Age-stratified infection fatality rate of COVID-19 in the non-elderly population

Revisiting the link between COVID-19 incidence and infection fatality rate during the first pandemic wave

Several studies found an association between COVID-19 incidence, cumulated over the first pandemic wave, and the risk of death for infected individuals. They attributed this association to hospital overload. We studied this association across the French departments using 82,467 serological samples and a hierarchical Bayesian model with spatial smoothing. In high-incidence areas, we hypothesized that hospital overload would increase infection fatality rate (IFR) without increasing infection hospitalization rate (IHR). The analyses were adjusted for intensive care beds per capita, age of the population, and diabetes prevalence (as a surrogate for obesity). We found that increasing departmental incidence from 3 to 9% rose IFR from 0.42 to 1.14% (difference 0.72%, 95% CI 0.49-1.01%), and IHR from 1.66 to 3.61% (difference 1.94%, 95% CI 1.18-2.80%). An increase in incidence from 6 to 12% in people under 60 was associated with an increased proportion of people over 60 among those infected, from 11.6 to 17.4% (difference 5.8%, 95% CI 2.9-8.8%). Higher incidence increased the risk of death for infected individuals and their risk of hospitalization by the same magnitude. These findings could be explained by a higher age among infected individuals in high-incidence areas, rather by than hospital overload.

Kidney Function Following COVID-19 in Children and Adolescents

Importance

It remains unclear whether children and adolescents with SARS-CoV-2 infection are at heightened risk for long-term kidney complications.

Objective

To investigate whether SARS-CoV-2 infection is associated with an increased risk of postacute kidney outcomes among pediatric patients, including those with preexisting kidney disease or acute kidney injury (AKI).

Design, Setting, and Participants

This retrospective cohort study used data from 19 health institutions in the National Institutes of Health Researching COVID to Enhance Recovery (RECOVER) initiative from March 1, 2020, to May 1, 2023 (follow-up ≤2 years completed December 1, 2024; index date cutoff, December 1, 2022). Participants included children and adolescents (aged <21 years) with at least 1 baseline visit (24 months to 7 days before the index date) and at least 1 follow-up visit (28 to 179 days after the index date).

Exposures

SARS-CoV-2 infection, determined by positive laboratory test results (polymerase chain reaction, antigen, or serologic) or relevant clinical diagnoses. A comparison group included children with documented negative test results and no history of SARS-CoV-2 infection.

Main Outcomes and Measures

Outcomes included new-onset chronic kidney disease (CKD) stage 2 or higher or CKD stage 3 or higher among those without preexisting CKD; composite kidney events (≥50% decline in estimated glomerular filtration rate [eGFR], eGFR ≤15 mL/min/1.73 m2, dialysis, transplant, or end-stage kidney disease diagnosis), and at least 30%, 40%, or 50% eGFR decline among those with preexisting CKD or acute-phase AKI. Hazard ratios (HRs) were estimated using Cox proportional hazards regression models with propensity score stratification.

Results

Among 1 900 146 pediatric patients (487 378 with and 1 412 768 without COVID-19), 969 937 (51.0%) were male, the mean (SD) age was 8.2 (6.2) years, and a range of comorbidities was represented. SARS-CoV-2 infection was associated with higher risk of new-onset CKD stage 2 or higher (HR, 1.17; 95% CI, 1.12-1.22) and CKD stage 3 or higher (HR, 1.35; 95% CI, 1.13-1.62). In those with preexisting CKD, COVID-19 was associated with an increased risk of composite kidney events (HR, 1.15; 95% CI, 1.04-1.27) at 28 to 179 days. Children with acute-phase AKI had elevated HRs (1.29; 95% CI, 1.21-1.38) at 90 to 179 days for composite outcomes.

Conclusions and Relevance

In this large US cohort study of children and adolescents, SARS-CoV-2 infection was associated with a higher risk of adverse postacute kidney outcomes, particularly among those with preexisting CKD or AKI, suggesting the need for vigilant long-term monitoring.

COVID-19 case fatality rate and infection fatality rate from 2020 to 2023: Nationwide analysis in Austria

BACKGROUND

Comprehensive analyses of COVID-19 case fatality rates (CFRs) and infection fatality rates (IFRs) that span the entire pandemic are not yet available but critical to retrospectively evaluate the COVID-19 disease burden and its related public health policies. We used nationwide individual participant data from Austria, the continental country with the highest SARS-CoV-2 testing rate per capita, to calculate COVID-19 CFR and estimate IFR covering the entire pandemic.

METHODS

This retrospective observational study included all Austrian residents and covered the time from February 2020 to May 2023, examining CFRs overall, monthly, and during dominant SARS-CoV-2 variant periods. CFRs were calculated for the whole population and stratified according to immunization status (presence of previous vaccination and/or infection), age, gender and nursing home residency. We additionally estimated the IFRs based on estimations of undocumented infections using a test positivity model.

RESULTS

The overall CFR of 30-day COVID-19 mortality was 0.31 % but varied depending on month, with the highest being 5.9 % in April 2020 and the lowest 0.07 % in January 2022. The variant periods reflected this trend of decreasing CFR, with the highest for Wuhan-Hu-1 (2.05 %) and the lowest for BA.1 (0.08 %). Overall CFRs were particularly high in the group without any previous immunizing event (0.67 %), the elderly (85 + year group: 7.88 %) and in nursing home residents (7.92 %). Nursing home residents accounted for 30.82 % of all COVID-19 deaths while representing only 1.22 % of diagnosed infections. Total SARS-CoV-2 infections were estimated to be almost double than confirmed cases with a corresponding overall IFR of 0.16 %.

CONCLUSION

This estimation of nationwide CFR and IFR across the entirety of the SARS-CoV-2 pandemic gives crucial insights into the period-dependent variability of the severity of diagnosed COVID-19 cases and its risk factors. Our findings further underline the disproportionate severity of COVID-19 among the elderly and especially nursing home residents.

The devil's in the detail: an appraisal of the use of innovative financing mechanisms for pandemic prevention, preparedness and response

This is the first published study examining whether, and to what degree, innovative financing could effectively support the financing needs of the global pandemic prevention, preparedness and response (PPPR) agenda.

BACKGROUND

What is already known? In the context of global health, innovative financing encompasses a range of financial instruments that supplement international development assistance and other traditional sources of financing, with the intention of mobilising additional resources and channelling them more effectively. Examples including Advance Market Commitments (AMCs), Advance Purchase Commitments (APCs), vaccine bonds and pandemic bonds, have been used in the past to address major disease outbreaks, such as the Ebola and Covid-19 crises. Following the Covid-19 outbreak, innovative financing has been proposed as a major vehicle to fund PPPR.

RESULTS

What are the new findings? Despite recent pronouncements that innovative financing has 'huge untapped potential' for PPPR, there is little evidence within the literature to support such claims. This has been confirmed by our examination of four innovative financing mechanisms and their historical use in response to disease outbreaks. Our findings suggest that flaws and trade-offs in the design and application of these mechanisms have resulted in failure to deliver on their promise, raising concerns regarding their prospective use in financing PPPR. Although innovative financing could play a role, existing mechanisms in health have not generated the scale of funds proposed. In addition, the amounts generated have historically focused on specific interventions, which threaten to enhance fragmentation (disjointed financing of health) and alignment failures (not well integrated within overall national strategic plans) with and within PPPR.

CONCLUSIONS

What do the new findings imply? Our findings reveal a set of innovative financing tools shrouded in unsubstantiated claims to success and effectiveness that look to have underwhelming promise of 'value for money' in global health. This stems from evidence suggesting design flaws, inadequate application, lack of transparency, private sector profiteering and associated opportunity costs. Thus, contrary to popular claims, they may not be the 'silver bullet' for bridging PPPR financing gaps and addressing costly, complex and multifaceted PPPR interventions.

Vaccine Impact Bonds: An Alternative Way of Allocating the Economic Risks of Mass Vaccination Programs

Vaccines can be an appropriate tool for combating pandemics. Accordingly, expectations were high when the first Covid-19 vaccines were administered. However, even though the vaccines have not met these high initial expectations, vaccine manufacturers and their investors were making large profits, while most of the associated economic risks have remained with the taxpaying public. Thus, this paper applies the concept of social impact bonds to mass vaccination programs by conceptualizing vaccine impact bonds (VIBs) as an alternative to the advance purchase agreements (APAs) for Covid-19 vaccines. Rather than rewarding vaccine manufacturers and their investors based on the quantity of doses distributed, VIBs intend to link the real-world vaccine impact to the financial returns of vaccine manufacturers and their investors. This paper indicates that VIBs can theoretically shift the economic risks of mass vaccination programs from the taxpaying public to private investors, thereby aligning commercial and public interests. However, it also identifies several major weaknesses such as the complexity of defining and evaluating the vaccine impact as well as the inherent trade-off between relieving taxpayers (through VIBs) and allowing innovation. As these substantial drawbacks outweigh the theoretical strengths of VIBs, this paper calls for further research in order to identify better alternatives to the Covid-19 vaccine contracts.

Pediatric Gastrointestinal Tract Outcomes During the Postacute Phase of COVID-19

Importance

The profile of gastrointestinal (GI) tract outcomes associated with the postacute and chronic phases of COVID-19 in children and adolescents remains unclear.

Objective

To investigate the risks of GI tract symptoms and disorders during the postacute (28-179 days after documented SARS-CoV-2 infection) and the chronic (180-729 days after documented SARS-CoV-2 infection) phases of COVID-19 in the pediatric population.

Design, Setting, and Participants

This retrospective cohort study was performed from March 1, 2020, to September 1, 2023, at 29 US health care institutions. Participants included pediatric patients 18 years or younger with at least 6 months of follow-up. Data analysis was conducted from November 1, 2023, to February 29, 2024.

Exposures

Presence or absence of documented SARS-CoV-2 infection. Documented SARS-CoV-2 infection included positive results of polymerase chain reaction analysis, serological tests, or antigen tests for SARS-CoV-2 or diagnosis codes for COVID-19 and postacute sequelae of SARS-CoV-2.

Main Outcomes and Measures

GI tract symptoms and disorders were identified by diagnostic codes in the postacute and chronic phases following documented SARS-CoV-2 infection. The adjusted risk ratios (ARRs) and 95% CI were determined using a stratified Poisson regression model, with strata computed based on the propensity score.

Results

The cohort consisted of 1 576 933 pediatric patients (mean [SD] age, 7.3 [5.7] years; 820 315 [52.0%] male). Of these, 413 455 patients had documented SARS-CoV-2 infection and 1 163 478 did not; 157 800 (13.6%) of those without documented SARS-CoV-2 infection had a complex chronic condition per the Pediatric Medical Complexity Algorithm. Patients with a documented SARS-CoV-2 infection had an increased risk of developing at least 1 GI tract symptom or disorder in both the postacute (8.64% vs 6.85%; ARR, 1.25; 95% CI, 1.24-1.27) and chronic (12.60% vs 9.47%; ARR, 1.28; 95% CI, 1.26-1.30) phases compared with patients without a documented infection. Specifically, the risk of abdominal pain was higher in COVID-19-positive patients during the postacute (2.54% vs 2.06%; ARR, 1.14; 95% CI, 1.11-1.17) and chronic (4.57% vs 3.40%; ARR, 1.24; 95% CI, 1.22-1.27) phases.

Conclusions and Relevance

In this cohort study, the increased risk of GI tract symptoms and disorders was associated with the documented SARS-CoV-2 infection in children or adolescents during the postacute or chronic phase. Clinicians should note that lingering GI tract symptoms may be more common in children after documented SARS-CoV-2 infection than in those without documented infection.

Strengthening serological studies: the need for greater geographical diversity, biobanking, and data-accessibility

Serological studies uniquely strengthen infectious disease surveillance, expanding prevalence estimates to encompass asymptomatic infections, and revealing the otherwise inapparent landscape of immunity, including who is and is not susceptible to infection. They are thus a powerful complement to often incomplete epidemiological and public health measures (administrative measures of vaccination coverage, incidence estimates, etc.). The recent surge in the deployment of serological surveys globally (in part due to the SARS-CoV-2 pandemic), alongside the development of new assays and new inference methods, means that the time is ripe to interrogate areas to strengthen future serosurveillance efforts. We identify three themes warranting attention: first, expanding the geographical diversity of these studies; second, investing globally in infrastructure for storage of blood samples (biobanking), opening the way to future analyses; and third, establishing protocols to increase data accessibility and to facilitate data usage for current and future studies. We conclude that strengthening serological studies is necessary and achievable through thoughtful sampling design, wide-scale sample storage, and thorough reporting practices.

A Hierarchical Bayesian Model for Estimating Age-Specific COVID-19 Infection Fatality Rates in Developing Countries

The COVID-19 infection fatality rate (IFR) is the proportion of individuals infected with SARS-CoV-2 who subsequently die. As COVID-19 disproportionately affects older individuals, age-specific IFR estimates are imperative to facilitate comparisons of the impact of COVID-19 between locations and prioritize distribution of scarce resources. However, there lacks a coherent method to synthesize available data to create estimates of IFR and seroprevalence that vary continuously with age and adequately reflect uncertainties inherent in the underlying data. In this article, we introduce a novel Bayesian hierarchical model to estimate IFR as a continuous function of age that acknowledges heterogeneity in population age structure across locations and accounts for uncertainty in the estimates due to seroprevalence sampling variability and the imperfect serology test assays. Our approach simultaneously models test assay characteristics, serology, and death data, where the serology and death data are often available only for binned age groups. Information is shared across locations through hierarchical modeling to improve estimation of the parameters with limited data. Modeling data from 26 developing country locations during the first year of the COVID-19 pandemic, we found seroprevalence did not change dramatically with age, and the IFR at age 60 was above the high-income country estimate for most locations.

Sociodemographic differences in the response to changes in COVID-19 testing guidelines

During the coronavirus disease 2019 (COVID-19) pandemic, Sweden emphasized voluntary guidelines over mandates. We exploited a rapid change and reversal of the Public Health Agency of Sweden's COVID-19 testing guidelines for vaccinated and recently infected individuals as a quasi-experiment to examine sociodemographic differences in the response to changes in pandemic guidelines. We analyzed daily polymerase chain reaction tests from 1 October 2021 to 15 December 2021, for vaccinated or recently infected adults (≥20 years; n = 1 596 321) from three Swedish regions (Stockholm, Örebro, and Dalarna). Using interrupted time series analysis, we estimated abrupt changes in testing rates at the two dates when the guidelines were changed (1 November and 22 November). Stratified analysis and meta-regression were employed to explore sociodemographic differences in the strength of the response to the guideline changes. Testing rates declined substantially when guideline against testing of vaccinated and recently infected individuals came into effect on 1 November [testing rate ratio: 0.50 (95% confidence interval, CI 0.41, 0.61)], and increased again from these lowered levels by a similar amount upon its reversal on 22 November [testing rate ratio: 2.19 (95% CI: 1.69, 2.85)]. Being Sweden-born, having higher household income, or higher education, were all associated with a stronger adherent response to the guideline changes. Adjusting for stratum-specific baseline testing rates and test-positivity did not influence the results. Our findings suggest that the population was responsive to the rapid changes in testing guidelines, but with clear sociodemographic differences in the strength of the response.

Differential risk of healthcare workers versus the general population during outbreak, war and pandemic crises

Healthcare workers may have different risk for severe outcomes compared with the general population during diverse crises. This paper introduces the concept of healthcare worker versus population hazard (HPH), the risk of an outcome of interest in active healthcare workers compared with the general population they serve. HPH can be expressed with relative risk (HPH(r)) and absolute risk difference (HPH(a)) metrics. Illustrative examples are drawn from infectious outbreaks, war, and the COVID-19 pandemic on death outcomes. HPH can be extreme for lethal outbreaks (HPH(r) = 30 to 143, HPH(a) = 8 to 91 per 1000 for Ebola deaths in 3 Western African countries in 2013-5), and modestly high in relative terms and very high in absolute terms for protracted, major armed conflicts (HPH(r) = 1.38 and HPH(a) = 10.2 for Syria during 2011-2024). Conversely, healthcare workers had 8-12-fold lower risk than the population they served for pandemic excess deaths (physicians in USA) or COVID-19 deaths (physicians in Ontario, healthcare workers in Finland), while healthcare workers in Indonesia did not have this advantage for COVID-19 deaths versus the general population. HPH is susceptible to data inaccuracies in numbers of at-risk populations and of outcomes of interest. Importantly, inferences about healthcare worker risk can be misleading, if deaths of retired healthcare workers contaminate the risk calculations- as in the case of misleading early perceptions of exaggerated COVID-19 risk for healthcare professionals. HPH can offer useful insights for risk assessment to healthcare professionals, the general public, and policy makers and may be useful to monitor for planning and interventions during crises.

Is Covid-19 "vaccine uptake" in postsecondary education a "problem"? A critical policy inquiry

Since the launch of the Covid-19 global vaccination campaign, postsecondary institutions have strongly promoted vaccination, often through mandates, and the academic literature has identified "vaccine uptake" among postsecondary students as a problem deserving monitoring, research, and intervention. However, with the admission that vaccines do not stop viral spread, that older-age and co-morbidities are major determinants of poor outcomes, and that many vaccine side effects disproportionately affect the young, it cannot be assumed that a risk-benefit analysis favors vaccinating postsecondary students. Drawing from critical policy studies, I appraise the literature on Covid-19 vaccine uptake in postsecondary education. I find that this literature reflects the "scientific consensus," hardly acknowledging contradictory medical evidence, ignoring coercive elements underlying "vaccine acceptance," and neglecting ethical tensions built into the very design of vaccination policies. I discuss potential explanations for my findings, and their implications for academia's role in society in the COVID-19 era and beyond.

Pharmaceutical product recall and educated hesitancy towards new drugs and novel vaccines

Background: Of many pharmaceutical products launched for the benefit of humanity, a significant number have had to be recalled from the marketplace due to adverse events. A systematic review found market recalls for 462 pharmaceutical products between 1953 and 2013. In our current and remarkable period of medical history, excess mortality figures are high in many countries. Yet these statistics receive limited attention, often ignored or dismissed by mainstream news outlets. This excess mortality may include adverse effects caused by novel pharmaceutical agents that use gene-code technology.Objective: To examine key pharmaceutical product withdrawals and derive lessons that inform the current use of gene-based COVID-19 vaccines.Methods: Selective narrative review of historical pharmaceutical recalls and comparative issues with recent COVID-19 vaccines.Results: Parallels with past drug withdrawals and gene-based vaccines include distortion of clinical trial data, with critical adverse event data absent from high-impact journal publications. Delayed regulatory action on pharmacovigilance data to trigger market withdrawal occurred with Vioxx (rofecoxib) and is apparent with the gene-based COVID-19 vaccines.Conclusion: Public health requires access to raw clinical trial data, improved transparency from corporations and heightened, active pharmacovigilance worldwide.

Antibody levels versus vaccination status in the outcome of older adults with COVID-19

BACKGROUNDDespite the currently prevailing, milder Omicron variant of COVID-19, older adults remain at elevated risk of hospital admission, critical illness, and death. Loss of efficacy of the immune system, including reduced strength, quality, and durability of antibody responses, may render generalized recommendations on booster vaccinations inadequate. There is a lack of data on the efficacy of antibody levels in older adults and on the utility of vaccination status versus antibody levels as a correlate of protection. It is further unclear whether antibody levels may be used to guide the timing of booster vaccinations in older adults.METHODSWe conducted a prospective multicenter cohort study comprising hospitalized patients with COVID-19. Anti-SARS-CoV-2 spike antibodies were measured on hospital admission. The primary endpoint was in-hospital mortality. Patients were stratified by age, antibody levels, and vaccination status. Multiple logistic regression and Cox regression analyses were conducted.RESULTSIn total, 785 older patients (≥60 years of age [a]) and 367 controls (<60a) were included. After adjusting for confounders, risk of mortality, ICU admission, endotracheal intubation, and oxygen administration was 4.9, 2.6, 6.5, and 2.3 times higher, respectively, if antibody levels were < 1,200 BAU/mL (aOR, 4.92 [95%CI, 2.59-9.34], P < 0.0001; aOR, 2.64 [95%CI, 1.52-4.62], P = 0.0006; aOR, 6.50 [95%CI, 1.48-28.47], P = 0.013; aOR, 2.34 [95%CI, 1.60-3.343], P < 0.0001). Older adults infected with the Omicron variant were approximately 6 times more likely to die if antibody levels were < 1,200 BAU/mL (aOR, 6.3 [95% CI, 2.43-16.40], P = 0.0002).CONCLUSIONAntibody levels were a stronger predictor of in-hospital mortality than vaccination status. Monitoring antibody levels may constitute a better and more direct approach for safeguarding older adults from adverse COVID-19 outcomes.

Evidence base for yearly respiratory virus vaccines: Current status and proposed improved strategies

Annual vaccination is widely recommended for influenza and SARS-CoV-2. In this essay, we analyse and question the prevailing policymaking approach to these respiratory virus vaccines, especially in the United States. Every year, licensed influenza vaccines are reformulated to include specific strains expected to dominate in the season ahead. Updated vaccines are rapidly manufactured and approved without further regulatory requirement of clinical data. Novel vaccines (i.e. new products) typically undergo clinical trials, though generally powered for clinically unimportant outcomes (e.g. lab-confirmed infections, regardless of symptomatology or antibody levels). Eventually, the current and future efficacy of influenza and COVID-19 vaccines against hospitalization or death carries considerable uncertainty. The emergence of highly transmissible SARS-CoV-2 variants and waning vaccine-induced immunity led to plummeting vaccine effectiveness, at least against symptomatic infection, and booster doses have since been widely recommended. No further randomized trials were performed for clinically important outcomes for licensed updated boosters. In both cases, annual vaccine effectiveness estimates are generated by observational research, but observational studies are particularly susceptible to confounding and bias. Well-conducted experimental studies, particularly randomized trials, are necessary to address persistent uncertainties about influenza and COVID-19 vaccines. We propose a new research framework which would render results relevant to the current or future respiratory viral seasons. We demonstrate that experimental studies are feasible by adopting a more pragmatic approach and provide strategies on how to do so. When it comes to implementing policies that seriously impact people's lives, require substantial public resources and/or rely on widespread public acceptance, high evidence standards are desirable.

Effectiveness of the First and Second Severe Acute Respiratory Syndrome Coronavirus 2 Vaccine Dose: A Nationwide Cohort Study From Austria on Hybrid Versus Natural Immunity

Background

We aimed to evaluate the effectiveness of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccinations in previously SARS-CoV-2-infected adults in the general population of Austria during the Delta wave and with extended follow-up.

Methods

In a nationwide retrospective cohort study, we calculated age-, sex-, and nursing home residency-adjusted Cox proportional hazard ratios (HRs) of coronavirus disease 2019 (COVID-19) deaths, SARS-CoV-2 infections, and non-COVID-19 deaths from 1 October to 31 December 2021, and secondarily with extended follow-up to 30 June 2022. Relative vaccine effectiveness (rVE) is rVE = (1 - HR) × 100.

Results

Among 494 646 previously infected adults, 169 543 had received 2 vaccine doses, 133 567 had received 1 dose, and 190 275 were unvaccinated at baseline. We recorded 17 COVID-19 deaths (6 vaccinated, 11 unvaccinated) and 8209 SARS-CoV-2 infections. Absolute risk of COVID-19 deaths was 0.003%. rVE estimates for COVID-19 deaths and reinfections exceeded 75% until the end of 2021 but decreased substantially with extended follow-up. The risk of non-COVID-19 death was lower in those vaccinated versus unvaccinated.

Conclusions

First and second SARS-CoV-2 vaccine doses appear effective in the short-term, but with diminishing effectiveness over time. The extremely low COVID-19 mortality, regardless of vaccination, indicates strong protection of previous infection against COVID-19 death. Lower non-COVID-19 mortality in the vaccinated population might suggest a healthy vaccinee bias.

Excess Deaths in Korea During the COVID-19 Pandemic: 2020-2022

OBJECTIVES

Excess deaths, an indicator that compares total mortality rates before and during a pandemic, offer a comprehensive view of the pandemic's impact. However, discrepancies may arise from variations in estimating expected deaths. This study aims to compare excess deaths in Korea during the coronavirus disease 2019 pandemic using 3 methods and to analyze patterns using the most appropriate method.

METHODS

Expected deaths from 2020 to 2022 were estimated using mortality data from 2015-2019 as reference years. This estimation employed 3 approaches: (1) simple average, (2) age-adjusted average, and (3) age-adjusted linear regression. Excess deaths by age, gender, and cause of death were also presented.

RESULTS

The number of excess deaths varied depending on the estimation method used, reaching its highest point with the simple average and its lowest with the age-adjusted average. Age-adjusted linear regression, which accounts for both the aging population and declining mortality rates, was considered most appropriate. Using this model, excess deaths were estimated at 0.3% for 2020, 4.0% for 2021, and 20.7% for 2022. Excess deaths surged among individuals in their 20s throughout the pandemic, largely attributed to a rise in self-harm and suicide. Additionally, the results indicated sharp increases in deaths associated with "endocrine, nutritional, and metabolic diseases" and "symptoms, signs, and abnormal clinical and laboratory findings, not elsewhere classified."

CONCLUSIONS

Substantial variations in excess deaths were evident based on estimation method, with a notable increase in 2022. The heightened excess deaths among young adults and specific causes underscore key considerations for future pandemic responses.

Pediatric Gastrointestinal Outcomes During the Post-Acute Phase of COVID-19: Findings from RECOVER Initiative from 29 Hospitals in the US

Importance

The profile of gastrointestinal (GI) outcomes that may affect children in post-acute and chronic phases of COVID-19 remains unclear.

Objective

To investigate the risks of GI symptoms and disorders during the post-acute phase (28 days to 179 days after SARS-CoV-2 infection) and the chronic phase (180 days to 729 days after SARS-CoV-2 infection) in the pediatric population.

Design

We used a retrospective cohort design from March 2020 to Sept 2023.

Setting

twenty-nine healthcare institutions.

Participants

A total of 413,455 patients aged not above 18 with SARS-CoV-2 infection and 1,163,478 patients without SARS-CoV-2 infection.

Exposures

Documented SARS-CoV-2 infection, including positive polymerase chain reaction (PCR), serology, or antigen tests for SARS-CoV-2, or diagnoses of COVID-19 and COVID-related conditions.

Main Outcomes and Measures

Prespecified GI symptoms and disorders during two intervals: post-acute phase and chronic phase following the documented SARS-CoV-2 infection. The adjusted risk ratio (aRR) was determined using a stratified Poisson regression model, with strata computed based on the propensity score.

Results

Our cohort comprised 1,576,933 patients, with females representing 48.0% of the sample. The analysis revealed that children with SARS-CoV-2 infection had an increased risk of developing at least one GI symptom or disorder in both the post-acute (8.64% vs. 6.85%; aRR 1.25, 95% CI 1.24-1.27) and chronic phases (12.60% vs. 9.47%; aRR 1.28, 95% CI 1.26-1.30) compared to uninfected peers. Specifically, the risk of abdominal pain was higher in COVID-19 positive patients during the post-acute phase (2.54% vs. 2.06%; aRR 1.14, 95% CI 1.11-1.17) and chronic phase (4.57% vs. 3.40%; aRR 1.24, 95% CI 1.22-1.27).

Conclusions and Relevance

In the post-acute phase or chronic phase of COVID-19, the risk of GI symptoms and disorders was increased for COVID-positive patients in the pediatric population.

Post-acute and Chronic Kidney Function Outcomes of COVID-19 in Children and Adolescents: An EHR Cohort Study from the RECOVER Initiative

We investigated the risks of post-acute and chronic adverse kidney outcomes of SARS-CoV-2 infection in the pediatric population via a retrospective cohort study using data from the RECOVER program. We included 1,864,637 children and adolescents under 21 from 19 children's hospitals and health institutions in the US with at least six months of follow-up time between March 2020 and May 2023. We divided the patients into three strata: patients with pre-existing chronic kidney disease (CKD), patients with acute kidney injury (AKI) during the acute phase (within 28 days) of SARS-CoV-2 infection, and patients without pre-existing CKD or AKI. We defined a set of adverse kidney outcomes for each stratum and examined the outcomes within the post-acute and chronic phases after SARS-CoV-2 infection. In each stratum, compared with the non-infected group, patients with COVID-19 had a higher risk of adverse kidney outcomes. For patients without pre-existing CKD, there were increased risks of CKD stage 2+ (HR 1.20; 95% CI: 1.13-1.28) and CKD stage 3+ (HR 1.35; 95% CI: 1.15-1.59) during the post-acute phase (28 days to 365 days) after SARS-CoV-2 infection. Within the post-acute phase of SARS-CoV-2 infection, children and adolescents with pre-existing CKD and those who experienced AKI were at increased risk of progression to a composite outcome defined by at least 50% decline in estimated glomerular filtration rate (eGFR), eGFR <15 mL/min/1.73m2, End Stage Kidney Disease diagnosis, dialysis, or transplant.

Is resistance to Covid-19 vaccination a "problem"? A critical policy inquiry of vaccine mandates for healthcare workers

As the COVID-19 global vaccination campaign was launched in December of 2020, vaccination became mandatory for many healthcare workers (HCWs) worldwide. Large minorities resisted the policy, and the responses of authorities to this resistance led to damaged professional reputations, job losses, and suspension or termination of practice licenses. The joint effect of dismissals, early retirements, career changes, and vaccine injuries disabling some compliant HCWs from adequate performance has exacerbated existing crises within health systems. Nevertheless, leading health authorities have maintained that the benefits of a fully vaccinated healthcare labor force-believed to be protecting health systems, vulnerable patient populations, and even HCWs themselves-achieved through mandates, if necessary, outweigh its potential harms. Informed by critical policy and discourse traditions, we examine the expert literature on vaccine mandates for HCWs. We find that this literature neglects evidence that contradicts official claims about the safety and effectiveness of COVID-19 vaccines, dismisses the science supporting the contextual nature of microbial virulence, miscalculates patient and system-level harms of vaccination policies, and ignores or legitimizes the coercive elements built into their design. We discuss the implications of our findings for the sustainability of health systems, for patient care, and for the well-being of HCWs, and suggest directions for ethical clinical and policy practice.

Physical activity, problematic gaming behavior, and quality of life prior and during the first 9 months of the COVID-19 pandemic: Findings from a longitudinal study among university students

BACKGROUND

Generally, there is limited information on longitudinal trends and the interrelations between physical activity (PA), problematic gaming behavior (PGB), described as a dysfunctional pattern of videogame activities, and quality of life (QoL) based on data that include measurements from both pre- and postpandemic onset. This is also the case for university students. As society faced unprecedented restrictions during this period, these aspects may have developed unfavorably.

OBJECTIVE

To examine PA, PGB, and QoL among Norwegian University students prior to and during the initial stages of the pandemic and assess their temporal interrelations.

METHOD

The data are derived from the "Students' Psychological Health Over Time" study (SPOT). Linear mixed models were used to examine the development from January 2020 to November 2020 over three time points for the total sample and across gender. A traditional cross-lagged panel model analysis was used to estimate temporal associations. Age, gender, socioeconomic status, and partner status were included as covariates.

FINDINGS

PA and QoL decreased linearly over time (Cohen's d = 0.12 and 0.35, respectively), while only male students reported a small reduction in PGB (Cohen's d = 0.03). PA levels decreased considerably more for male students than female students (Cohen's d = 0.17 and 0.09, respectively). There was a small reciprocal negative temporal association between PA and PGB (standardized β = -0.04 and -0.05, respectively). All other temporal associations were not statistically significant in the adjusted analysis.

CONCLUSION

The findings highlight gender-variant negative developments in PA and QoL and suggest a negative reciprocal interrelation between PA and PGB. The findings point to potential adverse health effects that should be taken into account when restrictive pandemic measures are considered.

Estimation of standardized real-time fatality rate for ongoing epidemics

BACKGROUND

The fatality rate is a crucial metric for guiding public health policies during an ongoing epidemic. For COVID-19, the age structure of the confirmed cases changes over time, bringing a substantial impact on the real-time estimation of fatality. A 'spurious decrease' in fatality rate can be caused by a shift in confirmed cases towards younger ages even if the fatalities remain unchanged across different ages.

METHODS

To address this issue, we propose a standardized real-time fatality rate estimator. A simulation study is conducted to evaluate the performance of the estimator. The proposed method is applied for real-time fatality rate estimation of COVID-19 in Germany from March 2020 to May 2022.

FINDINGS

The simulation results suggest that the proposed estimator can provide an accurate trend of disease fatality in all cases, while the existing estimator may convey a misleading signal of the actual situation when the changes in temporal age distribution take place. The application to Germany data shows that there was an increment in the fatality rate at the implementation of the 'live with COVID' strategy.

CONCLUSIONS

As many countries have chosen to coexist with the coronavirus, frequent examination of the fatality rate is of paramount importance.

Estimating SARS-CoV-2 infection probabilities with serological data and a Bayesian mixture model

The individual results of SARS-CoV-2 serological tests measured after the first pandemic wave of 2020 cannot be directly interpreted as a probability of having been infected. Plus, these results are usually returned as a binary or ternary variable, relying on predefined cut-offs. We propose a Bayesian mixture model to estimate individual infection probabilities, based on 81,797 continuous anti-spike IgG tests from Euroimmun collected in France after the first wave. This approach used serological results as a continuous variable, and was therefore not based on diagnostic cut-offs. Cumulative incidence, which is necessary to compute infection probabilities, was estimated according to age and administrative region. In France, we found that a "negative" or a "positive" test, as classified by the manufacturer, could correspond to a probability of infection as high as 61.8% or as low as 67.7%, respectively. "Indeterminate" tests encompassed probabilities of infection ranging from 10.8 to 96.6%. Our model estimated tailored individual probabilities of SARS-CoV-2 infection based on age, region, and serological result. It can be applied in other contexts, if estimates of cumulative incidence are available.

Wearing face masks as a potential source for inhalation and oral uptake of inanimate toxins - A scoping review

BACKGROUND

From 2020 to 2023 many people around the world were forced to wear masks for large proportions of the day based on mandates and laws. We aimed to study the potential of face masks for the content and release of inanimate toxins.

METHODS

A scoping review of 1003 studies was performed (database search in PubMed/MEDLINE, qualitative and quantitative evaluation).

RESULTS

24 studies were included (experimental time 17 min to 15 days) evaluating content and/or release in 631 masks (273 surgical, 228 textile and 130 N95 masks). Most studies (63%) showed alarming results with high micro- and nanoplastics (MPs and NPs) release and exceedances could also be evidenced for volatile organic compounds (VOCs), xylene, acrolein, per-/polyfluoroalkyl substances (PFAS), phthalates (including di(2-ethylhexyl)-phthalate, DEHP) and for Pb, Cd, Co, Cu, Sb and TiO2.

DISCUSSION

Of course, masks filter larger dirt and plastic particles and fibers from the air we breathe and have specific indications, but according to our data they also carry risks. Depending on the application, a risk-benefit analysis is necessary.

CONCLUSION

Undoubtedly, mask mandates during the SARS-CoV-2 pandemic have been generating an additional source of potentially harmful exposition to toxins with health threatening and carcinogenic properties at population level with almost zero distance to the airways.

Ethics of Nudging in the COVID-19 Crisis and the Necessary Return to the Principles of Shared Decision Making: A Critical Review

Nudging, a controversial technique for modifying people's behavior in a predictable way, is claimed to preserve freedom of choice while simultaneously influencing it. Nudging had been largely confined to situations such as promoting healthy eating choices but has been employed in the coronavirus disease 2019 (COVID-19) crisis in a shift towards measures that involve significantly less choice, such as shoves and behavioral prods. Shared decision making (SDM), a method for direct involvement and autonomy, is an alternative approach to communicate risk. Predominantly peer-reviewed scientific publications from standard literature databases like PubMed, PsycInfo, and Psyndex were evaluated in a narrative review. The so-called fear nudges, as well as the dissemination of strongly emotionalizing or moralizing messages can lead to intense psycho-physical stress. The use of these nudges by specialized units during the COVID-19 pandemic generated a societal atmosphere of fear that precipitated a deterioration of the mental and physical health of the population. Major recommendations of the German COVID-19 Snapshot Monitoring (COSMO) study, which are based on elements of nudging and coercive measures, do not comply with ethical principles, basic psychological principles, or evidence-based data. SDM was misused in the COVID-19 crisis, which helped to achieve one-sided goals of governments. The emphasis on utilitarian thinking is criticized and the unethical behavior of decision makers is explained by both using the concept of moral disengagement and the maturity level of coping strategies. There should be a return to an open-ended, democratic, and pluralistic scientific debate without using nudges. It is therefore necessary to return to the origins of SDM.

Vaccination strategies impact the probability of outbreak extinction: A case study of COVID-19 transmission

Mass vaccination has proven to be an effective control measure for mitigating the transmission of infectious diseases. Throughout history, various vaccination strategies have been employed to control infections and terminate outbreaks. In this study, we utilized the transmission of COVID-19 as a case study and constructed a stochastic age-structured compartmental model to investigate the effectiveness of different vaccination strategies. Our analysis focused on estimating the outbreak extinction probability under different vaccination scenarios in both homogeneous and heterogeneous populations. Notably, we found that population heterogeneity can enhance the likelihood of outbreak extinction at varying levels of vaccine coverage. Prioritizing vaccinations for individuals with higher infection risk was found to maximize outbreak extinction probability and reduce overall infections, while allocating vaccines to those with higher mortality risk has been proven more effective in reducing deaths. Moreover, our study highlighted the significance of booster doses as the vaccine effectiveness wanes over time, showing that they can significantly enhance the extinction probability and mitigate disease transmission.

Is society caught up in a Death Spiral? Modeling societal demise and its reversal

Just like an army of ants caught in an ant mill, individuals, groups and even whole societies are sometimes caught up in a Death Spiral, a vicious cycle of self-reinforcing dysfunctional behavior characterized by continuous flawed decision making, myopic single-minded focus on one (set of) solution(s), denial, distrust, micromanagement, dogmatic thinking and learned helplessness. We propose the term Death Spiral Effect to describe this difficult-to-break downward spiral of societal decline. Specifically, in the current theory-building review we aim to: (a) more clearly define and describe the Death Spiral Effect; (b) model the downward spiral of societal decline as well as an upward spiral; (c) describe how and why individuals, groups and even society at large might be caught up in a Death Spiral; and (d) offer a positive way forward in terms of evidence-based solutions to escape the Death Spiral Effect. Management theory hints on the occurrence of this phenomenon and offers turn-around leadership as solution. On a societal level strengthening of democracy may be important. Prior research indicates that historically, two key factors trigger this type of societal decline: rising inequalities creating an upper layer of elites and a lower layer of masses; and dwindling (access to) resources. Historical key markers of societal decline are a steep increase in inequalities, government overreach, over-integration (interdependencies in networks) and a rapidly decreasing trust in institutions and resulting collapse of legitimacy. Important issues that we aim to shed light on are the behavioral underpinnings of decline, as well as the question if and how societal decline can be reversed. We explore the extension of these theories from the company/organization level to the society level, and make use of insights from both micro-, meso-, and macro-level theories (e.g., Complex Adaptive Systems and collapsology, the study of the risks of collapse of industrial civilization) to explain this process of societal demise. Our review furthermore draws on theories such as Social Safety Theory, Conservation of Resources Theory, and management theories that describe the decline and fall of groups, companies and societies, as well as offer ways to reverse this trend.

Effectiveness of a fourth SARS-CoV-2 vaccine dose in previously infected individuals from Austria

INTRODUCTION

Evidence is limited on the effectiveness of a fourth vaccine dose against coronavirus disease 2019 (COVID-19) in populations with prior severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections. We estimated the risk of COVID-19 deaths and SARS-CoV-2 infections according to vaccination status in previously infected individuals in Austria.

METHODS

This is a nationwide retrospective observational study. We calculated age and gender adjusted Cox proportional hazard ratios (HRs) of COVID-19 deaths (primary outcome) and SARS-CoV-2 infections (secondary outcome) from 1 November to 31 December 2022, primarily comparing individuals with four versus three vaccine doses. Relative vaccine effectiveness (rVE) was calculated as (1-HR) X 100.

RESULTS

Among 3,986,312 previously infected individuals, 281,291 (7,1%) had four and 1,545,242 (38.8%) had three vaccinations at baseline. We recorded 69 COVID-19 deaths and 89,056 SARS-CoV-2 infections. rVE for four versus three vaccine doses was -24% (95% CI: -120 to 30) against COVID-19 deaths, and 17% (95% CI: 14-19) against SARS-CoV-2 infections. This latter effect rapidly diminished over time and infection risk with four vaccinations was higher compared to less vaccinated individuals during extended follow-up until June 2023. Adjusted HR (95% CI) for all-cause mortality for four versus three vaccinations was 0.79 (0.74-0.85).

DISCUSSION

In previously infected individuals, a fourth vaccination was not associated with COVID-19 death risk, but with transiently reduced risk of SARS-CoV-2 infections and reversal of this effect in longer follow-up. All-cause mortality data suggest healthy vaccinee bias.

The Ethical Obligation for Research During Public Health Emergencies: Insights From the COVID-19 Pandemic

In times of crises, public health leaders may claim that trials of public health interventions are unethical. One reason for this claim can be that equipoise-i.e. a situation of uncertainty and/or disagreement among experts about the evidence regarding an intervention-has been disturbed by a change of collective expert views. Some might claim that equipoise is disturbed if the majority of experts believe that emergency public health interventions are likely to be more beneficial than harmful. However, such beliefs are not always justified: where high quality research has not been conducted, there is often considerable residual uncertainty about whether interventions offer net benefits. In this essay we argue that high-quality research, namely by means of well-designed randomized trials, is ethically obligatory before, during, and after implementing policies in public health emergencies (PHEs). We contend that this standard applies to both pharmaceutical and non-pharmaceutical interventions, and we elaborate an account of equipoise that captures key features of debates in the recent pandemic. We build our case by analyzing research strategies employed during the COVID-19 pandemic regarding drugs, vaccines, and non-pharmaceutical interventions; and by providing responses to possible objections. Finally, we propose a public health policy reform: whenever a policy implemented during a PHE is not grounded in high-quality evidence that expected benefits outweigh harms, there should be a planned approach to generate high-quality evidence, with review of emerging data at preset time points. These preset timepoints guarantee that policymakers pause to review emerging evidence and consider ceasing ineffective or even harmful policies, thereby improving transparency and accountability, as well as permitting the redirection of resources to more effective or beneficial interventions.

The effects of COVID-19 infection on working memory: a systematic review

BACKGROUND

Studies demonstrate that people who have been infected by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the causative agent of COVID-19, have experienced cognitive dysfunction, including working memory impairment, executive dysfunction, and decreased concentration. This review aimed to explore the incidence of working memory impairment and possible concomitant symptoms in the acute phase (< 3 months) and chronic phase (> 6 months) of COVID-19.

METHODS

We conducted a systematic review of the following databases for inception: MEDLINE via Pub Med, Cochrane EMBASE, and Web of Science electronic databases. The search strategy was comprised of all the observational studies with COVID-19 patients confirmed by PCR or serology who were infected by SARS-CoV-2 with no previous cognitive impairment. This review protocol was recorded on PROSPERO with registration number CRD 42023413454.

RESULTS

A total of 16 studies from 502 retrieved articles were included. COVID-19 could cause a decline in working memory ability, the results showed that 22.5-55% of the people suffered from working memory impairment in the acute phase (< 3 months) of COVID-19, at 6 months after SARS-CoV2 infection, the impairment of working memory caused by COVID-19 still existed, the prevalence was about 6.2-10%, and 41.1% of the patients had a slight decrease in working memory or a negative change in the boundary value. Moreover, concomitant symptoms could persist for a long time. To some extent, the performance of working memory was affected by age, the time after infection, and the severity of infection (β = -.132, p <.001; β = .098, p <.001; β = .075, p = .003). The mechanism of working memory impairment after infection was mainly focused on the aspects of neuroinflammation and the nerve invasiveness of the virus; at the same time, we also noticed some changes of the brain parenchymal structure.

CONCLUSION

COVID-19 can cause a decline in working memory ability, accompanied by neurological symptoms. However, there is a lack of studies to identify the structural and functional changes in specific brain regions that relate to the impaired working memory.

COVID-19 mRNA Vaccines: Lessons Learned from the Registrational Trials and Global Vaccination Campaign

Our understanding of COVID-19 vaccinations and their impact on health and mortality has evolved substantially since the first vaccine rollouts. Published reports from the original randomized phase 3 trials concluded that the COVID-19 mRNA vaccines could greatly reduce COVID-19 symptoms. In the interim, problems with the methods, execution, and reporting of these pivotal trials have emerged. Re-analysis of the Pfizer trial data identified statistically significant increases in serious adverse events (SAEs) in the vaccine group. Numerous SAEs were identified following the Emergency Use Authorization (EUA), including death, cancer, cardiac events, and various autoimmune, hematological, reproductive, and neurological disorders. Furthermore, these products never underwent adequate safety and toxicological testing in accordance with previously established scientific standards. Among the other major topics addressed in this narrative review are the published analyses of serious harms to humans, quality control issues and process-related impurities, mechanisms underlying adverse events (AEs), the immunologic basis for vaccine inefficacy, and concerning mortality trends based on the registrational trial data. The risk-benefit imbalance substantiated by the evidence to date contraindicates further booster injections and suggests that, at a minimum, the mRNA injections should be removed from the childhood immunization program until proper safety and toxicological studies are conducted. Federal agency approval of the COVID-19 mRNA vaccines on a blanket-coverage population-wide basis had no support from an honest assessment of all relevant registrational data and commensurate consideration of risks versus benefits. Given the extensive, well-documented SAEs and unacceptably high harm-to-reward ratio, we urge governments to endorse a global moratorium on the modified mRNA products until all relevant questions pertaining to causality, residual DNA, and aberrant protein production are answered.

Anti-SARS-CoV-2 Antibody Testing: Role and Indications

Since the onset of the COVID-19 pandemic in March 2020, over 769 million confirmed COVID-19 cases, including close to 7 million COVID-19-related deaths, have been reported. Although mortality rates have dropped notably compared to the first months of the pandemic, spikes in reported cases and mortality rates continue to be registered. Both recent spikes in case numbers and the continued emergence of new variants suggest that vulnerable patient groups, including older adults, immunocompromised patients, and patients with severe comorbidities, are going to continue to be affected by COVID-19. In order to curb the pandemic, relieve the pressure on primary care facilities, and reduce mortality rates, global vaccination programs have been established by the WHO, with over 13.5 billion vaccine doses having been administered globally. In most immunocompetent individuals, vaccination against COVID-19 results in the production of anti-SARS-CoV-2 spike antibodies. However, certain patient subsets have inadequate or reduced immune responses, and immune responses are known to decrease with age. General recommendations on the timing of booster vaccinations may therefore be insufficient to protect vulnerable patients. This review aims to evaluate the clinical role of anti-SARS-CoV-2 antibodies, focusing on measurement indications, prognostic value, and potential as a correlate of protection to guide future booster vaccination strategies.

Variability in excess deaths across countries with different vulnerability during 2020-2023

Excess deaths provide total impact estimates of major crises, such as the COVID-19 pandemic. We evaluated excess death trajectories across countries with accurate death registration and population age structure data and assessed relationships with vulnerability indicators. Using the Human Mortality Database on 34 countries, excess deaths were calculated for 2020-2023 (to week 29, 2023) using 2017-2019 as reference, with adjustment for 5 age strata. Countries were divided into less and more vulnerable; the latter had per capita nominal GDP < $30,000, Gini > 0.35 for income inequality and/or at least ≥2.5% of their population living in poverty. Excess deaths (as proportion of expected deaths, p%) were inversely correlated with per capita GDP (r = -0.60), correlated with proportion living in poverty (r = 0.66), and modestly correlated with income inequality (r = 0.45). Incidence rate ratio for deaths was 1.062 (95% CI, 1.038-1.087) in more versus less vulnerable countries. Excess deaths started deviating in the two groups after the first wave. Between-country heterogeneity diminished gradually within each group. Less vulnerable countries had mean p% = -0.8% and 0.4% in 0-64 and >65-y-old strata. More vulnerable countries had mean p% = 7.0% and 7.2%, respectively. Lower death rates were seen in children of age 0-14 y during 2020-2023 versus prepandemic years. While the pandemic hit some countries earlier than others, country vulnerability dominated eventually the cumulative impact. Half the analyzed countries witnessed no substantial excess deaths versus prepandemic levels, while the others suffered major death tolls.

Does equipoise exist for masking children for COVID-19?

Clinical equipoise is characterized by genuine uncertainty within the medical community about the effectiveness of a medical intervention. Its existence is often deemed necessary for clinical trials and signals a need for higher quality evidence, most often with randomized controlled trials, before the intervention can be considered effective. A leading official of the United States' Centers for Disease Control and Prevention Director, when testifying before Congress in February of 2023, indicated there was no need for randomized controlled trials of masking because, owing to overwhelming evidence of benefit, there was no longer equipoise about masking children for COVID-19. We disagree with this statement and outline the reasons why in this piece. We review the concept of clinical equipoise specifically using the example of child masking. We list reasons equipoise still exists for masking children, including a lack of consensus among experts, contradictory medical evidence and recent and ongoing randomized efforts. Finally, we differentiate between clinical equipoise and ethical appropriateness. Despite ongoing equipoise about masking children, we outline why, owing to lack of evidence of net benefit, recommending this intervention does not currently appear to be medically ethical.

Autoimmune inflammatory reactions triggered by the COVID-19 genetic vaccines in terminally differentiated tissues

As a result of the spread of SARS-CoV-2, a global pandemic was declared. Indiscriminate COVID-19 vaccination has been extended to include age groups and naturally immune people with minimal danger of suffering serious complications due to COVID-19. Solid immuno-histopathological evidence demonstrates that the COVID-19 genetic vaccines can display a wide distribution within the body, affecting tissues that are terminally differentiated and far away from the injection site. These include the heart and brain, which may incur in situ production of spike protein eliciting a strong autoimmunological inflammatory response. Due to the fact that every human cell which synthesises non-self antigens, inevitably becomes the target of the immune system, and since the human body is not a strictly compartmentalised system, accurate pharmacokinetic and pharmacodynamic studies are needed in order to determine precisely which tissues can be harmed. Therefore, our article aims to draw the attention of the scientific and regulatory communities to the critical need for biodistribution studies for the genetic vaccines against COVID-19, as well as for rational harm-benefit assessments by age group.

Appraising the decision-making process concerning COVID-19 policy in postsecondary education in Canada: A critical scoping review protocol

Background

Responses to COVID-19 in Canadian postsecondary education have overhauled usual norms and practices, with policies of unclear rationale implemented under the pressure of a reported public health emergency.

Objective

To critically appraise the decision-making process informing COVID-19 policy in the postsecondary education sector.

Methods

Our scoping review will draw from macro and micro theories of public policy, specifically the critical tradition exemplified by Carol Bacchi's approach "What is the problem represented to be" and will be guided by Arksey and O'Malley's framework for scoping reviews and the team-based approach of Levan and colleagues. Data will include diverse and publicly available documents to capture multiple stakeholders' perspectives on the phenomenon of interest and will be retrieved from university newsletters and legal websites using combinations of search terms adapted to specific data types. Two reviewers will independently screen, chart, analyze and synthesize the data. Disagreements will be resolved through full team discussion.

Discussion

Despite the unprecedented nature of the mass medical mandates implemented in the postsecondary sector and their dramatic impact on millions of lives-students, faculty, staff and their families, friends and communities-the decision-making process leading to them has not been documented or appraised. By identifying, summarizing and appraising the evidence, our review should inform practices that can contribute to effective and equitable public health policies in postsecondary institutions moving forward.

Scanning Electron Microscopy and EDX Spectroscopy of Commercial Swabs Used for COVID-19 Lateral Flow Testing

The chemical composition of COVID test swabs has not been examined beyond the manufacturer's datasheets. The unprecedented demand for swabs to conduct rapid lateral flow tests and nucleic acid amplification tests led to mass production, including 3D printing platforms. Manufacturing impurities could be present in the swabs and, if so, could pose a risk to human health. We used scanning electron microscopy and energy dispersive X-ray (EDX) spectroscopy to examine the ultrastructure of seven assorted brands of COVID test swabs and to identify and quantify their chemical elements. We detected eight unexpected elements, including transition metals, such as titanium and zirconium, the metalloid silicon, as well as post-transition metals aluminium and gallium, and the non-metal elements sulphur and fluorine. Some of the elements were detected as trace amounts, but for others, the amount was close to reported toxicological thresholds for inhalation routes. Experimental studies have shown that the detrimental effects of unexpected chemical elements include moderate to severe inflammatory states in the exposed epithelium as well as proliferative changes. Given the massive testing still being used in the context of the COVID pandemic, we urge caution in continuing to recommend repeated and frequent testing, particularly of healthy, non-symptomatic, individuals.

Intervening on Global Emergencies: The Value of Human Interactions for People's Health

Literature about global emergencies and their impact on people's health underlines the need to improve the social cohesion of human community and the availability of tools to support people and foster community interactions. This paper illustrates research aimed at describing and measuring human interactions in the Veneto community and its changing during the COVID-19 pandemic. 50,000 text occurrences from social media and newspapers about these topics were analyzed between December 2021 and January 2022. People present themselves as members of different teams, pursuing conflicting aims, and attributing the decision-making responsibility of emergencies management exclusively to governments, without considering themselves as active parts of the community. This delegation process on citizens' behalf can affect their health: by taking minor responsibility in handling the repercussions of these events on the community and by arguing over the most effective way to deal with them, they risk freezing and waiting for action by third parties, thus leaving mutual interactions and the promotion of their own health at a standstill. Local institutions can use these data to shape prevention policies to manage the community's emergencies and use them as opportunities to promote public health.

Long COVID as a functional somatic symptom disorder caused by abnormally precise prior expectations during Bayesian perceptual processing: A new hypothesis and implications for pandemic response

This review proposes a model of Long-COVID where the constellation of symptoms are in fact genuinely experienced persistent physical symptoms that are usually functional in nature and therefore potentially reversible, that is, Long-COVID is a somatic symptom disorder. First, we describe what is currently known about Long-COVID in children and adults. Second, we examine reported "Long-Pandemic" effects that create a risk for similar somatic symptoms to develop in non-COVID-19 patients. Third, we describe what was known about somatization and somatic symptom disorder before the COVID-19 pandemic, and suggest that by analogy, Long-COVID may best be conceptualized as one of these disorders, with similar symptoms and predisposing, precipitating, and perpetuating factors. Fourth, we review the phenomenon of mass sociogenic (functional) illness, and the concept of nocebo effects, and suggest that by analogy, Long-COVID is compatible with these descriptions. Fifth, we describe the current theoretical model of the mechanism underlying functional disorders, the Bayesian predictive coding model for perception. This model accounts for moderators that can make symptom inferences functionally inaccurate and therefore can explain how to understand common predisposing, precipitating, and perpetuating factors. Finally, we discuss the implications of this framework for improved public health messaging during a pandemic, with recommendations for the management of Long-COVID symptoms in healthcare systems. We argue that the current public health approach has induced fear of Long-COVID in the population, including from constant messaging about disabling symptoms of Long-COVID and theorizing irreversible tissue damage as the cause of Long-COVID. This has created a self-fulfilling prophecy by inducing the very predisposing, precipitating, and perpetuating factors for the syndrome. Finally, we introduce the term "Pandemic-Response Syndrome" to describe what previously was labeled Long-COVID. This alternative perspective aims to stimulate research and serve as a lesson learned to avoid a repeat performance in the future.

Infant and Neonatal Mortality During the Covid-19 Pandemic: An Interrupted Time Series Analysis From Five Low- and Middle-Income Countries

Background

The Covid-19 pandemic led to widespread changes to health and social institutions. The effects of the pandemic on neonatal and infant health outcomes in low- and middle-income countries (LMICs) are poorly understood, and nationally representative data characterizing changes to health care and outcomes is only now emerging.

Methods

We used nationally representative survey data with vital status and perinatal care information on 2,959,203 children born in India, Madagascar, Cambodia, Nepal, and the Philippines. Using interrupted time series models, we estimated the change in neonatal mortality (death in first 30 days of life) and infant mortality (death in first year of life) following the start of the Covid-19 pandemic, controlling for granular location fixed-effects and seasonality.

Findings

We analyzed 2,935,052 births (146,820 deaths) before March 2020 and 24,151 births (799 deaths) after March 2020. We estimated that infant mortality increased by 9.9 deaths per 1,000 live births after March 2020 (95% CI 5.0, 15.0; p<0.01; 22% increase) and neonatal mortality increased by 6.7 deaths per 1,000 live births (95% CI 2.4, 11.1; p<0.01; 27% increase). We observe increased mortality in all study countries. We also estimated a 3.8 percentage point reduction in antenatal care use (95% CI -4.9, -2.7; p<0.01) and a 5.6 percentage point reduction in facility deliveries (95% CI -7.2, -4.0; p<0.01) during the pandemic.

Interpretation

Since the start of the Covid-19 pandemic, neonatal and infant mortality are higher than expected in five LMICs. Helping LMICs resume pre-pandemic declines in neonatal and infant mortality should be a major global priority.

Flaws and uncertainties in pandemic global excess death calculations

Several teams have been publishing global estimates of excess deaths during the COVID-19 pandemic. Here, we examine potential flaws and underappreciated sources of uncertainty in global excess death calculations. Adjusting for changing population age structure is essential. Otherwise, excess deaths are markedly overestimated in countries with increasingly aging populations. Adjusting for changes in other high-risk indicators, such as residence in long-term facilities, may also make a difference. Death registration is highly incomplete in most countries; completeness corrections should allow for substantial uncertainty and consider that completeness may have changed during pandemic years. Excess death estimates have high sensitivity to modelling choice. Therefore different options should be considered and the full range of results should be shown for different choices of pre-pandemic reference periods and imposed models. Any post-modelling corrections in specific countries should be guided by pre-specified rules. Modelling of all-cause mortality (ACM) in countries that have ACM data and extrapolating these models to other countries is precarious; models may lack transportability. Existing global excess death estimates underestimate the overall uncertainty that is multiplicative across diverse sources of uncertainty. Informative excess death estimates require risk stratification, including age groups and ethnic/racial strata. Data to-date suggest a death deficit among children during the pandemic and marked socioeconomic differences in deaths, widening inequalities. Finally, causal explanations require great caution in disentangling SARS-CoV-2 deaths, indirect pandemic effects and effects from measures taken. We conclude that excess deaths have many uncertainties, but globally deaths from SARS-CoV-2 may be the minority of calculated excess deaths.

On the gap between objective and perceived risks of COVID-19

A survey conducted by the German Socio-Economic Panel during the early phase of the SARS-CoV‑2 pandemic in spring 2020 showed that the perceived risks of SARS-CoV‑2 infection were a massive overestimation of the actual risks. A total of 5783 people (2.3% missing data) stated how likely they thought it was that SARS-CoV‑2 would cause a life-threatening illness in them in the next 12 months. The average subjective probability was 26%. We consider how such an overestimation could have occurred and how a more realistic risk assessment could be achieved in the population in a future pandemic. We show that qualitative attributes of the pandemic, the reporting of the media, and psychological features may have contributed to the overestimation of SARS-CoV‑2 risks. In its early stages, the SARS-CoV‑2 pandemic had qualitative characteristics known to lead to an overestimation of risks: The risks associated with the pandemic were new, unfamiliar, perceived as poorly controllable, and were taken involuntarily. Phenomena known from cognitive psychology such as the availability and anchor heuristics can also explain the overestimation of pandemic risks. Characteristics of media coverage such as the focus on individual fates and the associated neglect of the denominator also contributed to the gap between perceived and objective risk. In a potential future pandemic, people need to be vigilant but not in a panic. Better risk communication-for example, with better prepared figures and graphically presented percentages while avoiding the denominator neglect-could help the population to perceive risks of future pandemics more realistically.

Study of optimal vaccination strategies for early COVID-19 pandemic using an age-structured mathematical model: A case study of the USA

In this paper we study different vaccination strategies that could have been implemented for the early COVID-19 pandemic. We use a demographic epidemiological mathematical model based on differential equations in order to investigate the efficacy of a variety of vaccination strategies under limited vaccine supply. We use the number of deaths as the metric to measure the efficacy of each of these strategies. Finding the optimal strategy for the vaccination programs is a complex problem due to the large number of variables that affect the outcomes. The constructed mathematical model takes into account demographic risk factors such as age, comorbidity status and social contacts of the population. We perform simulations to assess the performance of more than three million vaccination strategies which vary depending on the vaccine priority of each group. This study focuses on the scenario corresponding to the early vaccination period in the USA, but can be extended to other countries. The results of this study show the importance of designing an optimal vaccination strategy in order to save human lives. The problem is extremely complex due to the large amount of factors, high dimensionality and nonlinearities. We found that for low/moderate transmission rates the optimal strategy prioritizes high transmission groups, but for high transmission rates, the optimal strategy focuses on groups with high CFRs. The results provide valuable information for the design of optimal vaccination programs. Moreover, the results help to design scientific vaccination guidelines for future pandemics.

Estimating the risk reduction of isolation on COVID-19 nonhousehold transmission and severe/critical illness in nonimmune individuals: September to November 2021

There is growing scientific interest in immunity mandates/passports (IMP) for viral diseases in light of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. IMP isolate those who remain nonimmune from various settings to reduce nonhousehold transmissions from the nonimmune and reduce severe/critical illness among the nonimmune. A major limitation in the scientific literature is that there are currently no methods to quantify how many nonimmune individuals need to be isolated to achieve these purported benefits. This paper develops a procedure for estimating the benefits of IMP using a novel variant of the number needed to treat which we call the number needed to isolate (NNI). We use data from the SARS-CoV-2 pandemic to demonstrate the properties and utility of the NNI and to inform the debate about IMP. We focus on data from the European Union, United Kingdom, United States, Canada, Australia, and Israel during the fall 2021 when the Delta (B.1.617.2) variant predominated.

SEIR models in the light of Critical Realism - A critique of exaggerated claims about the effectiveness of Covid 19 vaccinations

In a recent modeling study Watson et al. (Lancet Infect Dis 2022;3099:1-10) claim that Covid-19 vaccinations have helped to prevent roughly 14-20 million deaths in 2021. This conclusion is based on an epidemiological susceptible-exposed-infectious-recovered (SEIR) model trained on partially simulated data and yielding a reproduction number distribution which was then applied to a counterfactual scenario in which the efficacy of vaccinations was removed. Drawing on the meta-theory of Critical Realism, we point out several caveats of this model and caution against believing in its predictions. We argue that the absence of vaccinations would have significantly changed the causal tendencies of the system being modelled, yielding a different reproduction number than obtained from training the model on actually observed data. Furthermore, the model omits many important causal factors. Therefore this model, similar to many previous SEIR models, has oversimplified the complex interplay between biomedical, social and cultural dimensions of health and should not be used to guide public health policy. In order to predict the future in epidemic situations more accurately, continuously optimized dynamic causal models which can include the not directly tangible, yet real causal mechanisms affecting public health appear to be a promising alternative to SEIR-type models.

Estimates of COVID-19 deaths in Mainland China after abandoning zero COVID policy

BACKGROUND

China witnessed a surge of Omicron infections after abandoning 'zero COVID' strategies on 7 December 2022. The authorities report very sparse deaths based on very restricted criteria, but massive deaths are speculated.

METHODS

We aimed to estimate the COVID-19 fatalities in Mainland China until summer 2023 using the experiences of Hong Kong and of South Korea in 2022 as prototypes. Both these locations experienced massive Omicron waves after having had very few SARS-CoV-2 infections during 2020-2021. We estimated age-stratified infection fatality rates (IFRs) in Hong Kong and South Korea during 2022 and extrapolated to the population age structure of Mainland China. We also accounted separately for deaths of residents in long-term care facilities in both Hong Kong and South Korea.

RESULTS

Infection fatality rate estimates in non-elderly strata were modestly higher in Hong Kong than South Korea and projected 987,455 and 619,549 maximal COVID-19 deaths respectively, if the entire China population were infected. Expected COVID-19 deaths in Mainland China until summer 2023 ranged from 49,962 to 691,219 assuming 25-70% of the non-elderly population being infected and variable protection of elderly (from none to three-quarter reduction in fatalities). The main analysis (45% of non-elderly population infected and fatality impact among elderly reduced by half) estimated 152,886-249,094 COVID-19 deaths until summer 2023. Large uncertainties exist regarding potential changes in dominant variant, health system strain and impact on non-COVID-19 deaths.

CONCLUSIONS

The most critical factor that can affect total COVID-19 fatalities in China is the extent to which the elderly can be protected.

Differential COVID-19 infection rates in children, adults, and elderly: Systematic review and meta-analysis of 38 pre-vaccination national seroprevalence studies

Background

Debate exists about whether extra protection of elderly and other vulnerable individuals is feasible in COVID-19. We aimed to assess the relative infection rates in the elderly vs the non-elderly and, secondarily, in children vs adults.

Methods

We performed a systematic review and meta-analysis of seroprevalence studies conducted in the pre-vaccination era. We identified representative national studies without high risk of bias through SeroTracker and PubMed searches (last updated May 17, 2022). We noted seroprevalence estimates for children, non-elderly adults, and elderly adults, using cut-offs of 20 and 60 years (or as close to these ages, if they were unavailable) and compared them between different age groups.

Results

We included 38 national seroprevalence studies from 36 different countries comprising 826 963 participants. Twenty-six of these studies also included pediatric populations and twenty-five were from high-income countries. The median ratio of seroprevalence in elderly vs non-elderly adults (or non-elderly in general, if pediatric and adult population data were not offered separately) was 0.90-0.95 in different analyses, with large variability across studies. In five studies (all in high-income countries), we observed significant protection of the elderly with a ratio of <0.40, with a median of 0.83 in high-income countries and 1.02 elsewhere. The median ratio of seroprevalence in children vs adults was 0.89 and only one study showed a significant ratio of <0.40. The main limitation of our study is the inaccuracies and biases in seroprevalence studies.

Conclusions

Precision shielding of elderly community-dwelling populations before the availability of vaccines was indicated in some high-income countries, but most countries failed to achieve any substantial focused protection.

Registration

Open Science Framework (available at: https://osf.io/xvupr).