Tag: Respiratory

  • New tARC-seq method enhances precision in tracking SARS-CoV-2 mutations

    New tARC-seq method enhances precision in tracking SARS-CoV-2 mutations

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    In a recent study published in Nature Microbiology, researchers developed a targeted accurate ribonucleic acid (RNA) consensus sequencing (tARC-seq) approach to precisely determine severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) mutation frequency and types in cell culture and clinical samples.

    Study: Targeted accurate RNA consensus sequencing (tARC-seq) reveals mechanisms of replication error affecting SARS-CoV-2 divergence. Image Credit: Andrii Vodolazhskyi/Shutterstock.comStudy: Targeted accurate RNA consensus sequencing (tARC-seq) reveals mechanisms of replication error affecting SARS-CoV-2 divergence. Image Credit: Andrii Vodolazhskyi/Shutterstock.com

    Background

    SARS-CoV-2 replicates via RNA-dependent RNA polymerases (RdRp), which are prone to errors. Monitoring replication mistakes is critical to understanding the virus’s development, but existing approaches are insufficient to identify infrequent de novo ribonucleic acid alterations.

    During the coronavirus disease 2019 (COVID-19) pandemic, SARS-CoV-2 mutation rates ranged from 10−6 to 10−4 per base per cell. Exonuclease proofreading activity boosts mutation rates, leading to a mean of two mutations in each genome monthly.

    About the study

    In the present study, researchers created tARC-seq to investigate the mechanisms of replication errors impacting the divergence of SARS-CoV-2.

    The tARC-seq approach combines ARC-seq characteristics with hybrid capturing technology to enhance targets, allowing in-depth variant interrogation of these samples.

    The researchers used tARC-seq to discover RNA variations in the original SARS-CoV-2 wild-type (WT) strain, SARS-CoV-2 Alpha and Omicron variants, and clinical and Omicron samples.

    The researchers sequenced SARS-CoV-2 wild-type RNA following 4.0 infectious cycles, generating 9.0 × 105 plaque-forming units (pf.u.) of SARS-CoV-2 RNA. They added E. coli messenger RNA (mRNA) as an enzyme carrier to prepare libraries. Hybrid capture detected E. coli RNA in the genetic library, which the researchers examined individually and used as internal controls.

    To further investigate selections in tARC sequencing data, the researchers mapped non-sense-type, synonymous, and non-synonymous variant frequencies identified by tARC sequencing across mon-structural protein 12 (nsp12), a critical gene that encodes SARS-CoV-2 RdRp.

    They determined the evolutionary action (EA) scorings and variation frequencies for nonsense-type and non-synonymous single-nucleotide polymorphisms (SNPs) found in SARS-CoV-2 spike (S) and nsp12. They also computed the average mutational frequencies of open reading frames (ORFs) in the wild-type virus, broken down by mutational type and base alterations.

    The researchers investigated the random distribution of RNA variants across the SARS-CoV-2 genome using location-based estimations and nucleotide identity analysis. They also used tARC-seq on two clinical samples to look for de novo mutations caused by spontaneous infection.

    They matched the top ten most common C>TT and G>AA mutations to known A3A editing sites in the wild-type virus. The researchers examined all SID occurrences with ≥2 nucleotides of complementarity between donor and acceptor sites downstream in WT, Alpha, and Omicron. They investigated the genome-wide prevalence of TC>TT mutations in WT-Vero cells.

    Results

    Researchers found 2.7 × 10−5 (mean) de novo mistakes per cycle in the SARS-CoV-2 virus, with C>T biases not primarily due to apolipoprotein B mRNA-editing enzyme, catalytic polypeptide (APOBEC) editing.

    They identified cool and hot areas across the genome, according to low or high GC concentration, and highlighted transcription regulatory regions as sites more prone to mistakes. The tARC-seq approach enables the detection of template switches such as deletions, insertions, and complicated alterations.

    The WT virus has 1.1 × 10−4 RNA variations per base, with base substitutions accounting for the majority (8.4 × 10−5), followed by insertions (2.5 × 10−6) and deletions (2.1 × 10−5). The G > A and C > T transitions dominate the viral mutation landscape, contributing 9.0% and 44% of all occurrences.

    The mutational spectrum and frequency of wild-type SARS-CoV-2 off-target reads differ from those of E. coli, showing that these mutational events are genuine viral alterations rather than library preparation artifacts.

    Random distributions and comparable rates of all three nsp12 mutation types suggest that most RNA variations found by tARC sequencing were de novo-type replication mistakes. The researchers found no differences in variant frequencies between the SNPs with low evolutionary action scores (estimated neutral effects) and those with high EA values (estimated harmful impacts) over the base substitution range, indicating that selection has a limited influence.

    Variant rates vary considerably between locations, with 643 loci in WT viral duplicates showing considerably higher base substitution frequencies and 80 recurring throughout both WT replicates.

    The researchers found no overlap between the highest-frequency tARC sequencing C>TT hotspots and A3A editing regions in the wild-type virus. The tARC sequencing C>TT frequencies at A3A editing regions were lower than the C>TT frequencies of the highest-frequency tARC sequencing C>TT hotspots by one to two orders of magnitude.

    The study highlighted tARC-seq, a specialized sequencing approach, to investigate the replication mistakes that influence SARS-CoV-2 divergence. This approach selectively reads specific RNA molecules to generate a consensus sequence, allowing researchers to detect and evaluate minor differences and mistakes during viral replication.

    It may also detect de novo insertions and deletions in SARS-CoV-2 resulting from cell culture infection, corroborating worldwide pandemic sequencing findings.

    The study also discovered that SARS-CoV-2 possesses exonuclease proofreading capabilities, which may aid in understanding ExoN’s critical function.

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  • Global study reveals mismatch in COVID-19 treatment guidelines with WHO standards

    Global study reveals mismatch in COVID-19 treatment guidelines with WHO standards

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    In a recent study published in the journal BMJ Global Health, researchers compare coronavirus disease 2019 (COVID-19) management guidelines to those published by the World Health Organization (WHO) among different member states.

    Study: Comparison of WHO versus national COVID-19 therapeutic guidelines across the world: not exactly a perfect match. Image Credit: Cryptographer / Shutterstock.com Study: Comparison of WHO versus national COVID-19 therapeutic guidelines across the world: not exactly a perfect match. Image Credit: Cryptographer / Shutterstock.com

    Global disparities in managing COVID-19

    Since the beginning of the COVID-19 pandemic, the therapeutic landscape has changed dramatically, with increasing vaccine coverage, more frequent infections, and viral evolution reducing pathogenicity.

    However, the poorest nations have often suffered the worst societal and economic consequences of the pandemic. Variations in treatment recommendations between nations have not been publicly measured or thoroughly investigated, with uneven administration of effective vaccines and medications.

    About the study

    In the present study, researchers performed a retrospective analysis of each nation’s guidelines (NGs) for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection therapy using the Reporting Checklist for Public Versions of Guidelines (RIGHT-PVG) survey checklist and a developed comparison metric based on WHO standards.

    Between September and November 2022, data for guidelines compiled by the Ministries of Health, National Infectious Disease websites, COVID-19 Clinical Research Coalition, and key opinion researchers and leaders were analyzed. The most recent national guidelines for SARS-CoV-2 infection therapy were stratified by severity while eliminating local or regional hospital guidelines, vaccination policies, infection control measures, and those without pharmacological recommendations. Any information about COVID-19 complications, such as bacterial pneumonia and thrombosis, was eliminated from the guidelines.

    Eight physicians and one clinical nurse extracted information, including publication dates, language, body, illness severity rating, prescribed medications, regulatory status, and regulatory data collected by national-level authorities. Antibiotic suggestions were omitted unless intended for SARS-CoV-2 infection.

    Countries were categorized into five areas based on WHO classification, which included the European Region (EUR), the African Region (AFR), the Southeast Asian Region (SEAR), the Region of the Americas (AMR), the Western Pacific, and Eastern Mediterranean Region (EMR). Data on treatment recommendations from the relevant health authorities in each nation were obtained and analyzed.

    The alignment between national recommendations and the WHO’s 11th iteration of recommendations was determined. To this end, positive numeric weights were assigned to suggestions that adhered to WHO criteria, whereas negative weights were assigned to those that discouraged or included non-evidence-based advice. The final score reflected the country’s adherence to WHO recommendations.

    Therapeutic suggestions and illness severity categories were evaluated using the World Bank’s gross domestic product (GDP) per capita, Human Development Index, and Global Health Security Index.

    Study findings

    COVID-19 treatment guidelines were obtained from 109 WHO member countries and exhibited significant variability in recommendations and illness severity categories. Therapeutic advice in some NGs deviated significantly from WHO recommendations. In late 2022, 93% of national guidelines recommended one or more medications that failed randomized trials and were unauthorized by the WHO. 

    Despite robust evidence of treatment benefits, approximately 10% of NGs did not recommend corticosteroids for severe sickness. Stratifying by yearly GDP, Human Development Index (HDI), and Global Health Security Index (GHS), NGs from low-resource countries showed the highest gap.

    The median population of nations with acquired recommendations was 14 million, with 70% of guidelines implemented in EUR, followed by the AFR at 53%. Moreover, 65% of guidelines were released six months before the WHO protocols, with 31% issued or revised over the same period.

    About 84% of recommendations did not describe COVID-19 severity according to WHO definitions, with only 9.2% of guidelines incorporating severity criteria equivalent to those used by the WHO. The range of therapies included in the recommendations ranged from one to 22, with the median being five, regardless of severity. Comparatively, WHO guidelines prescribe ten medicines.

    In late 2022, several NGs continued to advocate medications that the WHO had previously cautioned against, with some regional variance. Taken together, 105 NGs recommended at least one WHO-approved therapy, with 71% of medications appropriate for the severity of SARS-CoV-2 infection.

    Corticosteroids were the most widely recommended medicine, with 92% of NGs using these therapeutics and 80% indicating their use for the same illness severity as the WHO. Moreover, 23% and 79% of the 72 NGs recommended remdesivir and tocilizumab for mild COVID-19, respectively.

    Conclusions

    Based on the study findings, COVID-19 has resulted in considerable variance in NG recommendations, with many advocating inefficient, costly, and inaccessible remedies, particularly in low-resource areas.

    The study findings emphasize the importance of formalizing procedures for generating NGs for infectious diseases to ensure their development based on the best available data. Recommendations provided by NGs varied greatly, some of which did not have any national guidelines, omitted WHO-recommended medicines, proposed untested medications, or used different SARS-CoV-2 infection severity classifications.

    Journal reference:

    • Cokljat, M., Cruz, C. V., Carrara, V. I., et al. (2024). Comparison of WHO versus national COVID-19 therapeutic guidelines across the world: not exactly a perfect match. BMJ Global Health. doi:10.1136/bmjgh-2023-014188

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  • Higher zinc intake linked to lower asthma risk in overweight kids

    Higher zinc intake linked to lower asthma risk in overweight kids

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    In a recent study published in the World Allergy Organization Journal, researchers examined the relationship between asthma occurrence and intake of dietary zinc among children and adolescents overweight and obesity, utilizing data from the National Health and Nutrition Examination Survey (NHANES) spanning 2011 to 2020.

    The study suggests that higher dietary zinc intake is associated with a reduced risk of asthma in this population, highlighting the potential role of zinc in mitigating asthma risk among children and adolescents.

    Study: Association between dietary zinc intake and asthma in overweight or obese children and adolescents: A cross-sectional analysis of NHANES. Image Credit: Danijela Maksimovic / ShutterstockStudy: Association between dietary zinc intake and asthma in overweight or obese children and adolescents: A cross-sectional analysis of NHANES. Image Credit: Danijela Maksimovic / Shutterstock

    Background

    Childhood asthma, a prevalent respiratory condition, poses a growing global concern, with increasing rates among children and adolescents. This trend is compounded by the rising prevalence of obesity in this demographic, which exacerbates asthma symptoms and reduces treatment effectiveness.

    Recent research has focused on the role of nutrients, particularly zinc, in asthma management due to its involvement in inflammation and oxidative stress regulation. Prior studies yielded inconsistent results regarding the association between asthma and zinc intake.

    To address this gap, a study utilizing NHANES data examined the relationship between dietary zinc intake and asthma among overweight or obese children and adolescents, hypothesizing that asthmatic individuals in this group would have lower zinc intake than their healthy counterparts.

    About the study

    The study utilized data from NHANES, covering four survey cycles from 2011 to 2020, to investigate the relationship between asthma and dietary zinc intake among overweight or obese adolescents and children in the United States.

    Participants under 20 years old were included, with those having incomplete data or falling under the categories of underweight or normal weight being excluded.

    Asthma status was determined based on participants’ self-reported history of diagnosis and recent asthma attacks. Dietary zinc intake was assessed through 24-hour dietary recall interviews and categorized into quartiles.

    In multivariate logistic regression models, various potential covariates, including demographic factors, family history of asthma, and dietary factors, were considered and adjusted for.

    Restricted cubic splines were used to analyze the relationship between zinc intake and asthma while controlling for these covariates.

    Additionally, multivariate logistic regression analysis was performed to evaluate potential interactions between dietary zinc and other factors such as sex, age, and family history of asthma.

    Sensitivity analyses were conducted to validate the robustness of the findings.

    Findings

    The final sample included 4,597 individuals, 20, with 963 reporting asthma. Participants with incomplete asthma questionnaires, incomplete dietary zinc intake data, or normal weight were excluded.

    The median age was 11 years, and 20.9% of the participants were diagnosed with asthma; 49.6% reported their gender as male. Higher zinc intake was correlated with male gender, non-Hispanic white ethnicity, lower household income, absence of familial asthma history, and no dietary supplement use.

    After controlling for various factors, including demographics and dietary intake, a significant inverse relationship was found between dietary zinc intake and asthma.

    The adjusted odds ratios for asthma in the second, third, and fourth quartiles were 0.78, 0.76, and 0.71, respectively, compared to the lowest zinc intake quartile.

    Stratified analyses showed no significant interactions, and sensitivity analyses confirmed the robustness of the findings. Furthermore, dietary zinc intake was inversely associated with recent asthma attacks and remained so after adjusting for asthma treatment.

    These results suggest a consistent negative linear trend between the intake of dietary zinc and the risk of developing asthma in children and adolescents who are overweight or obese.

    Conclusions

    Researchers found a significant inverse association between dietary zinc intake and asthma risk, even after controlling for various factors such as demographics and dietary intake. This association remained robust across stratified and sensitivity analyses, indicating its reliability.

    Previous research has shown inconsistent conclusions regarding the relationship between zinc levels and asthma, with most focusing on body fluid zinc levels rather than dietary intake.

    However, the current study, focusing on dietary zinc intake in a large population of overweight or obese children and adolescents, demonstrated a clear inverse correlation with asthma risk.

    The study highlighted potential pathways through which zinc may influence asthma, including its antioxidant properties, immunomodulatory effects, and anti-inflammatory effects. These mechanisms suggest that zinc could be a potential therapeutic target for alleviating asthma symptoms among people with overweight or obesity.

    The study’s strengths include its large sample size, focus on overweight or obese children and adolescents, and use of diverse statistical methods. However, limitations such as potential residual confounding effects, reliance on self-reported asthma diagnosis, and the cross-sectional design prevent causal inferences.

    These results emphasize the importance of considering nutritional factors in asthma management and warrant further research into the therapeutic potential of zinc supplementation.

    Future studies using prospective cohort designs and randomized controlled trials may shed further light on the causal effect of dietary zinc intake on alleviating asthma in this population.

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  • WHO publishes report introducing updated terminology for airborne pathogens

    WHO publishes report introducing updated terminology for airborne pathogens

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    Following consultation with public health agencies and experts, the World Health Organization (WHO) publishes a global technical consultation report introducing updated terminology for pathogens that transmit through the air. The pathogens covered include those that cause respiratory infections, e.g. COVID-19, influenza, measles, Middle East respiratory syndrome (MERS), severe acute respiratory syndrome (SARS), and tuberculosis, among others.

    The publication, entitled “Global technical consultation report on proposed terminology for pathogens that transmit through the air”, is the result of an extensive, multi-year, collaborative effort and reflects shared agreement on terminology between WHO, experts and four major public health agencies: Africa Centres for Disease Control and Prevention; Chinese Center for Disease Control and Prevention; European Centre for Disease Prevention and Control; and United States Centers for Disease Control and Prevention. This agreement underlines the collective commitment of public health agencies to move forward together on this matter. 

    The wide-ranging consultation was conducted in multiple steps in 2021-2023 and addressed a lack of common terminology to describe the transmission of pathogens through the air across scientific disciplines. The challenge became particularly evident during the COVID-19 pandemic as experts from various sectors were required to provide scientific and policy guidance. Varying terminologies highlighted gaps in common understanding and contributed to challenges in public communication and efforts to curb the transmission of the pathogen.

    Together with a very diverse range of leading public health agencies and experts across multiple disciplines, we are pleased to have been able to address this complex and timely issue and reach a consensus. The agreed terminology for pathogens that transmit through the air will help set a new path for research agendas and implementation of public health interventions to identify, communicate and respond to existing and new pathogens.”


    Dr Jeremy Farrar, WHO Chief Scientist

    The extensive consultation resulted in the introduction of the following common descriptors to characterize the transmission of pathogens through the air (under typical circumstances):

    • Individuals infected with a respiratory pathogen can generate and expel infectious particles containing the pathogen, through their mouth or nose by breathing, talking, singing, spitting, coughing or sneezing. These particles should be described with the term ‘infectious respiratory particles’ or IRPs.
    • IRPs exist on a continuous spectrum of sizes, and no single cut off points should be applied to distinguish smaller from larger particles. This facilitates moving away from the dichotomy of previously used terms: ‘aerosols’ (generally smaller particles) and ‘droplets’ (generally larger particles).

    The descriptor ‘through the air’ can be used in a general way to characterize an infectious disease where the main mode of transmission involves the pathogen travelling through the air or being suspended in the air. Under the umbrella of ‘through the air transmission’, two descriptors can be used:

    1. Airborne transmission or inhalation, for cases when IRPs are expelled into the air and inhaled by another person. Airborne transmission or inhalation can occur at a short or long distance from the infectious person and distance depends on various factors (airflow, humidity, temperature, ventilation etc). IRPs can theoretically enter the body at any point along the human respiratory tract, but preferred sites of entry may be pathogen-specific.

    2. Direct deposition, for cases when IRPs are expelled into the air from an infectious person, and are then directly deposited on the exposed mouth, nose or eyes of another person nearby, then entering the human respiratory system and potentially causing infection.

    “This global technical consultation process was a concerted effort of many influential and experienced experts,” said Dr Gagandeep Kang, Christian Medical College, Vellore, India who is a Co-Chair of the WHO Technical Working Group. “Reaching consensus on these terminologies bringing stakeholders in an unprecedented way was no small feat. Completing this consultation gives us a new opportunity and starting point to move forward with a better understanding and agreed principles for diseases that transmit through the air,” added Dr Yuguo Li from the University of Hong Kong, Hong Kong SAR (China), who also co-chaired the Technical Working Group.

    This consultation was the first phase of global scientific discussions led by WHO. Next steps include further technical and multidisciplinary research and exploration of the wider implementation implications of the updated descriptors. 

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  • Aging affects immune response and virus dynamics in COVID-19 patients, study finds

    Aging affects immune response and virus dynamics in COVID-19 patients, study finds

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    In a recent study published in the journal Science Translational Medicine, researchers investigated the impact of aging on immune response, viral dynamics, and nasal microbiome in 1031 hospitalized coronavirus disease 2019 (COVID-19) patients, using advanced profiling techniques to understand age-related differences in disease severity and immune function.

    Study: Host-microbe multiomic profiling reveals age-dependent immune dysregulation associated with COVID-19 immunopathology. Image Credit: Corona Borealis Studio / ShutterstockStudy: Host-microbe multiomic profiling reveals age-dependent immune dysregulation associated with COVID-19 immunopathology. Image Credit: Corona Borealis Studio / Shutterstock

    Background 

    Age is a significant risk factor for severe COVID-19 outcomes, with older adults facing drastically higher risks of complications and mortality than younger individuals. Despite high vaccination rates, older adults are still profoundly vulnerable. Aging correlates with elevated levels of inflammatory cytokines, like interleukin-6 (IL-6), which are critical markers of COVID-19 severity, hinting at a link between aging and disease pathophysiology. Studies show that aging dampens both innate and adaptive immune responses, including reduced type I interferon (IFN) production. Additionally, older adults show enhanced inflammatory responses and impaired immune signaling when infected with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). Further research is needed to fully understand the complex interactions between aging, immune response variations, and COVID-19 severity to improve treatment strategies and outcomes for older populations.

    About the study 

    The present study utilized data from 1,031 participants enrolled in the IMmunoPhenotyping Assessment in a COVID-19 Cohort (IMPACC) observational cohort, which involved 20 hospitals across 15 medical centers in the United States from May 5, 2020, to March 19, 2021. It involved hospitalized individuals with reverse transcription polymerase chain reaction (rt-PCR) confirmed SARS-CoV-2 infections, displaying typical COVID-19 symptoms. Blood and respiratory tract samples were collected within 72 hours of hospitalization, following a standardized protocol across participating institutions. Ethical approval was granted under the public health surveillance exception, with participant consent for follow-up involvement and data usage.

    Statistical analysis was performed using R software. Initial assessments were done within 72 hours of hospital admission, followed by longitudinal evaluations at subsequent visits. Data analysis applied various statistical methods depending on the data type and required adjustments for factors like age, sex, and baseline disease severity. For longitudinal studies, age groups were divided into quintiles and analyzed for changes in viral abundance and immune response, employing linear and generalized additive models to account for the observed non-linear patterns. All p-values were adjusted using the Benjamini-Hochberg method, considering results statistically significant at p < 0.05.

    Study results 

    The study involved analyzing blood and nasal swab specimens from 1,031 vaccine-naïve adults hospitalized with COVID-19. These participants were part of the IMPACC cohort, sourced from 20 hospitals across the United States. They were categorized into five age quintiles, ranging from 18 to 96 years, with each group comprising between 187 and 223 individuals. Samples were collected at the time of hospital admission and during up to five follow-up visits. The distribution of ages showed that older individuals were often more severely affected by the disease, evident in both the initial severity of symptoms and the outcomes, including mortality.

    At the initial hospital visit, typically within 72 hours of admission, a range of diagnostic assays was conducted. These included transcriptional profiling of peripheral blood mononuclear cells (PBMCs) and nasal swabs, serum inflammatory protein profiling, whole blood mass cytometry (CyTOF), nasal metatranscriptomics, and SARS-CoV-2 antibody (Ab) assays. A significant finding from these initial tests was that older adults displayed higher viral loads and experienced delayed viral clearance compared to younger patients. Moreover, age-related differences in immune cell populations were noted, with older adults showing higher proportions of various monocyte subtypes and activated T cells but lower levels of naïve T and B cells.

    The study’s longitudinal analysis revealed that these differences persisted over time, affecting viral load dynamics, antibody titers, and immune response. Specifically, the eldest participants not only retained high levels of the virus longer but also showed more significant fluctuations in antibody levels over time. Additionally, immune cell analysis by CyTOF highlighted that with advancing age, certain immune cell types, including different monocyte classes and differentiated natural killer cells, increased, suggesting shifts in immune system composition and function with age.

    Changes in cytokine and chemokine levels measured in the participants’ serum further underscored the impact of aging on the immune response. Older individuals showed elevated levels of inflammatory markers at hospital admission, which were linked to more severe disease outcomes. 

    Moreover, the analysis extended to the nasal microbiome and upper respiratory gene expression, revealing age-associated changes in the microbial composition and host gene activity. Changes in Toll-like receptor signaling and other immune pathways were evident, suggesting that older adults experience different immune modulations, possibly influencing their susceptibility to severe outcomes.

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  • Global disease burden study highlights COVID-19 impact and health inequities

    Global disease burden study highlights COVID-19 impact and health inequities

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    Rates of early death and poor health caused by HIV/AIDS and diarrhea have been cut in half since 2010, and the rate of disease burden caused by injuries has dropped by a quarter in the same time period, after accounting for differences in age and population size across countries, based on a new study published in The Lancet. The study measures the burden of disease in years lost to early death and poor health. The findings indicate that total rates of global disease burden dropped by 14.2% between 2010 and 2019. However, the researchers found that the COVID-19 pandemic interrupted these downward trends: rates of disease burden increased overall since 2019 by 4.1% in 2020 and by 7.2% in 2021. This is the first study to measure premature death and disability due to the COVID-19 pandemic globally and compare it to other diseases and injuries. 

    The study reveals how healthy life expectancy, which is the number of years a person can expect to live in good health, rose from 61.3 years in 2010 to 62.2 years in 2021. Pinpointing the factors driving these trends, the researchers point to rapid improvements within the three different categories of disease burden: communicable, maternal, neonatal, and nutritional diseases; non-communicable diseases; and injuries. Among communicable, maternal, neonatal, and nutritional diseases, the burden of disease declined for neonatal disorders (diseases and injuries that appear uniquely in the first month of life), lower respiratory infections, diarrhea, malaria, tuberculosis, and HIV/AIDS between 2010 and 2021, ranging from reductions of 17.1% for neonatal disorders to 47.8% for HIV/AIDS. In the category of non-communicable diseases, disease burden from stroke dropped by 16.9%, while disease burden from ischemic heart disease fell by 12.0% during this period. 

    For injuries, the years of healthy life lost due to road injuries was slashed by nearly a quarter (22.9%), while disease burden from falls was reduced by 6.9%. Progress in reducing disease burden varied by countries’ Socio-demographic Index – a measure of income, fertility, and education – underscoring inequities. For example, the burden of disease due to stroke dropped by 9.6% from 2010 to 2021 in countries with the lowest Socio-demographic Index, but it declined faster – by 24.9% – among countries with higher Socio-demographic Index. 

    Our study illuminates both the world’s successes and failures. It demonstrates how the world made huge strides in expanding treatment for HIV/AIDS and combatting vaccine-preventable diseases and deaths among children under 5. At the same time, it shows how COVID-19 exacerbated inequities, causing the greatest disease burden in countries with the fewest resources, where health systems were strained and vaccines were difficult to secure. Governments should prioritize equitable pandemic preparedness planning and work to preserve the momentum that we’ve seen in improving children’s health.” 


    Dr. Alize Ferrari, Affiliate Associate Professor at the Institute for Health Metrics and Evaluation (IHME) at the University of Washington, Honorary Associate Professor at the School of Public Health at the University of Queensland, and co-first author of the study

    The research presents updated estimates from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021. The GBD 2021 study analyzes incidence, prevalence, years lived with disability (years lived in less-than-ideal health), and disability-adjusted life years (lost years of healthy life) at global, regional, national, and subnational levels. It presents estimates of health and health loss in age-adjusted rates and total rates per 100,000 people. The study provides globally comparable measures of healthy life expectancy and is the first study to fully evaluate burden of disease amid the first two years of the COVID-19 pandemic. COVID-19 was the single leading cause of disease burden worldwide in 2021, accounting for 7.4% of total disease burden globally. 

    The study also examined how the COVID-19 pandemic affected males and females differently. The researchers found that males were more likely than females to die of COVID-19; the age-standardized disease burden rate for COVID-19 among males was nearly twice that of females. However, the secondary effects of the COVID-19 pandemic, including long COVID and mental disorders, hit females hardest. For example, females were twice as likely as males to develop long COVID. Depression, which increased sharply during the pandemic, was most likely to affect females between ages 15 and 65. Looking at differences between age groups, COVID-19 caused the most disease burden in older adults. For COVID-19, adults 70 years and older had more than double the levels of disease burden compared to adults between the ages of 50 and 69. 

    The study highlights not only the diseases and injuries that cut life short and cause poor health, and how the burden of disease from different causes has changed over time, but also examines how these patterns differ across countries and regions. “In essence,” the authors write, the study “provides a comprehensive toolkit to inform and enhance decision-making processes across various levels of governance and practice.” 

    GBD 2021 shines a light on the different causes of disease burden, showing which ones have improved and which are stagnating or worsening. It also tallies the number of years that people are living healthy lives. Healthy life expectancy rose significantly in 59 countries and territories between 2010 and 2021, with the greatest improvements in countries ranking lowest on the Socio-demographic Index, jumping from 52.2 years in 2010 to 54.4 years in 2021. In contrast, healthy life expectancy showed minimal change among countries in the highest levels of the Socio-demographic Index, decreasing slightly from 68.9 years in 2010 to 68.5 years in 2021. The findings on healthy life expectancy demonstrate that even though people are living longer lives all over the world, they aren’t spending all those years in good health. The researchers found that the main causes of poor health were low back pain, depressive disorders, and headache disorders. 

    “With low back pain, the leading cause of poor health globally, we see that the existing treatments aren’t working well to address it,” said Dr. Damian Santomauro, Affiliate Assistant Professor of Health Metrics Sciences at IHME; Stream Lead at Queensland Centre for Mental Health Research; Adjunct Fellow at the School of Public Health at the University of Queensland; and co-first author of the study. “We need better tools to manage this major cause of global disease burden.” 

    “In contrast, for depressive disorders, we know what can work: therapy, medication, or both in combination for an adequate period of time. However, most people in the world have little or no access to treatment, unfortunately,” he said. “Considering how depression increased dramatically during the COVID-19 pandemic, it’s urgent to ensure that everyone with this disorder can get treatment.” 

    Another way to understand what is making people ill is by looking at which diseases are growing fastest. GBD 2021 reveals that diabetes experienced the most rapid growth among the different causes of poor health, what the researchers call years lived with disability. Age-adjusted years lived with disability due to diabetes rose by 25.9% between 2010 and 2021. Poor health from diabetes increased in every country and territory that the researchers studied. 

    “Diabetes is a major contributor to stroke and ischemic heart disease, which are among the top three causes of disease burden worldwide,” said Dr. Theo Vos, Professor Emeritus at IHME and one of the study’s senior authors. “Without intervention, more than 1.3 billion people in the world will be living with diabetes by 2050. To counter the threat of diabetes, we must ensure that people in all countries can access preventive care and treatment, including to anti-obesity medications, which can lower a person’s risk of developing diabetes.” 

    Source:

    Journal reference:

    GBD 2021 Diseases and Injuries Collaborators., (2024) Global incidence, prevalence, years lived with disability (YLDs), disability-adjusted life-years (DALYs), and healthy life expectancy (HALE) for 371 diseases and injuries in 204 countries and territories and 811 subnational locations, 1990–2021: a systematic analysis for the Global Burden of Disease Study 2021. The Lancet. doi.org/10.1016/S0140-6736(24)00757-8.

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  • Antibiotics ineffective for cough treatment in lower respiratory tract infections

    Antibiotics ineffective for cough treatment in lower respiratory tract infections

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    Use of antibiotics provided no measurable impact on the severity or duration of coughs even if a bacterial infection was present, finds a large, prospective study of people who sought treatment in U.S. primary or urgent care settings for lower-respiratory tract infections.

    The study by researchers at Georgetown University Medical Center and colleagues appeared April 15, 2024, in the Journal of General Internal Medicine.

    Upper respiratory tract infections usually include the common cold, sore throat, sinus infections and ear infections and have well established ways to determine if antibiotics should be given. Lower respiratory tract infections tend to have the potential to be more dangerous, since about 3% to 5% of these patients have pneumonia. But not everyone has easy access at an initial visit to an X-ray, which may be the reason clinicians still give antibiotics without any other evidence of a bacterial infection. Plus, patients have come to expect antibiotics for a cough, even if it doesn’t help. Basic symptom-relieving medications plus time brings a resolution to most people’s infections.”


    Dan Merenstein, MD, professor of family medicine at Georgetown University School of Medicine

    The antibiotics prescribed in this study for lower tract infections were all appropriate, commonly used antibiotics to treat bacterial infections. But the researchers’ analysis showed that of the 29% of people given an antibiotic during their initial medical visit, there was no effect on the duration or overall severity of cough compared to those who didn’t receive an antibiotic.

    “Physicians know, but probably overestimate, the percentage of lower tract infections that are bacterial; they also likely overestimate their ability to distinguish viral from bacterial infections,” says Mark H. Ebell, MD, MS, a study author and professor in the College of Public Health at the University of Georgia. “In our analysis, 29% of people were prescribed an antibiotic while only 7% were given an antiviral. But most patients do not need antivirals as there exist only two respiratory viruses where we have medications to treat them: influenza and SARS-COV-2. There are none for all of the other viruses.”

    To determine if there was an actual bacterial or viral infection present, beyond the self-reported symptoms of a cough, the investigators confirmed the presence of pathogens with advanced lab tests to look for microbiologic results classified as only bacteria, only viruses, both virus and bacteria, or no organism detected. Very importantly, for those with a confirmed bacterial infection, the length of time until illness resolution was the same for those receiving an antibiotic versus those not receiving one – about 17 days.

    Overuse of antibiotics can result in dizziness, nausea, diarrhea, and rash along with about a 4% chance of serious adverse effects including anaphylaxis, which is a severe, life-threatening allergic reaction; Stevens-Johnson syndrome, a rare, serious disorder of the skin and mucous membranes; and Clostridioides difficile-associated diarrhea. Another significant concern of the overuse of antibiotics is resistance. The World Health Organization released a statement on April 4, 2024, stating: “Uncontrolled antimicrobial resistance [due to the overuse of antibiotics] is expected to lower life expectancy and lead to unprecedented health expenditure and economic losses.”

    “We know that cough can be an indicator of a serious problem. It is the most common illness-related reason for an ambulatory care visit, accounting for nearly 3 million outpatient visits and more than 4 million emergency department visits annually,” says Merenstein. “Serious cough symptoms and how to treat them properly needs to be studied more, perhaps in a randomized clinical trial as this study was observational and there haven’t been any randomized trials looking at this issue since about 2012.”

    In addition to Merenstein and Ebell, the other co-author is Bruce Barrett MD, PhD at the University of Wisconsin, Madison,

    This work was supported by an AHRQ grant R01HS025584.

    Source:

    Journal reference:

    Merenstein, D.J., et al. (2024) Antibiotics Not Associated with Shorter Duration or Reduced Severity of Acute Lower Respiratory Tract Infection. Journal of General Internal Medicine. doi.org/10.1007/s11606-024-08758-y.

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  • Study reveals how SARS-CoV-2 hijacks lung cells to drive COVID-19 severity

    Study reveals how SARS-CoV-2 hijacks lung cells to drive COVID-19 severity

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    In a recent study published in the Journal of Experimental Medicine, researchers identified the cellular tropism and transcriptome consequences of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) by infecting human lung tissue and using single-cell ribonucleic acid sequencing (scRNA-seq) to rebuild the transcriptional program in “infection pseudotime” for distinct lung cell types.

    Lower respiratory infections, such as coronavirus disease 2019 (COVID-19), are a leading cause of death worldwide, producing pneumonia and acute respiratory distress syndrome. Understanding their early phases is difficult. Researchers used classical histopathological approaches and single-cell multi-omic profiling to infer early phases in human pathogenesis from lung lavage, biopsy, or autopsy materials. These approaches reveal a thorough picture of COVID-19 pneumonia at unparalleled cellular and molecular resolution, implying infection models including alveolar epithelium, capillaries, macrophages, and myeloid cells.

    Study: Interstitial macrophages are a focus of viral takeover and inflammation in COVID-19 initiation in human lung. Image Credit: Dotted Yeti / ShutterstockStudy: Interstitial macrophages are a focus of viral takeover and inflammation in COVID-19 initiation in human lung. Image Credit: Dotted Yeti / Shutterstock

    About the study

    In the present study, researchers developed an experimental COVID-19 model to investigate early molecular processes and pathogenic mechanisms of SARS-CoV-2 infection at the cellular level in native tissues of the human lung.

    The researchers established SARS-CoV-2’s cellular tropism and its unique and dynamic impacts on host cellular gene expression in specific types of lung cells. Prominent targets were lung-resident macrophages, of which one SARS-CoV-2 takes over transcriptomes, inducing a targeted host interferon (IFN) antiviral program, and several chemokines and pro-fibrotic and pro-inflammatory and cytokines signaling to various structural and immunological cells of the lung.

    To determine the early stages of COVID-19 in human lungs, the researchers sliced lung tissue obtained from surgical specimens or organ donor individuals into thick sections and used them for tissue culture analysis. Subsequently, they exposed the tissues to the SARS-CoV-2 USA-WA1 2020 strain at 1.0 multiplicity of infection (MOI) for two hours before allowing the SARS-CoV-2 infection to continue for two to three days. They performed a plaque test on culture supernatants.

    The researchers separated the slices and examined them by scRNA-seq to evaluate host and viral genetic expression during the SARS-CoV-2 infection. They also examined the viral RNA molecules’ junctional structure and processing by analyzing the scRNA-seq dataset with the SICILIAN framework. They used molecular atlas markers to distinguish lung cell types in healthy lung slices and measure viral RNA levels in infected cells.

    The team performed multiplexed single-molecule fluorescence in situ hybridization (smFISH) to confirm lung cell tropism findings and show infected cells. They used single-cell gene expression patterns to identify cellular targets for inflammatory and pro-fibrotic signals elicited by the SARS-CoV-2 infection of a-IMs. They devised a technique for purifying macrophage populations from human lungs with a SARS-CoV-2 spike (S) protein-pseudotyped lentivirus (lenti-S-NLuc-tdT) to investigate lung macrophage entrance routes.

    The researchers productively infected human lung slices cultivated ex vivo with SARS-CoV-2, with production rising between 24 and 72 hours of culture. They heat-inactivated, ultraviolet (UV)-treated, or administered 10.0 µM remdesivir, an RNA-dependent RNA polymerase inhibitor used as a COVID-19 therapeutic, to prevent viral stock infection.

    Results

    The analysis showed that SARS-CoV-2 preferentially infects active interstitial macrophages (IMs), which can amass hundreds of SARS-CoV-2 RNA molecules, comprising >60% of the cell transcriptome and producing dense viral RNA bodies. Infected alveolar macrophages (AMs) exhibit no severe reactions, with spike (S) protein-dependent viral entrance into AMs utilizing angiotensin-converting enzyme 2 (ACE2) and the cluster of differentiation 169 (CD169) and IM entry via CD209.

    They found canonical sub-genomic junctions between the unusual sequence reads beyond their 39 terminal regions, indicating canonical-type SARS-CoV-2 messenger RNA (mRNA) production in the pulmonary cultures. They also found hundreds of new subgenomic junctions, showing a wide range of non-canonical and canonical sub-genomic SARS-CoV-2 RNAs produced during pulmonary infection.

    Model of initiation, transition, and pathogenesis of COVID-19 and the viral lifecycle in AMs and IMs. (a–d) Model of COVID-19 initiation in the human lung and transition from viral pneumonia to lethal COVID-19 ARDS. (a) SARS-CoV-2 virion dissemination and arrival in the alveoli. Luminal AM encounter virions shed from the upper respiratory tract that enter the lung. AMs can express low to moderate numbers of viral RNA molecules and can propagate the infection but “contain” the viral RNA from taking over the total transcriptome and show only a very limited host cell inflammatory response to viral infection. (b) Replication and epithelial injury. SARS-CoV-2 virions enter AT2 cells through ACE2, its canonical receptor, and “replicate” to high viral RNA levels, producing infectious virions and initiating viral pneumonia. (c) a-IM takeover and inflammation signaling. SARS-CoV-2 virions spread to the interstitial space through either transepithelial release of virions by AT2 cells or injury of the epithelial barrier, and enter a-IMs. Infected a-IMs can express very high levels of viral RNA that dominate (“take over”) the host transcriptome and can propagate the infection. Viral takeover triggers induction of the chemokines and cytokines shown, forming a focus of inflammatory and fibrotic signaling. (d) Endothelial breach and immune infiltration. The a-IM inflammatory cytokine IL6 targets structural cells of the alveolus causing epithelial and endothelial breakdown, and the inflammatory cytokines recruit the indicated immune cells from the interstitium or bloodstream, which flood and infiltrate the alveolus causing COVID-19 ARDS. Local inflammatory molecules are amplified by circulating immune cells, and reciprocally can spread through the bloodstream to cause systemic symptoms of cytokine storm. (e) Comparison of the SARS-CoV-2 viral lifecycle in AMs and IMs. Although both can produce infectious virions, note differences in viral entry receptors (AMs can use ACE2 and CD169/SIGLEC1, whereas IMs use CD209); viral RNA transcription of dsRNA intermediates (greater in AMs); replication of full-length genomic RNA (greater in IMs); viral takeover, formation of RNA bodies, and induction of a robust host cell inflammatory response (only in IMs), and cell destruction/death (only in IMs).Model of initiation, transition, and pathogenesis of COVID-19 and the viral lifecycle in AMs and IMs. (a–d) Model of COVID-19 initiation in the human lung and transition from viral pneumonia to lethal COVID-19 ARDS. (a) SARS-CoV-2 virion dissemination and arrival in the alveoli. Luminal AM encounter virions shed from the upper respiratory tract that enter the lung. AMs can express low to moderate numbers of viral RNA molecules and can propagate the infection but “contain” the viral RNA from taking over the total transcriptome and show only a very limited host cell inflammatory response to viral infection. (b) Replication and epithelial injury. SARS-CoV-2 virions enter AT2 cells through ACE2, its canonical receptor, and “replicate” to high viral RNA levels, producing infectious virions and initiating viral pneumonia. (c) a-IM takeover and inflammation signaling. SARS-CoV-2 virions spread to the interstitial space through either transepithelial release of virions by AT2 cells or injury of the epithelial barrier, and enter a-IMs. Infected a-IMs can express very high levels of viral RNA that dominate (“take over”) the host transcriptome and can propagate the infection. Viral takeover triggers induction of the chemokines and cytokines shown, forming a focus of inflammatory and fibrotic signaling. (d) Endothelial breach and immune infiltration. The a-IM inflammatory cytokine IL6 targets structural cells of the alveolus causing epithelial and endothelial breakdown, and the inflammatory cytokines recruit the indicated immune cells from the interstitium or bloodstream, which flood and infiltrate the alveolus causing COVID-19 ARDS. Local inflammatory molecules are amplified by circulating immune cells, and reciprocally can spread through the bloodstream to cause systemic symptoms of cytokine storm. (e) Comparison of the SARS-CoV-2 viral lifecycle in AMs and IMs. Although both can produce infectious virions, note differences in viral entry receptors (AMs can use ACE2 and CD169/SIGLEC1, whereas IMs use CD209); viral RNA transcription of dsRNA intermediates (greater in AMs); replication of full-length genomic RNA (greater in IMs); viral takeover, formation of RNA bodies, and induction of a robust host cell inflammatory response (only in IMs), and cell destruction/death (only in IMs).

    Heat, UV-C inactivation, or remdesivir therapy prevented the development of canonical and non-canonical connections. The team observed SARS-CoV-2 takeover of an activated IM subtype in 176,382 cells with high-quality transcriptomes obtained from infected lung slices of four donor lungs and in 112,359 cells from mock-infected slices (cultured without viral addition) and 95,389 uncultured control cells (directly from freshly cut lung slices). A differential gene expression study of a-IMs over infection pseudotime revealed host gene expression alterations corresponding to SARS-CoV-2 RNA levels.

    The study found that COVID-19 pneumonia infection and takeover cause an early antiviral cell response specific to activated interstitial macrophages, resulting in a powerful immunological and fibrotic signaling center. Inflammasome activation is uncommon and only detectable late in a-IM infection. Blocking antibodies against CD169 and CD209 prevented entrance into IMs and AMs. The study also highlighted IMs as the most vulnerable lung target, with initial emphasis on inflammation and fibrosis. Two unique molecular lineages of macrophage targets react differently to SARS-CoV-2, influencing etiology and treatments.

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  • Annual COVID-19 vaccine proves to be a wise investment for personal health and pocketbook

    Annual COVID-19 vaccine proves to be a wise investment for personal health and pocketbook

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    In a recent study published in The Journal of Infectious Diseases, a team of researchers from the United States (U.S.) attempted to understand whether individuals experienced any economic benefits in getting an annual coronavirus disease 2019 (COVID-19) vaccine, given that the morbidity and mortality rates associated with the disease have decreased and the government no longer covers the vaccine costs.

    Study: What is the economic benefit of annual COVID-19 vaccination from the adult individual perspective? Image Credit: eamesBot / ShutterstockStudy: What is the economic benefit of annual COVID-19 vaccination from the adult individual perspective? Image Credit: eamesBot / Shutterstock

    Background

    The rapid development of vaccines to combat the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has helped significantly reduce the disease’s severity and limit the transmission of the virus. Although subvariants of SARS-CoV-2 continue to emerge and circulate, the virus’s virulence and transmissibility seem to have reduced due to the protection afforded by large-scale vaccination efforts worldwide.

    With the drop in hospitalization and mortality rates, COVID-19 is no longer considered a significant public health risk, leading to a substantial decrease in vaccination rates across the U.S. Furthermore, employment organizations and businesses are no longer mandating booster  COVID-19 vaccination shots. With the government no longer funding the cost of the vaccine, individuals have to pay for the COVID-19 booster shots either out-of-pocket or through their insurance. However, the gradual decrease in vaccination coverage and waning of infection-induced immunity could influence the control of viral transmission and disease severity.

    About the study

    In the present study, the researchers examined the benefits of getting annual COVID-19 vaccines, similar to the influenza vaccine, from an individual perspective instead of from the perspective of a third-party payer or society, which has already been examined in previous studies. The researchers believe that while the findings might not contribute to recommendations and decisions made by governments or insurance companies, they will help individuals assess the merits of an annual COVID-19 vaccination from their perspective.

    The study developed and used a Markov computational simulation model to assess the values and trade-offs of getting the annual vaccine. This model used eight mutually exclusive states of SARS-CoV-2 infections and the economic and clinical outcomes for each state.

    The state at which an individual begins is the state of no infection with pre-existing protection from previous vaccinations or infections. Based on factors such as risk of infection, probability of clinical outcomes based on age, and pre-existing protection levels, the model calculates the probability of an individual moving to a COVID-19 state. The model also calculates the probabilities of returning to the non-infected state or developing long COVID based on various levels of symptoms ranging from asymptomatic to severe.

    These probabilities are calculated twice for each individual, once with and once without the annual COVID-19 vaccination. Minor to severe adverse effects, as well as changing vaccine efficacy, are also factors that are incorporated into the model. The economic measures are calculated based on factors such as loss of productivity due to vaccination absenteeism, mortality, out-of-pocket costs, presenteeism, healthcare visits, and medications. The cost-benefits were calculated for each scenario. Sensitivity analyses were also conducted for varying disease severity based on different SARS-CoV-2 variants.

    Results

    The results suggested that an individual stood to benefit clinically and economically by getting vaccinated annually against COVID-19. The model showed that adults between the ages of 18 and 49 saved an average of $30 to $603 if they did not have health insurance, while insured individuals of the same age group saved $4 to $437.

    These estimates were on the assumption that the efficacy of the vaccine against SARS-CoV-2 started at greater than or equal to 50%, the individuals interacted with about nine people a day, the infection probability was more significant than or equal to 0.2%, the infection prevalence was 10%, and the conditions were for the Omicron variant of SARS-CoV-2 during the winter of 2023-2024.

    For individuals between the ages of 50 and 64, the average economic benefits were even higher, with savings of $119 to $1706 and $111 to $1278 for individuals with and without insurance, respectively. Furthermore, in cases where the previous vaccination was nine months ago, and 13.4% of the pre-existing protection remained, the model showed that the risk threshold was greater than or equal to 0.4%.

    Conclusions

    Overall, the study found that the annual COVID-19 vaccine was economically and clinically beneficial to individuals with or without health insurance. The economic value of getting the COVID-19 vaccine was higher for individuals between 50 and 64 years of age.

    Journal reference:

    • Bartsch, S. M., O’Shea, K. J., Weatherwax, C., Strych, U., Velmurugan, K., John, D. C., Bottazzi, M. E., Hussein, M., Martinez, M. F., Chin, K. L., Ciciriello, A., Heneghan, J., Dibbs, A., Scannell, S. A., Hotez, P. J., & Lee, B. Y. (2024). What is the economic benefit of annual COVID-19 vaccination from the adult individual perspective? The Journal of Infectious Diseases. DOI: 10.1093/infdis/jiae179, https://academic.oup.com/jid/advance-article/doi/10.1093/infdis/jiae179/7641782 

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  • Nirmatrelvir fails to shorten COVID-19 symptoms in latest trial

    Nirmatrelvir fails to shorten COVID-19 symptoms in latest trial

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    In a recent study published in The New England Journal of Medicine, researchers evaluate the efficacy of nirmatrelvir in combination with ritonavir against the coronavirus disease 2019 (COVID-19).

    Study: Nirmatrelvir for Vaccinated or Unvaccinated Adult Outpatients with Covid-19. Image Credit: Alexsey t17 / Shutterstock.com

    A brief history of COVID-19 patient care

    Since its emergence at the end of 2019, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus responsible for COVID-19, has infected almost 700 million individuals and claimed over seven million lives worldwide. COVID-19 is associated with a wide range of pathologies in different populations, with the very young and elderly at the most significant risk of mortality and morbidity.

    Rapid global medical research and vaccination programs have significantly reduced the burden of COVID-19 by attenuating SARS-CoV-2 transmission. Currently, COVID-19 patients are treated symptomatically through general antiviral interventions; however, an extensive search for a COVID-19-specific cure is still in the clinical trials phase.

    Nirmatrelvir is an orally administered antiviral agent that inhibits the SARS-CoV-2 main protease (Mpro), which is critical for viral replication. Nirmatrelvir is administered with the pharmacokinetic enhancer ritonavir to inhibit metabolism by CYP3A4.”

    One of the most promising antiviral therapies currently in clinical trials is the combination of nirmatrelvir and ritonavir. In unvaccinated adults, phase II and III clinical trials have produced promising results by reducing COVID-19 mortality risk by over 80%. Nevertheless, the anti-COVID-19 benefits of this intervention in vaccinated individuals remain unverified.

    About the study

    In the current study, researchers evaluate the efficacy and side effects of nirmatrelvir-ritonavir in non-hospitalized patients of various ages, ethnicities, and infection severity.

    Data were obtained from the Evaluation of Protease Inhibition for Covid-19 in Standard-Risk Patients (EPIC-SR) trial, which is a randomized, double-blind, and placebo-controlled trial involving adult participants 18 years of age and older with laboratory reverse transcriptase-polymerase chain reaction (RT-PCR)-confirmed COVID-19. Individuals were enrolled in the study between August 2021 and July 2022 if their symptoms initially appeared in the five days prior to study enrollment.

    Study participants were randomly assigned to receive either the nirmatrelvir-ritonavir intervention, which comprised 300 mg of nirmatrelvir and 100 mg of ritonavir, or placebo. The dosage was fixed once every 12 hours for five days, thus leading to a final total of 10 doses.

    For statistical analyses, randomization was stratified across vaccination status, geographic region, and COVID-19 symptom onset. Data collection included participants’ sociodemographic, anthropometric, and medical records.

    Digital diaries were also used to record daily intervention use, COVID-19 symptom severity on a four-point scale, and associated side effects. Efficacy measurements were conducted through day 34.

    Sustained alleviation was considered to have occurred on the first of four consecutive days during which all symptoms that had been scored as moderate or severe and as mild or absent at baseline were scored as mild or absent and as absent, respectively.”

    Study findings and relevance

    Of the 1,296 participants initially enrolled in the study, 1,288 individuals, 654 of whom received nirmatrelvir-ritonavir and 634 placebo, provided completed data and were included in the statistical analyses. The study cohort primarily comprised women and individuals of the White ethnicity at 54% and 78.5%, respectively.

    About 57% of the study cohort were vaccinated, with smoking as the most commonly severe COVID-19 risk factor reported among 13.3% of the study participants. Study intervention compliance was high across both cohorts at 94.8% and 96.5% for nirmatrelvir-ritonavir and placebo, respectively.

    Efficacy evaluations revealed no statistically different outcomes between nirmatrelvir-ritonavir and placebo treatment cohorts. While the safety evaluation found no statistically significant differences between the side effects reported across trial groups, dysgeusia, diarrhea, and nausea were often reported by those who received nirmatrelvir-ritonavir during the study.

    Conclusions

    The study findings suggest that nirmatrelvir-ritonavir may not be as effective as suspected in alleviating adverse viral SARS-CoV-2 outcomes, especially in symptomatic, non-hospitalized, vaccinated, or unvaccinated adults. Given the known and study-reported side effects, nirmatrelvir-ritonavir cannot yet be established as a safe and beneficial treatment for severe COVID-19 outpatients, irrespective of prior vaccination status.

    Nirmatrelvir–ritonavir was not associated with a significantly shorter time to sustained alleviation of COVID-19 symptoms than placebo, and the usefulness of nirmatrelvir–ritonavir in patients who are not at high risk for severe COVID-19 has not been established.”

    Journal reference:

    • Hammond, J., Fountaine, R. J., Yunis, C., et al. (2024). Nirmatrelvir for Vaccinated or Unvaccinated Adult Outpatients with Covid-19. The New England Journal of Medicine 390(13); 1186-1195. doi:10.1056/nejmoa2309003

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