 2021 were evaluated. Statistical analysis was performed with Mann Whitney test. The mean age of patient was 66 years (19-99). 55 (25%) patients died (25%), 168 (75%) survived. Mean hospital stay was 15 days;17 for survivors and 10 for deceased (p<0.00001). Mean age was 77 years for deceased, 63 for survivors (p<0.00001). Mean P/F at admission was 204 for survivors, 129 for deceased (p<0.0001). The 4C Mortality Score was 11 for survivors, 15 for deceased (p<0.00001). The most represented comorbidity was hypertension (108;48%), followed by cardiovascular disease (61;27%), diabetes mellitus (42;18%), obesity (33;15%), and dyslipidemia (31;14%). The number of asthmatics and COPD was small. At 3 months after discharge, 78 patients underwent DLCO assessment, the mean percent to predicted was 77%. Of these;21 with values <80% of predicted were evaluated after a further 3 months showing a significant improvement (63% to 74%;p<0.002). 73 patients underwent a walking test, only 3 showed SpO2 <90%. 73 patients were submitted to walking test, only 3 presented a transcutaneous oxygen saturation <90%. Conclusion(s): Mortality appears to be significantly related to older age, and it was quite early (mean hospital stay 10 days). The P/F appeared to be a good predictor of severity, as did the 4C Mortality Sore. The most frequent comorbidities were cardiovascular.

Migrant and ethnic minorities at higher risk of COVID-19 severe outcomes? A systematic review : Elena Mazzalai

Background The Covid-19 pandemic has had a recognised impact in widening health inequalities, both between and within countries, with a major impact on socially disadvantaged population groups such as Migrants and Ethnic Minorities (MEMs). While there is growing evidence on the matter worldwide, data specific to the WHO European Region is scarce. The issue, however, is pressing, since it is estimated that almost 10% of the population living in the WHO European Region is made up of migrants. The aim of the study is to investigate the impact of Covid-19 on MEMs compared to the general population in terms of serious outcomes. Methods We conducted a systematic review collecting studies on the impact of Covid-19 on MEMs compared to the general population in the WHO European Region regarding hospitalisation, intensive care unit (ICU) admission and mortality, published between 01/01/2020 and 19/03/2021. Fourteen researchers were involved in selection, study quality assessment, data extraction and analysis. Results Of the 82 studies included, 15 of the 16 regarding hospitalisation for Covid-19 reported an increased risk for MEMs compared to the white and/or native population and 22 out of the 28 studies focusing on the ICU admission rates found an increased risk for MEMs. Among the 65 studies on mortality, 43 report a higher risk for MEMs. 82% of the studies were conducted in the UK. Conclusions These findings highlight the disproportionate impact of Covid-19 on MEMs population, with an increased risk of all the adverse outcomes taken into consideration. Social determinants of health are among the main factors involved in the genesis of health inequalities: a disadvantaged socio-economic status, a framework of structural racism and asymmetric access to healthcare are linked to increased susceptibility to the consequences of Covid-19. These findings underline the need for policy-makers to consider the socio-economic barriers when designing health promotion plans. Key messages • The combination of disadvantage socioeconomic conditions with COVID-19 transmission characteristics put migrants and ethnic minorities at a higher risk of facing sever health outcomes. • The amount of evidence on the inequal impact of COVID-19 on migrants and ethnic minorities produced by European countries is poor. This gap must be filled to develop effective health promotion plans.

From Cruel Optimism to Comforting Pessimism: Sex, Gender, Feminism and Hong Kong Protest Culture, October 1–December 31, 2019

In order to grasp the complexity of the events in Hong Kong leading up to the imposition of the National Security Law in 2020, a feminist critique inspired by Lauren Berlant’s notion of “cruel optimism” provides a productive place to expand the conversations about the role gender plays in the territory’s political culture. Concentrating on the period between October 1 and December 31, 2019, this analysis examines this more violent but also more optimistic period encompassing the lead up to the District Council elections and subsequent events before COVID-19 upended the city in early 2020. A feminist lens magnifies the discourses circulating through mass and social media. Attention turns to forms of political expression in films, cartoons, literature, and the other arts, which highlight the ways in which gender and sexuality play their parts in the cruel optimism of Hong Kong’s protest culture. © 2022, Yonsei Institute for English Studies. All rights reserved.

Differences in the incidence and clinical outcomes of SARS-CoV-2 infection between Italian and non-Italian nationals using routine data.

OBJECTIVES: This study was to compare the incidence and clinical outcomes of SARS-CoV-2 infection between Italian and non-Italian nationals. STUDY DESIGN: We retrospectively analysed data from the COVID-19 Italian integrated surveillance system (14 September 2020 to 17 October 2021). METHODS: We used multivariable Cox proportional hazards models to estimate the hazard ratio (HR) of infection and, among cases, the HRs of death, hospitalisation and subsequent admission to intensive care unit in non-Italian nationals relative to Italian nationals. Estimates were adjusted for differences in sociodemographic characteristics and in the week and region of diagnosis. RESULTS: Of 4,111,067 notified cases, 336,265 (8.2%) were non-Italian nationals. Compared with Italian nationals, non-Italians showed a lower incidence of SARS-CoV-2 infection (HR = 0.81, 95% confidence interval [CI]: 0.80-0.81). However, once diagnosed, they were more likely to be hospitalised (HR = 1.90, 95% CI: 1.87-1.92) and then admitted to intensive care unit (HR = 1.08, 95% CI: 1.04-1.13), with differences larger in those coming from countries with a lower human development index. Compared with Italian cases, an increased rate of death was observed in non-Italian cases from low-human development index countries (HR = 1.41, 95% CI: 1.23-1.62). The HRs of SARS-CoV-2 infection and severe outcomes slightly increased after the start of the vaccination campaign. CONCLUSIONS: Underdiagnosis and delayed diagnosis in non-Italian nationals could explain their lower incidence compared with Italians and, among cases, their higher probability to present clinical conditions leading to worse outcomes. Facilitating early access to vaccination, diagnosis and treatment would improve the control of SARS-CoV-2 transmission and health outcomes in this vulnerable group.

GDF-15 IS A PREDICTOR OF MORTALITY IN CHRONIC KIDNEY DISEASE PATIENTS WITH COVID-19 INFECTION

BACKGROUND AND AIMS: A cytokine storm drives the pathogenesis of severe coronavirus disease (COVID-19) and several biomarkers with different mechanisms of action have been linked to mortality. Chronic kidney disease (CKD) emerged as a very common risk factor for severe COVID-19. Indeed, CKD patients are at increased risk of premature death from many causes, including, but not limited to, cardiovascular disease (CVD) and infections. In this study, we aimed to investigate the associations between the growth differentiation factor 15 (GDF-15), an established cardiovascular and inflammatory biomarker and outcomes in CKD patients hospitalized for COVID-19. METHOD: A retrospective study on COVID-19 hospitalized subjects in the acute phase of the disease. A broad range of cytokines (CD25, IL-18, TNF-α, TNF RI, TNF RII, GDF-15, IL-7, LIF, IL-6, CHITINASE3-LIKE1, RAGE and Pentraxin-3) were assessed in plasma (Luminex, ELISA) collected upon hospitalization. A total of 77 subjects were divided into two groups according to their estimated glomerular filtration rate (eGFR, by CKD-EPI formula), ≥45 mL/min (n = 44), or <45 mL/min (n = 33). RESULTS: We found no statistical differences between the two groups in terms of demographic features. Among comorbidities, we found a higher percentage of patients with diabetes in the eGFR < 45 group. Likewise, the serum tests upon admission showed in the eGFR < 45 group a higher value of neutrophilic count. Upon hospital admission, the patient groups were comparable in terms of symptoms, time from symptom onset to admission and death or discharge, radiological evidence of pneumonia and respiratory parameters and time of hospitalization. Furthermore, there were no statistical differences between medical therapy during hospitalization, need for respiratory support with Continuous Positive Airways Pressure or Non-Invasive Mechanical Ventilation, or death rather than discharge as the clinical outcome. Serum levels of 20 different compounds were measured in COVID-19 patients admitted to the hospital 4-5 days after the onset of symptoms. Interestingly, we found that patients with lower renal function (eGFR < 45 mL/min) had a significant increase of GDF-15, CD-25 and RAGE and, furthermore, higher serum levels of these molecules were detected in non-survivor patients and in those who needed ventilation. Also, TNFα, TNFR I, TNFR II, IL-7 and LIF had a significant increase in patients with eGFR < 45 mL/min with more elevated levels in non-survivor patients. In univariate analysis low and mid-low GDF-15 quartiles (<4.45 ng/mL) were associated with lower mortality risk, while mid-high and high quartiles (>4.45 ng/mL) were associated with higher mortality risk (Figure 1). Independent association between GDF-15 quartiles and mortality risk was confirmed in Cox model adjusted for eGFR, age, fever, dyspnoea and P/F [hazard ratio (HR) 2.28, 95% confidence interval (CI) 1.53-3.39, P < 0.0001) The strength of association between GDF-15 quartiles and mortality risk was increased in patients with eGFR < 45 mL/min/1.73 m2 (HR 2.53, CI 1.34-4.79) compared with the other eGFR group (HR 1.99, CI 1.17-3.39) (Table 1). CONCLUSION: Our results demonstrate that GDF-15 is an independent predictor of COVID-19 mortality in CKD patients. Given the reported increase of this cytokine with age and its possible mechanistic role in various pathological conditions, our findings suggest that GDF-15 signalling pathway inhibitors may be included as possible therapeutic candidates for COVID-19 in CKD. (Table Presented).

SARS-CoV-2 PLASMA VIREMIA and DYSREGULATED IMMUNITY in SEVERE COVID-19

Background: Critical COVID-19 occurs ca. 7d from symptoms onset, and is associated to immune dysregulation as well as SARS-CoV-2 detection in plasma (i.e. viremia). We hereby sought to detail the association between SARS-CoV-2 viremia measured at the end of the first week of disease and immune phenotypes/function in COVID-19 patients. Methods: We consecutively enrolled patients hospitalized in the acute phase of ascertained SARS-CoV-2 pneumonia. In this disease stage, we studied SARS-CoV-2 viremia (RT-PCR) and cytokines (MACSPlex), HLA-DR+CD38+ activated, GRZB+PRF+ pro-cytolitic T-cells, intracellular cytokine production (IL-2, IFNγ, TNFα, IL-4, IL-17A) after SARS-CoV-2 challenge (S-N-M-peptide pool). Simultaneous Th1-cytokines production (polyfunctionality) and amount (iMFI) was assessed. Humoral response: anti-S1/S2 IgG, anti-RBD total-Ig, IgM, IgA, IgG1 and IgG3 (ELISA), pseudoviruses neutralization (ID50) and Fc-mediated functions (%ADCC). Results: Out of 54 patients, 27 had detectable viremia (V+). Albeit comparable age and co-morbidities, V+ patients more frequently required non-invasive/invasive ventilatory support (p=0.035), with a trend to higher death (p=0.099) vs patients with undetectable viremia (V-)(Fig.1A). V+ displayed higher circulating IFN-α (p=0.002) and IL-6 (0.003), lower activated HLA-DR+CD38+CD4 (p=0.01) and CD8 (p=0.02), with no differences in GRZB+PRF+ T-cells. V+ featured reduced SARS-CoV-2-specific cytokine-producing T-cells, reaching significance for IFNγ+CD4 (p=0.02), TNFα+CD8, IL-4+CD8 (p=0.04) (Fig.1B-C), with lower bi-and tri-functional SARS-CoV-2-specific CD4 Th1, reaching significance for IL-2+TNFα+CD4 (p=0.03) (Fig.1D). A trend towards lower cytokines iMFI in bi-and tri-functional SARS-CoV-2-specific CD4 Th1 was observed in V+, reaching significance for IL-2+TNFα+CD4, p=0.004. V+ displayed lower anti-S IgG, anti-RBD total-Ig, IgM, IgG1 and IgG3 (Fig.1E), with lower ID50 and %ADCC vs V-(Fig.1F-G). Conclusion: Hospitalized COVID-19 patients with detectable plasma SARS-CoV-2 RNA in the acute phase of disease present worse outcome, higher inflammatory cytokines, fewer activated and SARS-CoV-2-specific polyfunctional T-cells, suggesting a link between SARS-CoV-2 viremia at the end of the first stage of disease and immune dysregulation. Whether high ab initium viral burden and/or intrinsic host factors contribute to a delayed and/or exhausted immune response in severe COVID-19 remains to be elucidated, to further inform strategies of targeted therapeutic interventions.

GDF-15 AS A PREDICTOR of MORTALITY in COVID-19: IMPLICATIONS for TREATMENT

Background: A cytokine storm drives the pathogenesis of severe COVID-19 and has therefore prompted the use of cytokine/transduction pathway inhibitors in the treatment of disease. However, numerous markers with different mechanisms of action have been linked to mortality, complicating the understanding of disease pathogenesis and the elaboration of therapeutic strategies. Methods: Retrospective study on COVID-19 hospitalized subjects in the acute phase of disease. A broad range of cytokines (CD25, IL-18, TNF-α, TNF RI, TNF RII, GDF-15, IL-7, LIF, IL-6, CHITINASE3-LIKE1, RAGE and Pentraxin-3) was assessed on plasma samples (Luminex, ELISA) collected upon hospitalization. Subjects were divided into two groups according to their clinical in-hospital death (Survivors: S;Non-Survivors: NS). Comparisons between groups were performed by Fisher's exact test or Mann-Whitney U test as appropriate. The association between each variable and mortality was analysed through univariate and multiple logistic regression models. Subsequently, survival analysis was conducted with Cox proportional hazard models. Results: 77 hospitalised Covid-19 patients were enrolled: 42 S and 35 NS (Figure 1A). As expected, in the NS group we found a higher proportion of subjects with fever and dyspnoea upon admission, development of ARDS and need of PEEP respiratory support (Figure 1A). NS also displayed significantly higher blood neutrophils/lymphocytes, C-reactive protein, LDH and procalcitonin as well as lower PaO2/FiO2 and peripheral O2 saturation values at admission (Figure 1A). In keeping with these findings, CD25, IL-18, IL-6, TNF-α, TNFRI, TNFRII, GDF-15, IL-7, LIF and Chitinase3-Like1, Pentraxin-3 and RAGE were significantly higher in NS than S (Figure 1B) and were associated to mortality in univariate regression models. In the multivariate regression model GDF-15 and fever were the two more relevant features associated with mortality (Figure 1C). In the survival analysis GDF-15 was the strongest predictor of mortality (HR 2,26, 1,55-3,31;p<0,01 reference group bottom quartile Figure 1D, E). Conclusion: Our in-depth characterization of the cytokine storm demonstrates that GDF-15 is an independent predictor of Covid-19 mortality. Given the reported increase of this cytokine with age and its possible mechanistic role in various pathological conditions, our findings suggest that GDF-15 signalling pathway inhibitors may be included as possible therapeutic candidates for Covid-19.

Measuring breathability and bacterial filtration efficiency of face masks in the pandemic context: A round robin study with proficiency testing among non-accredited laboratories

Six Italian non-accredited laboratories participated to an interlaboratory study aimed at measuring Differential Pressure (DP) and Bacterial Filtration Efficiency (BFE) of three face-mask models using methods in-line with EN 14683 standard. Methodological non-conformities were annotated. Repeatability and reproducibility on quintuplicate samples were calculated according to ISO 5725-2. Sample stability was also assessed. Laboratories were ranked according to the total standard deviation over all samples and proficiency was evaluated using z-score according to ISO 13528. Although some non-conformities were present, performances for the DP measurements were always acceptable. One laboratory had to revise the bacterial suspension preparation for the BFE test. Overall, non-accredited laboratories working during pandemic emergency performed satisfactorily. Sample-to-sample variability impacted measurement repeatability. BFE values above 98% showed good repeatability (≤1.0%) and reproducibility (≤6.1%), but high BFE uncertainty was associated to community masks. Our findings suggest that relevant face-mask conformity standards should consider uncertainty of BFE and DP measurements. © 2021 The Authors

Vaccinations for migrants during and beyond the COVID-19 pandemic

Issue Migrants have suboptimal vaccination coverage compared to the general population in destination countries due to several factors -administrative barriers or lack of legal entitlements to health -health system barriers (language, lack of cultural sensitivity and community engagement capacity, vaccination costs) -lack of trust in the health system and misconceptions about vaccines due to misinformation or beliefs Problem Countries should develop national policies and ensure an inclusive, free of charge and proactive vaccination offer to migrants, irrespective of their legal status;and to extend this approach beyond the current pandemic and the sole COVID-19 vaccine Results To achieve COVID-19 global herd immunity all population groups, including migrants, needs to access vaccination. Tailored vaccination strategies, once devised, shall be applied to routine national vaccination plan to tackle health inequalities Lessons The following actions shall be implemented at national level Action 1. Develop tailored and equitable approaches for PH vaccination services targeting migrants through: -free of charge access -decentralization and outreach capacity of the health system -innovative service delivery models (mobile clinics, combined health services, mass vaccination) -health personnel and migrants participatory approach and engagement strategies Action 2. Increase staff engagement through: -increasing health personnel's difference sensitivity -strengthening health personnel's communication capacities Action 3. Increase migrants' health and vaccine literacy through: -establishing vaccine literacy education programmes and strategies -offering health promotion educational interventions Action 4. Monitor progress of inclusive vaccination offer by: -setting strategic goals, targets and indicators for national vaccination plans -expanding immunization information systems to monitor vaccination coverage, with appropriate disaggregation by migration status core variables Key messages Explicitly and proactively include migrants and displaced communities in vaccination plans and set up, test and implement new approaches in primary prevention and vaccination services. Extend this approach beyond the current pandemic and the sole COVID-19 vaccine in order to enhance preparedness to present and future health threats.