Background
The coronavirus disease 2019 (COVID-19) infection can have a variable impact on patients. Various host factors have been identified that play a significant role in the risk of COVID-19 infection and its severity. Patients with severe asthma have been clinically vulnerable since the first wave of the pandemic and the resurgence of COVID-19 in the United Kingdom in January 2020. In addition, those on treatment with monoclonal antibodies (mAbs) have been identified as being vulnerable to COVID-19 infection and severity by the World Health Organization and the Department of Health. However, the evidence to support this notion is limited, and there has been contrary evidence to suggest severe asthma is protective against COVID-19. In this study, a retrospective review of severe asthma patients in the Liverpool population between 1st January 2020 and 31st January 2021 was conducted. This study aimed to determine the association between asthma severity and the risk of COVID-19 infection and/or its severity for patients on mAb treatment.
We conducted a review of all patients from the Liverpool severe asthma database/spreadsheet who tested positive in the community and at the hospital. Admission records, primary records, emails, and microbiological data for Anglia ICE were reviewed at the Royal Liverpool and Aintree University Hospital.A COVID-19 diagnosis was predefined as a positive lateral flow test and a positive polymerase chain reaction test.The proportion of patients with COVID-19 pneumonia and severe COVID-19 disease requiring hospital admission and escalation to intensive care (observation, intubation, continuous positive airway pressure) was noted. Other patient characteristics were recorded including age, weight, body mass index (BMI), gender, smoking status (never, former, current smoker), bronchiectasis, and the forced expiratory volume.
In total, 760 patients were identified to have severe asthma, of whom 59 (7.8%) tested positive for COVID-19 and 701 (92.2%) tested negative. A total of 244 (32%) patients were taking mAbs, and 516 (68%) were not on mAb treatment. Patients were more susceptible to COVID-19 on an mAb (13.5%) versus non-mAb (5%) (odds ratio (OR) = 2.95; 95% confidence interval (CI) = 1.72 to 5.05) . A larger proportion of severe asthma patients on mAb treatment testing positive for COVID-19 were current smokers and had a higher BMI. Furthermore, severe asthmatics taking mAbs did not have a higher risk of severe COVID-19 disease, hospitalisation, and intensive care admission.
In the Liverpool severe asthma population, patients undergoing mAb therapy had a higher incidence of COVID-19 compared to non-mAb groups; however, they were not at a higher risk of severe disease progression. These findings suggest that continuing biologic therapy in severe asthmatics with COVID-19 appears to be safe to prevent exacerbations.
There were 10 million cases of coronavirus disease 2019 (COVID-19) and 500,000 deaths within the first six months of the first wave of the pandemic [1]. Patients presenting with comorbidities are known to have a higher risk of progressing to severe COVID-19 and hospitalisation [2]. A meta-analysis review showed that 50% of patients diagnosed with Middle Eastern respiratory syndrome (MERS) presented with pre-existing diabetes and hypertension, 30% presented with cardiac disease, and 16% were classed as obese [3]. These findings are consistent with current evidence which demonstrates the above conditions promote the downregulation of proinflammatory cytokines and dysregulate the innate and adaptive immune system making the host susceptible to infection with a poor prognosis [4,5]. While the aforementioned conditions have been linked to hospitalisation and severe COVID-19, few studies are available concerning the vulnerability of asthma patients and COVID-19 infection and severity. The available literature available is conflicting. In addition, studies concerning the role of treatment with monoclonal antibodies (mAbs) in severe asthma patients and the risk of severe COVID-19 are also limited [6]. This justifies and warrants further investigation.
Different mAbs target specific inflammatory pathways in eosinophilic inflammatory type 2 asthma and exert different effects. Mepolizumab and reslizumab exert their effects by downregulating the differentiation and activation of eosinophils through interaction of the interleukin (IL)-5 cytokines. Benralizumab acts as an IL-5 receptor antagonist and can activate natural killer cells, thus, promoting eosinophil apoptosis. Omalizumab prevents the release of mediators that are responsible for bronchospasm by blocking the interaction of immunoglobulin E and receptors located on mast and basophil cells. Dupilumab inhibits the release of proinflammatory cytokines by disrupting the IL-4 and IL-13 signalling pathways.
The current understanding is respiratory viruses such as coronaviruses are implicated in the exacerbation of asthma partly due to the association of bronchial inflammation [7-9]. However, there are conflicting studies that suggest asthma can have a protective role against COVID-19 through a dominant Th2 environment [10]. To unravel the clinical heterogeneity in this patient cohort, the risk of COVID-19 infection and severity in the severe asthma population was examined with respect to mAb treatment.
Retrospective data were collected from the Royal Liverpool and Aintree University Hospital between 1st January 2020 and 31st January 2021. The inclusion criterion was set to include all severe asthma patients attending the Liverpool asthma service. Patients had a confirmed diagnosis of severe asthma according to the British Thoracic Society. Patients residing outside of the Liverpool area, nonadherence to treatment, and patients testing positive for COVID-19 outside the set date were excluded. The data were collected from the dashboard, and admission records were reviewed from the Royal Liverpool and Aintree University Hospitals. Finally, the data were collated onto a spreadsheet using Microsoft Excel. To further this end, primary records were reviewed using eExchange to confirm patients testing positive or negative in the community for COVID-19. Correspondence emails were reviewed and sent by specialist asthma nurses, general practitioners, and patients that informed if they had tested positive for COVID-19 or were admitted elsewhere. To allow for a robust mode of data collection, microbiological data for Anglia ICE was utilised for confirmation of the positivity or negativity of COVID-19 swab tests. A COVID-19 diagnosis was predefined as a positive lateral flow test and a positive polymerase chain reaction (PCR) test for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Other patient characteristics were recorded that included age, weight, body mass index (BMI), gender, smoking status (never, former, current smoker), bronchiectasis, and forced expiratory volume (FEV1).The study was approved by the local ethics committee of the Royal Liverpool and Aintree University Hospital, and all patients provided their consent to be part of the study.
The incidence of COVID-19 was recorded in the severe asthma population. The number of patients testing positive in the community or hospital was noted as well as the confirmation of a positive swab. The proportion of patients who had COVID-19 pneumonia and severe COVID-19 was also recorded. To further this end, patients requiring either admission for COVID-19 or escalation to the intensive care unit (ICU) for observation, intubation, and continuous positive airway pressure (CPAP) were recorded. In addition, the number of patients requiring CPAPon the ward was documented. Following this, the number of severe asthma patients currently on mAbs and not on mAbs was calculated. The proportion of severe asthma patients on mAbs who tested positive or negative for COVID-19 was subsequently calculated. This was compared to the number of severe asthma patients not on mAbs who tested positive or negative for COVID-19. The average age, average weight, average BMI, gender, bronchiectasis, smoking status, and average FEV1 were calculated in patients testing positive or negative for COVID-19 with respect to the severe asthma population, severe asthma population on mAbs, and severe asthma population not on mAbs. An odds ratio (OR) was calculated with a 95% confidence interval (CI) taken as statistically significant. Because a small number of COVID-19 cases were anticipated in the Liverpool severe asthma population, regression analysis for adjustment of confounders was not planned.
Between 1st January 2020 and 31st January 2021, there were a total of 760 patients in the Liverpool severe asthma database. Of the 760 severe asthma patients, 59 (7.8%) tested positive and were laboratory confirmed for COVID-19 infection, and 701 (92.2%) tested negative. Overall, 27 of the 59 (45.8%)patients tested positive for COVID-19 in the hospital compared to 32 (54.2%) in the community. In total, 13 of the 59 (22%) patients who tested positive for COVID-19 developed COVID-19 pneumonia; 14 of the 59 (23.7%)patients progressed to severe COVID-19 disease; 22 of the 59 (37.3%)patients required admission; six (10.2%)patients received CPAP on the ward; and two (3.4%) patients of the 59 who tested positive for COVID-19 required ICU admission, both of whom received CPAP. This is summarised in Table 1.
Of the 760 patients identified from the Liverpool severe asthma database, 244 (32%) were on mAbs and 516 (68%) were not on mAbs. In total, 88 (36%)patients were on benralizumab, four (2%) were on dupilumab, 86 (35%) were on mepolizumab, 63 (26%) were on omalizumab, and three (1%) were on reslizumab. Of the 244 severe asthma patients on mAbs, 33 (13.5%) tested positive and confirmed for COVID-19 whereas 211 (86.5%) tested negative for COVID-19. In addition, of the 516 severe asthma patients not taking mAbs, 26 (5%) tested positive for COVID-19 compared to 490 (95%) who tested negative. This is summarised in Table 2.
The incidence of the severe asthma population undergoing mAb therapy testing positive for COVID-19 was higher compared to the severe asthma population not undergoing mAb therapywith a corresponding OR of 2.95 (95% CI = 1.72 to 5.05, p < 0.01).However, the incidence of the severe asthma population who tested positive for COVID-19 undergoing mAb therapy did not affect progression to severe COVID-19 disease and admission compared to those not on a mAb. This is summarised in Table 3.
In severe asthma patients on mAb therapy who tested positive for COVID-19, the average BMI was higher (35.9 vs. 33.3). In addition, more patients were current smokers (6.1% vs. 2.9%) compared to those who tested negative.
A key finding from this retrospective Liverpool study is the low incidence of COVID-19 (7.8%) in the severe asthma population. This links with other studies which document similar findings [11]. The low occurrence of COVID-19 seen in the Liverpool severe asthma population is consistent with an early study conducted in Wuhan which did not list asthma as a comorbidity but rather reported diabetes mellitus and hypertension as more common comorbidities [12,13]. Studies conducted in Italy and Belgium further support this notion [6,14]. This finding could be attributed to numerous causes. For example, it is thought an inflammatory type 2 response associated with cytokines (IL-4, IL-5, and IL-13) and the clinical inflammatory phenotype of asthma marked by eosinophilia may have protective effects through the activation of the antiviral host defence and promotion of viral clearance [15,16]. Moreover, the presence of eosinopenia was predominately seen in the peripheral blood among those testing positive for SARS-CoV-2 [12]. Perhaps, a pathological environment favouring a high eosinophil count may provide protection against COVID-19 such as the case evident in the airways of severe asthmatic patients.
In the Liverpool severe asthmatic population testing positive for SARS-CoV-2, patients were older,had a higher BMI, and a larger proportion of the patients were female compared to severe asthmatics testing negative for COVID-19. A similar finding was seen in previous studies which reported that patients with asthma and COVID-19 were older, predominately female, and obese [17,18]. The higher prevalence of women with COVID-19 has also been reported in previous research [19-21]. This could be due to a higher baseline prevalence of asthma in females in the Liverpool severe asthma population. The incidence of bronchiectasis in COVID-19-positive and negative patients was similar (8.5% vs. 8.7%). Current smokers in the COVID-19-positive cohort were lower (11.9%) compared to severe asthmatics testing negative (13.1%). However, the proportion of smokers in the severe COVID-19 group was higher compared to patients who did not progress to severe COVID-19 disease (14.3% vs. 11.1%). This implies smoking may increase the likelihood of disease progression and severity which is consistent with prior studies [22]. A lower FEV1 is observed in the severe asthma population testing positive for COVID-19 compared to patients testing negative (2.14 vs. 2.26). This suggests a lower FEV1 may be attributable to a higher risk of COVID-19 infection which was a key finding in a recent study [23].
A hallmark in COVID-19 pathogenesis involves a key receptor named angiotensin-converting enzyme-2 (ACE2). ACE2 is a cellular receptor utilised by the spike protein of SARS-CoV-2 to gain host entry [24]. This is facilitated by the membrane-bound protease serine 2 (TMPRSS2) [25,26]. Therefore, it follows comorbidities that increase the upregulation of the ACE2 and TMPRSS2 genes would thereby increase the susceptibility to COVID-19 infection. For instance, smoking promotes the upregulation of the ACE2 gene which has been linked with increased severity of illness [22]. This was shown in the Liverpool severe asthma population. For patients on mAb therapy, a higher proportion of patients testing positive for COVID-19 were current smokers and had a higher BMI. Educating patients on the importance of smoking cessation and weight loss is crucial in this subgroup.
A further critical finding of this Liverpool study is the incidence of COVID-19 in thesevere asthma patient population is higher in patients taking a mAb (13.5%) compared to those not taking a mAb (5%). A similar finding was seen in another study which highlighted that severe asthma patients on biologics were at higher risk of COVID-19 compared to the general Dutch population [27]. The mechanism of action of biologics varies in relation to the type of treatment used. For instance, mepolizumab and reslizumab work to counteract eosinophil expansion through inhibition of IL-5 inducing eosinophil cytotoxicity [28]. Considering the role of eosinophils in adaptive immunity and antiviral activity it follows depletion in numbers may increase the susceptibility to infections. Consequently, it can be deduced that careful monitoring of the eosinophil count is required for severe asthmatics under mAb treatment as low levels may increase the risk of COVID-19 infection. In addition, it was shown that severe asthma patients taking mAbs were not at a higher risk of severe COVID-19 disease, hospitalisation, or ICU admission in the Liverpool severe asthma population. A comparable result was found in a multitude of studies indicating no relationship between biologic use in severe asthmatics and poorer clinical outcomes of COVID-19 [29,30].The current evidence suggests it is safe to continue biological therapy in severe asthmatics with COVID-19 with no impact on disease severity.
A key strength of this study is the array of resources that were used to gather the data for this study which involved the use of a dashboard, ICE, eExchange and emails. This allowed for a more robust collection of primary and secondary care data.Objective measures of severity of disease (observation, intubation, CPAP) was anotherstrength of this study. A potential limitation of this study is COVID-19 infection rates in the Liverpool severe asthma population may have been underestimated due to patients not adhering to regular testing, strict shielding, and missed positive cases in the community due to nonreporting. In the future, telephone confirmation will be more appropriate to confirm presumed negative COVID-19 patients.
This study is among the first to review the incidence and severity of COVID-19 disease in the Liverpool severe asthma population undergoing biologic therapy. A fundamental finding is that severe asthmatic patients have a low incidence of COVID-19.Results also indicate patients on mAb treatment may be at a higher risk of COVID-19 infection. Furthermore, the presence of obesity or lifestyle factors such as smoking while on mAb therapy may increase the susceptibility to COVID-19 infection. It is also shown that severe asthmatics undergoing mAb treatment do not have a higher risk of severe disease progression or admission. This is consistent with previous studies. This research supports the current practice of continuing biologic therapy during COVID-19 infection in severe asthmatic patients.
In a recent study posted to the medRxiv* preprint server, researchers compared the percent excess mortalities due to the zero-coronavirus disease 2019 (COVID-19) (ZC) policy or the living-with-COVID (LWC) policy.
Since the emergence of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) Omicron variant in 2021, several countries have applied the LWC instead of the ZC policy to facilitate the normalcy of pre-COVID life. However, the high infectivity and transmissibility of Omicron have raised concerns regarding the mortality burden associated with the LWC policy.
In the present study, researchers estimated the excess mortalities to compare the efficacy of the LWC and ZC policies in protecting human lives within the same country during the COVID-19 pandemic.
The team collected all-cause mortality from governmental sources for four countries, including Australia, New Zealand, South Korea, and Singapore, and one region, including Hong Kong. The information collected included weekly or monthly data related to mortalities observed between January 2020 and March 2022 in Singapore, April 2022 in South Korea, March 2022 in Australia, June 2022 in New Zealand, and April 2022 in Hong Kong. Furthermore, data related to confirmed COVID-19 cases as well as COVID-19-associated mortalities were collected for the four countries and one region from Googles COVID map.
Expected mortality estimated in the study was defined as deaths noted in a period assuming the absence of the pandemic. It is calculated according to past trends of all-cause mortality. The team employed the linear regression method to calculate expected mortality. Furthermore, excess mortality was estimated as the difference between observed and expected mortality, while percent COVID-excess mortality (PCEM) was calculated as the percentage of deaths associated with COVID-19 divided by expected mortality. The team then compared PCEM with percent excess mortality (PEM) to assess the contribution of COVID-19-related deaths to overall excess mortality.
The Singaporean government's monthly mortality statistics generated a PEM curve from January 2020 to March 2022. Before August 2021, PEM in Singapore under the ZC policy ranged between 0 and 10%. In August 2021, Singapore adopted the LWC policy and then had the Delta epidemic. Peak PEM reached a value of 31.53%, while the average value from September to December 2021the time of the Delta outbreakwas 24.23%. Under the LWC program, the mortality burdenmeasured as the discrepancy between observed mortality and predicted mortalityrose sharply. Overall, Singapore's LWC strategy throughout the studied period could not effectively reduce the death burden.
In South Korea, PEM dropped to less than 0% in January 2022. According to the most recent data, PEM significantly rose following the policy change. Additionally, during the Omicron outbreak, the PECM curve was much lower than the PEM curve, indicating that COVID indirectly caused a high number of deaths under the LWC policy when coming into contact with the Omicron variety. It could be attributable to overburdened medical resources or an underestimation of mortality linked to COVID. Overall, the LWC policy in South Korea did not successfully reduce the mortality burden throughout the studied period, particularly in response to the Omicron variation.
According to the most recent data, PEM significantly rose following the regulation change. Additionally, the PCEM curve was much lower than the PEM curve, indicating that a sizable portion of deaths under the LWC policy was driven by COVID-19 indirectly. It could be attributable to overburdened medical resources or an underestimation of mortality linked to COVID. The mortality burden under the LWC policy also increased significantly, as shown by the discrepancy between observed mortality and predicted mortality. Before April 2022, Australia's LWC program as a whole did not effectively reduce the mortality burden.
In accordance with the LWC strategy, New Zealand was the only country to reach an average PEM of around 10%. This might be due to the country's extremely high vaccination rate, particularly among the elderly. The lack of a significant disparity between the PCEM and the PEM curves suggests that the mortality burden associated with COVID-19 was accurately reflected in the data on COVID-related deaths.
Furthermore, even during the period of the policy shift, the mortality burden, as shown by the discrepancy between observed mortality and projected mortality, remained virtually unchanged. Overall, the LWC strategy in New Zealand throughout the studied period had a satisfactory success rate in reducing the mortality burden.
The study findings showed that PEM was considerably higher when the LWC policy was applied than during the ZC policy application. The researchers believe that the precondition associated with the transition of each policy should be thoroughly examined, while the current LWC policy needs appropriate revision to attain a lower PEM.
medRxiv publishes preliminary scientific reports that are not peer-reviewed and, therefore, should not be regarded as conclusive, guide clinical practice/health-related behavior, or treated as established information.
In a recent study posted to the medRxiv* server, researchers investigated the vaccine efficacy (VE) of various coronavirus disease 2019 (COVID-19) vaccines against the BA.2, BA.4, and BA.5 sub-lineages of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) Omicron variant.
The UK experienced a surge of BA.4 and BA.5 cases after April 2022, despite the recent BA.1 and BA.2 wave. There have been extensive vaccination efforts since December 2020, with up to four doses offered by March 2022 to high-risk groups. The emergence of newer variants and sub-lineages highlights the need to investigate and monitor the effectiveness of the currently used vaccines in limiting severe infections by all co-circulating sub-lineages.
In the present study, researchers in the UK estimated the effectiveness of the vaccines currently being administered in preventing hospitalization following BA.4 and BA.5 sub-lineage infections compared to BA.2 infections, with all three sub-lineages co-circulating.
The BA.4 and BA.5 spike proteins are similar to those of BA.2, with additional mutations that increase their ability to evade antibodies in vaccinated individuals or BA.1-infected. The COVID-19 vaccination program in the UK offered a primary course of two doses of the Pfizer-BioNTech (BNT162b2), AstraZeneca (ChAdOx1-S), or Moderna (mRNA-1273) vaccines, and a third dose of either BNT162b2 or mRNA-1273 (half-dose). By March 2022, a fourth dose was being offered to the 75 years or older and high-risk groups.
The team carried out a test-negative case-control study to estimate the VE against hospitalization in individuals 18 or older infected with BA.2, BA.4, or BA.5 sub-lineages. The VE was defined as the odds of vaccination in cases divided by the odds of vaccination in controls, subtracted from one. They also compared the incremental VE of individuals with a third or fourth dose with those who had their second dose 25 weeks ago and had waned immunity. The incremental VE of the third and fourth dose vaccines were also compared by the manufacturer.
The data consisted of 32,845 individuals who underwent a polymerase chain reaction (PCR) test at a hospital or public health laboratory and were hospitalized between April 18 and July 17, 2022. Of these, 25,862 were negative and formed the control group. The number of BA.2, BA.4, BA.5, and BA.4 or BA.5 cases were 3,432, 273, 947, and 2,331, respectively. The vaccination status information was procured from the National Immunization Management System (NIMS) database, and the hospital admission data was gathered from the Secondary Care Hospital Admission Data (SUS) database.
The researchers found no evidence of reduced effectiveness of the vaccines against hospitalization for the sub-lineages BA.4 and BA.5 as compared to BA.2. The incremental VE in individuals with third or fourth doses of vaccination was 56.8%, 59.9%, and 52.4% for BA.4, BA.5 and BA.2 respectively, which waned to 1.5%, 23.3%, and 9.8%, respectively, at 25 weeks or more since the second dose.
Vaccine-specific incremental VE for the third or fourth dose did not show any significant difference for combined BA.4 and BA.5 cases compared to BA.2. The Moderna vaccine had a slightly higher incremental VE compared to the Pfizer-BioNTech vaccine, but the confidence intervals overlapped. The mRNA-1273 (Moderna) vaccine had a 62.2% incremental VE at two to 14 weeks after the third or fourth dose, which decreased to 42.0% at 15 to 24 weeks, while that of the BNT162b2 (Pfizer-BioNTech) vaccine decreased from 49.6% at two to 14 weeks to 16.7% at 15 to 25 weeks.
In summary, the study results showed that there was no decrease in VE against hospitalization for infections with SARS-CoV-2 Omicron sub-lineages BA.4 and BA.5 as compared to those with BA.2. Vaccine efficacy did not seem to vary significantly according to the manufacturer either, with third or fourth doses of either mRNA-1273 or BNT162b2 vaccines conferring similar levels of protection against severe infections. The findings of this study confirm that the vaccines currently administered in the UK effectively protect against severe Omicron BA.4 and BA.5 infections.
medRxiv publishes preliminary scientific reports that are not peer-reviewed and, therefore, should not be regarded as conclusive, guide clinical practice/health-related behavior, or treated as established information
The CSIRO has delivered a comprehensivereporton how we should prepare for future pandemics.
The report identifies six key science and technology areas such as faster development of vaccines and onshore vaccine manufacturing to ensure supply, new antivirals and ways of using the medicines we already have, better ways of diagnosing cases early, genome analysis, and data sharing.
It also recommends we learn more about viruses and their hosts across the five most concerning virus families. These causes of disease could fuel the next pandemic.
We asked leading experts about the diseases they can cause and why authorities should prepare well.
COVID-19, Middle East respiratory syndrome (MERS), severe acquired respiratory syndrome (SARS)
The first humanCoronaviruses(229E and OC43) were found in 1965 and 1967 respectively. They were low-grade pathogens causing only mild cold-like symptoms and gastroenteritis. Initial understanding of this family came from study of related strains that commonly infect livestock or laboratory mice that also caused non-fatal disease. TheHKU-1 strain in 1995again did not demonstrate an ability to generate high levels of disease. As such, coronaviridae were not considered a major concern until severe acquired respiratory syndrome (SARS-1) first appeared in 2002 in China.
Coronaviridae have avery long RNA genome, coding up to 30 viral proteins. Only four or five genes make infectious virus particles, but many others support diseases from this family by modifying immune responses. The viruses in this family mutate at a steady low rate, selecting changes in the outer spike to allow virus entry into new host cells.
Coronaviridae viruses are widespread in many ecological niches and common in bat species that make up20 per centof all mammals. Mutations spread in their roosts can spillover into other mammals, such as thecivet cat, then into humans.
Coronaviridaegenome surveillanceshows an array of previously unknown virus strains circulating in different ecological niches. Climate change threatens intersections of these viral transmission networks. Furthermore, pandemic human spread of SARS-CoV-2 (the virus that causes COVID) has now seeded new transmissions back into other species, such as mink, cats, dogs and white-tailed deer.
Ongoing viral evolution in new animal hosts and also in immune-compromisedHIV patients in under-resourced settings, presents an ongoing source of new variants of concern.
Damian Purcell
Dengue fever, Japanese encephalitis, Zika, West Nile fever
The flaviviridae family causes several diseases, including dengue, Japanese encephalitis, Zika, West Nile disease and others. These diseases are often not life-threatening, causing fever, sometimes with rash or painful joints. A small proportion of those infected get severe or complicated infection. Japanese encephalitis can cause inflammation of the brain, and Zika virus can cause birth defects.
While all these viruses may be spread by mosquito bites, when it comes to each individual virus, not all mosquitoes bring equal risk. There arekey mosquito speciesinvolved in transmission cycles of dengue and Zika virus, such asAedes aegyptiandAedes albopictus,that may be found in close to where people live. These mosquitoes are found in water-holding containers (such as potted plant saucers, rainwater tanks), water-filled plants, and tree holes. They also like to bite people.
The mosquitoes that spread these viruses are not currently widespread in Australia; they're generally limited to central and far north Queensland. They are routinely detected through biosecurity surveillance at Australia's majorairports and seaports. With a rapid return to international travel, movement of people and their belongings may become an ever-increasing pathway of introduction of the diseases and mosquitoes back into Australia.
Different mosquitoes are involved in thetransmissionof West Nile virus and Japanese encephalitis. These mosquitoes are more likely to be found in wetlands and bushland areas than backyards. They bite people but they also like tobite the animalsmost likely to be carrying these viruses.
Theemergence of Japanese encephalitis, a virus spread by mosquitoes between waterbirds, pigs, and people, is a perfect example. Extensive rains and flooding that provide idea conditions for mosquitoes and these animals create a "perfect storm" for disease emergence.
Cameron Webb and Andrew van den Hurk
Influenza
Before COVID-19, influenza was the infection mostwell-knownfor causing pandemics.
Influenza virus is subdivided into types (A, B, and rarely C and D). Influenza A is further classified into subtypes based on haemagglutinin (H) and neuraminidase (N) protein variants on the surface of the virus. Currently, the most common influenza strains in humans are A/H1N1 and A/H3N2.
Zoonotic infectionoccurs when influenza strains that primarily affect animals "spill over" to humans.
Major changes in the influenza virus usually result fromnew combinationsof influenza viruses that affect birds, pigs and humans. New strains have the potential to cause pandemics as there is little pre-existing immunity.
Since the beginning of the 20th century, there have been four influenzapandemics, in 1918, 1957, 1968, and 2009. In between pandemics, seasonal influenza circulates throughout the world.
Although influenza is not as infectious as many other respiratory infections, the very short incubation period of around 1.4 days means outbreaks can spread quickly.
Vaccines are available to prevent influenza, but are onlypartiallyprotective. Antiviral treatments are available, including oseltamivir, zanamivir, peramivir and baloxavir. Oseltamivirdecreasesthe duration of illness by around 24 hours if started early, but whether it reduces the risk of severe influenza and its complications iscontroversial.
Allen Cheng
Nipah virus, Hendra virus
Paramyxoviridae are a large group of viruses that affect humans and animals. The most well known are measles and mumps, as well as parainfluenza virus (a common cause ofcroupin children).
Globally,measlesis a dangerous disease for young children, particularly those who are malnourished. Vaccines are highly effective with the measles vaccine aloneestimatedto have saved 17 million lives between 2000 and 2014.
One group of paramyxoviruses is of particular importance for pandemic planning henipaviruses. This includes Hendra virus, Nipah virus and the newLangya virus(as well as the fictional MEV-1 in the filmContagion). These are all zoonoses (diseases that spill over from animals to humans)
Hendra virus was firstdiscoveredin Queensland in 1994, when it caused the deaths of 14 horses and their horse trainer. Infected flying foxes have since spread the virus to horses in Queensland and northern New South Wales. There have been sevenreportedhuman cases of Hendra virus in Australia, including four deaths.
Nipah virus is moresignificantglobally. Infection may be mild, but some people develop encephalitis (inflammation of the brain). Outbreaks frequently occur in Bangladesh, where the firstoutbreakwas reported in 1998. Significantly, Nipah virus appears to be able to betransmittedfrom person-to-person though close contact.
Allen Cheng
Chikungunya fever, Ross River fever, Eastern equine encephalitis, Western equine encephalitis, Venezuelan equine encephalitis
The most common disease symptoms caused by infection with alphaviruses like chikungunya and Ross River viruses are fever, rash and painful joints.
Like some flaviviruses,chikungunya virusis thought to be only spread by mosquitoes in Australia. This limits risks, for now, to central and far north Queensland.
Many different mosquitoes play a role in transmission of alphaviruses, including dozens of mosquito species suspected as playing a role in the spread ofRoss River fever. Many of these mosquitoesare commonly found across Australia.
But what role may these local mosquitoes play should diseases such as eastern equine encephalitis or western equine encephalitis make their way to Australia? Given the capacity of our home-grown mosquitoes to spread other alphaviruses, it is reasonable to assume they would be effective at transmitting these as well. That's why the CSIRO reportnotesfuture pandemic preparation should work alongside Australia's established biosecurity measures.
Cameron Webb and Andrew van den Hurk
Allen Cheng is Professor in Infectious Diseases Epidemiology atMonash University; Andrew van den Hurk is Medical Entomologist at The University of Queensland; Cameron Webb is Clinical Associate Professor and Principal Hospital Scientist, University of Sydney; and Damian Purcell is professor of virology and theme leader for viral infectious diseases at The Peter Doherty Institute for Infection and Immunity.This piece first appeared on The Conversation.
Gov. Phil Murphy said Sunday that New Jersey will soon begin a comprehensive review of the states response to the COVID-19 pandemic a step he promised more than two years ago.
During a TV interview on Fox News Sunday, the Democratic governor also said he expects people to debate forever and for always whether New Jersey closed schools for too long during the crisis and that officials had no other choice early on.
In addition, Murphy addressed speculation over whether he may run for president in 2024, saying he would back President Joe Biden should the president seek re-election and that he has not met with donors about his own possible bid if Biden decides not to.
Murphy first vowed New Jersey would conduct a postmortem on its handling of the pandemic in April 2020, just weeks after the coronavirus started spreading rapidly in the state, an early epicenter of the illness.
Last week, he reiterated officials are committed to a review but didnt have a date, saying the state is still not out of the woods with the virus.
Asked Sunday if that means there will be no review if COVID-19 is still in New Jersey, Murphy said: No, it does not.
I dont have news to break today, but I think were in a matter of weeks of coming up with a comprehensive program, he added, saying the review will focus on the states entire COVID response, including long-term care.
I want to make sure its effective, not just in teaching us what went right and what went wrong, but also that it can be a tool for future governors, future administrations, the governor said. COVID, sadly, is still with us. It will continue to be with us. But we cant wait til the last case to do that review, and we wont. Well be doing something, starting something soon.
The virus has killed more than 34,000 residents in the state in the last 2 1/2 years. More than 9,500 of those deaths have been among residents and staff members at nursing homes and other long-term care facilities, according to state data.
Murphy closed New Jerseys schools and switched them to remote classes in March 2020, days after the state reported its first coronavirus case. In-person classes did not return until the beginning of the 2021-22 school year.
Fox host Mike Emanuel a Westfield native and Rutgers University alum noted that test scores show evidence of learning loss because of virtual classes and asked Murphy if he felt the state kept schools closed for too long.
I think thats gonna be one of those things that folks debate forever and for always, Murphy said. We knew learning loss, we know its real, we know the mental health stress on everybody kids in particular, educators, families.
But Murphy said early on, when officials had little knowledge about the virus, we had no other choice.
He also insisted New Jersey will be laser-focused on closing those gaps when it comes to learning loss.
As for 2024? Murphy is considered by some to be a potential candidate if Biden, a fellow Democrat, doesnt run for re-election. People close to Murphy have said they consider him a strong contender and have discussed a possible campaign for the Democratic nomination.
Asked about Murphy for President in 2024, Murphy said he expects Biden to run again and that he would support him for a second term.
Hell have no bigger backer than yours truly, the governor said. I think thats really the base case right now. In the meantime, Im gonna have my nose pressed against the Jersey glass.
MORE: President Murphy? N.J. governor could run for White House if Biden doesnt.
Murphy said hes focused on New Jersey morning, noon and night.
Asked if he has met with donors about a 2024 campaign, he said: Ive met with no donors about my personal ambitions in that respect.
Murphy acknowledged a pair of political organizations formed by allies that could raise his national profile. He said those are focused mostly getting the word out in terms of what weve done in New Jersey.
Our journalism needs your support. Please subscribe today to NJ.com.
Brent Johnson may be reached at bjohnson@njadvancemedia.com. Follow him at @johnsb01.
Introduction
Benign paroxysmal positional vertigo (BPPV) is characterized by sudden onset of vertigo elicited by change of head position. BPPV is the most common cause of vertigo, with an idiopathic etiology in the majority of cases. Idiopathic BPPV can be defined when the etiology of BPPV is unrecognizable, and common conditions, which can be associated with secondary BPPV, include head trauma, vestibular neuritis, Menieres disease, sudden sensorineural hearing loss and postsurgical. BPPV most commonly involves the posterior semicircular canal (PSCC), followed by the lateral semicircular canal (LSCC); however, several recent studies have shown that LSCC BPPV might be more common than reported previously.14 Because spontaneous remission often occurs in BPPV,57 the time interval from onset of vertigo to initial evaluation should be considered when estimating the true incidence of BPPV subtypes. Additionally, patient-perceived subjective vertigo may vary among individuals with BPPV, which can thus affect hospital use behavior. Furthermore, patient referral systems may keep patients with BPPV waiting pending the results of initial evaluations at the OPD clinics of tertiary hospitals. We have recently reported that the incidence of BPPV subtypes differs according to the type of hospital visit, ie, whether the patient is evaluated at the outpatient department (OPD) vs emergency room (ER).8
The coronavirus disease 2019 (COVID-19) pandemic has markedly impacted patient and provider lifestyles, including patterns of healthcare system use. During the severe crisis period, only emergency and oncology services were active in the tertiary referral medical center, as was the case in many other hospitals. Because dizzy patients may be concerned that hospitals are high-risk environments for COVID-19 infection, the pattern of hospital visit behavior in these patients may be different from that prior to the pandemic. We hypothesized that COVID-19 pandemic affected the medical healthcare use behavior in patients with BPPV, eliciting the change in the diagnosis of BPPV. This study aimed to investigate the impact of COVID-19 on the incidence of BPPV subtypes by hospital visit type (OPD vs ER) in a single tertiary university hospital. We also compared the duration between symptom onset and the initial professional evaluation in different subtypes of BPPV.
The medical records of patients who presented with BPPV to the hospitals OPD and ER during and before the COVID-19 pandemic were retrospectively reviewed. A total of 517 patients diagnosed with idiopathic BPPV between March 2018 and December 2019 (before the COVID-19 pandemic) and a total of 435 patients diagnosed with idiopathic BPPV between March 2020 and December 2021 (during the COVID-19 pandemic) were included in this study. Neurological examinations were performed in each patient, and brain magnetic resonance imaging (MRI) was performed in patients with additional neurological abnormalities, and in those with severe imbalance, ataxia, and isolated vertigo with ocular movements suggesting central disorders such as gaze-evoked nystagmus, vertical or pure torsional spontaneous nystagmus, skew deviation or perverted head-shaking nystagmus. Nystagmus was examined using a video-oculography system in all BPPV patients at OPD and ER.
This study included only typical BPPV, including canalolithiasis-type PSCC BPPV, geotropic LSCC BPPV, and apogeotropic LSCC BPPV, and BPPV was diagnosed according to the clinical practice guidelines of the American Academy of Otorhinolaryngology-Head and Neck Surgery and Barany Society.9,10 PSCC BPPV was diagnosed when upbeat-torsional nystagmus was provoked by the DixHallpike test. Geotropic LSCC BPPV was diagnosed when positional geotropic nystagmus lasting less than 1 min was induced by a head-roll test. Geotropic nystagmus was defined when the right-beating nystagmus was observed upon right head-rolling and the left-beating nystagmus was observed upon left head-rolling. Apogeotropic LSCC BPPV was diagnosed when positional apogeotropic nystagmus lasting longer than 1 min was provoked by the head-roll test. Apogeotropic nystagmus was defined when the left-beating nystagmus was observed upon right head-rolling and the right-beating nystagmus was observed upon left head-rolling.
Patients with superior semicircular canal (SSCC) BPPV, multicanal BPPV, recurrent BPPV, or central positional nystagmus were excluded from this study. To include cases of idiopathic BPPV, patients with suspected secondary BPPV, such as those with a current or recent history of inner ear disease, were excluded. Patients with post-traumatic BPPV or post-surgery conditions were excluded. Patients diagnosed with BPPV during severe medical illnesses, such as those undergoing chemotherapy or hemodialysis, were also excluded. Ninety-eight patients with apogeotropic LSCC BPPV underwent diffusion-weighted brain MRIs in the ER, all of which revealed no acute brain lesions. Routine contrast-enhanced brain MRIs, which were conducted on only two OPD patients with apogeotropic LSCC BPPV, demonstrated no abnormal findings.
SPSS version 24.0 (IBM SPSS, Armonk, NY, USA) was used for statistical analyses. The chi-square test or Fishers exact test was used for categorical variables, and Students t-test or MannWhitney U-test was used for continuous variables. We conducted ShapiroWilk test to examine if the samples are from a normally distributed population before performing Students t-test, and MannWhitney U-test was used in cases that the data tested are not assumed to be normally distributed. To assess the homogeneity of variances, Levenes test of Equality of Variances was used in Students t-test. For categorical variables, Fishers exact test was used instead of chi-square test when more than 20% of cells have expected frequencies <5. A p value <0.05 was considered significant. This study was approved by the local institutional review board of Konkuk University Medical Center (No. 2022-04-042). Informed consents were exempted from all participants; this study is a retrospective study using only medical records. The study was conducted according to the guidelines of the Declaration of Helsinki for studies on human subjects.
A total of 517 and 435 patients were diagnosed with idiopathic BPPV before (March 2018 and December 2019) and during (March 2020 and December 2021) the COVID-19 pandemic period, respectively. The patients mean age was 54.6 12.9 years (range, 2083 years) before the COVID-19 pandemic and 55.2 17.2 years (range, 1484 years) during the pandemic; however, these findings were not significantly different (p = 0.156, Students t-test). The male-to-female ratios were 141 (27%): 376 (73%) before the COVID-19 pandemic, and 129 (30%): 306 (70%) during the pandemic; these findings were also not significantly different (p = 0.417, chi-square test). The right-to-left ratio of the involved side was 253:264 before the COVID-19 pandemic and 216:219 during the pandemic, which was not significantly different (p = 0.825, chi-square test). Thirty-eight percent of BPPV patients (199/517) was diagnosed at the OPD before the COVID-19 pandemic, and 39.3% of BPPV patients (171/435) were diagnosed at the OPD during the pandemic; the proportion of patients with BPPV evaluated at the OPD was not significantly different between the two periods (p = 0.741, chi-square test).
Of the 517 BPPV patients before the COVID-19 pandemic, 198 (38%) were diagnosed with PSCC BPPV, 102 (20%) with geotropic LSCC BPPV, and 217 (42%) with apogeotropic LSCC BPPV (Table 1). Among the 198 patients with PSCC BPPV, more patients were diagnosed at the OPD (106/198 [54%]) than at the ER (92/198 [46%]) (Table 1). However, more patients were diagnosed at the ER than OPD in geotropic LSCC BPPV (76/102 [75%] at ER vs 26/102 [25%] at OPD) and apogeotropic LSCC BPPV (150/217 [69%] at ER vs 67/217 [31%] at OPD) (Table 1). Compared with PSCC BPPV, significantly higher proportions of patients were diagnosed at the ER in geotropic LSCC BPPV and apogeotropic LSCC BPPV (Figure 1). The mean time interval from vertigo onset to diagnosis was significantly longer in patients with PSCC BPPV (7.58 16.13 days; range, 0120 days) than in those with geotropic LSCC BPPV (2.05 6.17 days; range, 052 days) or apogeotropic LSCC BPPV (3.32 11.31 days; range, 0120 days) (Table 1, Figure 2). Irrespective of BPPV subtype, the mean time interval between vertigo onset and diagnosis was remarkably longer in BPPV patients diagnosed at the OPD than those who were diagnosed at the ER (Table 1, Figure 3).
Table 1 Number of Patients and Mean Duration Between Symptom Onset and Evaluation According to BPPV Subtype During the Period Before COVID-19 Pandemic (Mar. 2018 ~ Dec. 2019)
Figure 1 Proportion of patients (%) with PSCC BPPV, geotropic LSCC BPPV, and apogeotropic LSCC BPPV by hospital visit type before and during the COVID-19 pandemic. Significantly higher proportions of geotropic LSCC BPPV (p < 0.001, chi-square test) and ageotropic LSCC BPPV (p < 0.001, chi-square test) patients were diagnosed in the ER compared with those with PSCC BPPV in both before and during the COVID-19 pandemic. The proportion of patients who were diagnosed at the ER was not significantly different from those diagnosed at the OPD in PSCC BPPV (p = 0.084, chi-square test).
Abbreviations: Apo, apogeotropic; BPPV, benign paroxysmal positional vertigo; COVID-19, coronavirus disease 2019; ER, emergency room; Geo, geotropic; LSCC, lateral semicircular canal; OPD, outpatient department; PSCC, posterior semicircular canal.
Figure 2 Mean time interval between symptom onset and clinical evaluation by BPPV subtype before and during the COVID-19 pandemic. Before COVID-19 pandemic, the mean time interval was significantly longer in patients with PSCC BPPV (7.58 16.13 days) than in those with geotropic LSCC BPPV (2.05 6.17 days, p = 0.001, MannWhitney U-test) or apogeotropic LSCC BPPV (3.32 11.31 days, p = 0.002, MannWhitney U-test). During COVID-19 pandemic, the mean time interval was significantly longer in patients with PSCC BPPV (14.22 39.00 days) than in those with geotropic LSCC BPPV (1.48 2.33 days, p = 0.001, MannWhitney U-test) or apogeotropic LSCC BPPV (2.94 8.05 days, p < 0.001, MannWhitney U-test). The mean time interval was remarkably longer during the COVID-19 pandemic than before the COVID-19 pandemic in PSCC BPPV (p < 0.001, MannWhitney U-test).
Abbreviations: Apo, apogeotropic; BPPV, benign paroxysmal positional vertigo; COVID-19, coronavirus disease 2019; Geo, geotropic; LSCC, lateral semicircular canal; PSCC, posterior semicircular canal.
Figure 3 Differences in mean time intervals between symptom onset and clinical evaluation according to BPPV subtype by hospital visit type before and during the COVID-19 pandemic. Before the COVID-19 pandemic, the mean time interval for patients who were assessed at the OPD vs the ER was 12.92 20.43 days vs 1.41 3.14 days for PSCC BPPV (p < 0.001, MannWhitney U-test), 6.62 10.98 days vs 0.49 1.13 days for geotropic-LSCC BPPV (p < 0.001, MannWhitney U-test), and 9.70 18.76 days vs 0.47 1.69 days for apogeotropic-LSCC BPPV (p < 0.001, MannWhitney U-test), respectively. During the COVID-19 pandemic, the mean time interval for the patients who were diagnosed at the OPD vs ER was 22.26 47.68 days vs 0.90 1.46 days for PSCC BPPV (p = 0.001, MannWhitney U-test), 4.10 2.98 days vs 0.70 1.37 days for geotropic LSCC BPPV (p < 0.001, MannWhitney U-test), and 10.07 13.39 days vs 0.39 0.66 days for apogeotropic LSCC BPPV (p < 0.001, MannWhitney U-test), respectively.
Abbreviations: Apo, apogeotropic; BPPV, benign paroxysmal positional vertigo; COVID-19, coronavirus disease 2019; ER, emergency room; Geo, geotropic; LSCC, lateral semicircular canal; OPD, outpatient department; PSCC, posterior semicircular canal.
Of the 435 BPPV patients during the COVID-19 pandemic, 163 (37%) were diagnosed with PSCC BPPV, 116 (27%) with geotropic LSCC BPPV, and 156 (36%) with apogeotropic LSCC BPPV (Table 2). The BPPV subtype distribution according to hospital visit type was similar before and during the COVID-19 pandemic. Among the 163 patients with PSCC BPPV, more patients were diagnosed at the OPD (102/163 [63%]) than at the ER (61/163 [37%]) (Table 2). However, more patients were diagnosed at the ER than at the OPD in geotropic LSCC BPPV (88/116 [76%] vs 28/116 [24%]) and apogeotropic LSCC BPPV (115/156 [74%] vs 41/156 [26%]) (Table 2). Significantly higher proportions of patients were diagnosed at the ER in geotropic LSCC BPPV and apogeotropic LSCC BPPV compared with PSCC BPPV (Figure 1). The mean time interval was significantly longer for PSCC BPPV (14.22 39.00 days; range, 0365 days) than for geotropic LSCC BPPV (1.48 2.33 days; range, 030 days) or apogeotropic LSCC BPPV (2.94 8.05 days; range, 060 days) (Table 2, Figure 2). Irrespective of BPPV subtype, the mean time interval was significantly longer in patients diagnosed at the OPD than the ER (Table 2, Figure 3).
Table 2 Number of Patients and Mean Duration Between Symptom Onset and Evaluation According to BPPV Subtype During the Period of COVID-19 Pandemic (Mar. 2020 ~ Dec. 2021)
We then compared the incidence of BPPV subtypes and symptom duration prior to hospital visits between the periods before and during the COVID-19 pandemic. Irrespective of BPPV subtype, the proportion of patients who were evaluated at the ER was not significantly different from those evaluated at the OPD in geotropic LSCC BPPV (p = 0.370, chi-square test), apogeotropic LSCC BPPV (p = 0.335, chi-square test), and PSCC BPPV (p = 0.084, chi-square test, Figure 1). However, while the mean time interval from vertigo onset to diagnosis was also not significantly different before and during the COVID-19 pandemic in geotropic LSCC BPPV (p = 0.309, MannWhitney U-test) and apogeotropic LSCC BPPV (p = 0.367, MannWhitney U-test), in the case of PSCC BPPV, the mean time interval was remarkably longer during the COVID-19 pandemic than before the COVID-19 pandemic (p < 0.001, MannWhitney U-test, Figure 2). We then investigated the actual change in the proportion of BPPV patients during the COVID-19 pandemic. The numbers of patients who visited our ENT OPD or those who were evaluated by ENT specialists at the ER during COVID-19 pandemic (16,835 OPD patients, 1980 ER patients) and before the pandemic (22,149 OPD patients, 3059 ER patients) was calculated. The proportion of BPPV patients at the OPD was 0.90% (199 of 22,149) before the COVID-19 pandemic and 1.02% (171/16,835), which was not significantly different (p = 0.237, chi-square test). However, the proportion of BPPV patients at the ER was 10.40% (318 of 3059) before the COVID-19 pandemic and 13.3% (264/1980), which show significant difference (p < 0.001, chi-square test) (Table 3).
Table 3 Change in the Proportion of BPPV Patients Before and During COVID-19 Pandemic
In the present study, we compared the incidence of BPPV subtypes and the mean time interval from vertigo onset to initial evaluation in patients with BPPV before and during the COVID-19 pandemic. The results demonstrated that although the incidence of BPPV subtypes according to hospital visit type was not significantly different before and during the COVID-19 pandemic, the mean time interval between vertigo onset and initial evaluation in patients with PSCC BPPV became significantly longer during the COVID-19 pandemic.
Several previous studies have investigated the impact of the COVID-19 pandemic on the hospital visit behavior of patients with dizziness, with controversial results. Ueda et al investigated the impact of the COVID-19 pandemic on OPD follow-up cancellations by dizziness/vertigo patients in a university hospital and found that while most of the patients who cancelled during the COVID-19 pandemic had BPPV, patients with Menieres disease had the least number of cancellations during the COVID-19 pandemic.11 Li et al compared the demographic characteristics and etiological distribution of dizziness/vertigo patients in the OPD during and before the COVID-19 pandemic and demonstrated that although the absolute number of dizziness/vertigo patients decreased 40.4% during the COVID-19 pandemic, the proportion of BPPV diagnoses in dizziness/vertigo patients increased from 30.7% to 35%.12 Waissbluth et al reported that a high proportion of consultations for vertigo were observed, although overall number of medical consultations dropped significantly due to preventive lockdown during COVID-19 pandemic; furthermore, the number of consultations for BPPV increased 183% during COVID-19 pandemic compared with pre-pandemic levels.13 Parrino et al reported that there were no differences in the absolute number of acute audio-vestibular disorders during the COVID-19 pandemic compared with previous periods, and sudden hearing loss during the pandemic seemed worse in terms of hearing threshold, and with a higher incidence of associated vestibular involvement.14 Di Mauro et al evaluated 33 patients with acute vertigo after COVID-19 vaccination, and BPPV was diagnosed in 9 (27%) of 33 patients.15 Other studies have suggested the COVID-19 infection as a cause of BPPV.16,17 Due to the limited access to medical care provider during the COVID-19 pandemic, telemedicine for diagnosis and treatment of BPPV was proposed as a good alternative.1820
To our knowledge, this study is the first to examine the impact of COVID-19 on the incidence of BPPV subtypes by hospital visit (OPD vs ER), and the mean time interval between vertigo onset and primary evaluation. Our data demonstrated that the total number of BPPV patients who were diagnosed in the ER and OPD decreased by 15.9% (517 to 435) during the COVID-19 pandemic compared with pre-pandemic levels. Age and sex distributions were not significantly different between the two time periods. Remarkably, the proportion of BPPV patients diagnosed at the OPD was significantly higher for PSCC BPPV than for LSCC BPPV during both periods (Figure 1). So why are patients with LSCC BPPV being diagnosed more commonly in the ER than in the PSCC BPPV? It has been reported that patient-perceived severity of vertigo is more intense with LSCC BPPV than with PSCC BPPV, leading to increased treatment urgency among patients with LSCC BPPV.21,22 In addition, spontaneous resolution of LSCC BPPV occurs more quickly and easily in than with PSCC BPPV;57 as a result, PSCC BPPV patients with longer symptom durations may be more likely to seek treatment at the OPD. Finally, under Koreas healthcare delivery system, before being evaluated at the OPD of a tertiary referral center, patients with BPPV must usually wait for several days after undergoing an initial evaluation by a primary care physician.
Another interesting finding of our research was that LSCC BPPV was a more common subtype than PSCC BPPV prior to and during the pandemic (Tables 1 and 2), which was inconsistent with most previous studies that reported a higher incidence of PSCC BPPV.9,10,23 However, if we estimate the incidence of BPPV subtypes in patients who were diagnosed at the OPD, PSCC BPPV was the most common subtype, which is consistent with previous study findings. Furthermore, considering that many patients with PSCC BPPV might have been diagnosed at a primary health care clinic without being referred to a tertiary referral center, the actual incidence of PSCC BPPV is probably higher than that estimated in the present study. On the other hand, we suspect that the incidence of LSCC BPPV might also have been underestimated because spontaneous remission of this subtype is more likely, and, consequently, the natural course of LSCC BPPV is shorter.57 In the present study, we demonstrated that PSCC BPPV is more commonly diagnosed in the OPD setting than LSCC BPPV, and that LSCC BPPV is more common than PSCC BPPV in the ER setting. Indeed, although it is known that PSCC is the most common subtype of BPPV,9,24 the diagnosis appeared to have been made at the OPD in most studies that reported higher incidences of PSCC BPPV.2529 Further studies are needed to clarify the true incidence of BPPV subtypes.
It is noteworthy that the mean time interval from onset of PSCC BPPV symptoms to hospital evaluation was significantly longer during the COVID-19 pandemic than it was before the pandemic, whereas the interval was not significantly in cases of geotropic and apogeotropic LSCC BPPV. This finding may be explained by the fact that LSCC BPPV patients had more severe symptoms and thus visited the hospital earlier despite treatment limitations during the COVID-19 pandemic, whereas the pandemic delayed hospital visits for patients with PSCC BPPV whose symptoms were less severe and more tolerable. Another interesting finding was that although the proportion of BPPV patients was not changed significantly between during and before the COVID-19 at the OPD, the proportion of BPPV patients significantly increased during COVID-19 pandemic at the ER.
This study has two primary limitations intrinsic to an incidence study. First, because this study was conducted at a single tertiary referral center, it is difficult to generalize our results to other facilities and populations. Second, because patients with atypical BPPV including SSCC BPPV, posttraumatic BPPV, multiple canal BPPV, and secondary BPPV were excluded from the study, the incidence in the present study may not represent all BPPV populations.
The present study demonstrated that no differences were observed in the incidence of BPPV subtypes by hospital visit type (OPD vs ER) during the COVID-19 pandemic when compared with pre-pandemic levels. In patients with PSCC BPPV, the mean interval between vertigo onset and the first evaluation was remarkably longer during the pandemic period. Telemedicine or e-medicine may be considered to improve hospital accessibility in similar circumstances, in order to minimize delays in clinical evaluation and treatment.
COVID-19, coronavirus disease 2019; ER, Emergency room; OPD, outpatient department; BPPV, benign paroxysmal positional vertigo; PSCC, posterior semicircular canal; LSCC, lateral semicircular canal; SSCC, superior semicircular canal.
This paper was supported by Konkuk University in 2022.
The authors declare no conflicts of interest in this work.
1. Kong TH, Song MH, Shim DB. Recurrence rate and risk factors of recurrence in benign paroxysmal positional vertigo: a single-center long-term prospective study with a large cohort. Ear Hear. 2021;43(1):234241.
2. Nahm H, Han K, Shin JE, Kim CH. Benign paroxysmal positional vertigo in the elderly: a single-center experience. Otol Neurotol. 2019;40:13591362. doi:10.1097/MAO.0000000000002385
3. Chung KW, Park KN, Ko MH, et al. Incidence of horizontal canal benign paroxysmal positional vertigo as a function of the duration of symptoms. Otol Neurotol. 2009;30:202205. doi:10.1097/MAO.0b013e31818f57da
4. Choi S, Choi HR, Nahm H, Han K, Shin JE, Kim CH. Utility of the bow and lean test in predicting subtype of benign paroxysmal positional vertigo. Laryngoscope. 2018;128:26002604. doi:10.1002/lary.27142
5. Shim DB, Ko KM, Lee JH, Park HJ, Song MH. Natural history of horizontal canal benign paroxysmal positional vertigo is truly short. J Neurol. 2015;262:7480. doi:10.1007/s00415-014-7519-0
6. Imai T, Ito M, Takeda N, et al. Natural course of the remission of vertigo in patients with benign paroxysmal positional vertigo. Neurology. 2005;64:920921. doi:10.1212/01.WNL.0000152890.00170.DA
7. Imai T, Takeda N, Ito M, Inohara H. Natural course of positional vertigo in patients with apogeotropic variant of horizontal canal benign paroxysmal positional vertigo. Auris Nasus Larynx. 2011;38:25. doi:10.1016/j.anl.2010.05.011
8. Kim CH, Jeong H, Shin J, Locke R, Kontorinis G. Incidence of idiopathic benign paroxysmal positional vertigo subtype by hospital visit type: experience of a single tertiary referral center. J Laryngol Otol. 2022;14. doi:10.1017/S0022215122000299
9. Bhattacharyya N, Gubbels SP, Schwartz SR, et al. Clinical practice guideline: benign paroxysmal positional vertigo (update). Otolaryngol Head Neck Surg. 2017;156:S1s47. doi:10.1177/0194599816689667
10. von Brevern M, Bertholon P, Brandt T, et al. Benign paroxysmal positional vertigo: diagnostic criteria. J Vestib Res. 2015;25:105117. doi:10.3233/VES-150553
11. Ueda K, Ota I, Yamanaka T, Kitahara T. The impact of the COVID-19 pandemic on follow-ups for vertigo/dizziness outpatients. Ear Nose Throat J. 2021;100:163s168s. doi:10.1177/0145561320980186
12. Li C, Guo D, Ma X, Liu S, Liu M, Zhou L. The impact of coronavirus disease 2019 epidemic on dizziness/vertigo outpatients in a neurological clinic in China. Front Neurol. 2021;12:663173. doi:10.3389/fneur.2021.663173
13. Waissbluth S, Garca-Huidobro F, Araya-Cspedes M. The impact of COVID-19 preventive lockdowns on the prevalence of benign paroxysmal positional vertigo. Medwave. 2021;21:e8174. doi:10.5867/medwave.2021.03.8174
14. Parrino D, Frosolini A, Toninato D, Matarazzo A, Marioni G, de Filippis C. Sudden hearing loss and vestibular disorders during and before COVID-19 pandemic: an audiology tertiary referral centre experience. Am J Otolaryngol. 2022;43:103241. doi:10.1016/j.amjoto.2021.103241
15. Di Mauro P, La Mantia I, Cocuzza S, et al. Acute vertigo after COVID-19 vaccination: case series and literature review. Front Med. 2021;8:790931. doi:10.3389/fmed.2021.790931
16. Maslovara S, Koec A, Yaman H. Post-COVID-19 benign paroxysmal positional vertigo. Case Rep Med. 2021;2021:9967555. doi:10.1155/2021/9967555
17. Picciotti PM, Passali GC, Sergi B, De Corso E. Benign paroxysmal positional vertigo (BPPV) in COVID-19. Audiol Res. 2021;11:418422. doi:10.3390/audiolres11030039
18. Bashir K, Yousuf A, Rauf L, Dewji M, Elmoheen A. Curing Benign Paroxysmal Positional Vertigo (BPPV) through telehealth: a case series. Cureus. 2021;13:e16363. doi:10.7759/cureus.16363
19. Harrell RG, Schubert MC, Oxborough S, Whitney SL. Vestibular rehabilitation telehealth during the SAEA-CoV-2 (COVID-19) pandemic. Front Neurol. 2021;12:781482. doi:10.3389/fneur.2021.781482
20. Barreto RG, Yacovino DA, Teixeira LJ, Freitas MM. Teleconsultation and teletreatment protocol to diagnose and manage patients with Benign Paroxysmal Positional Vertigo (BPPV) during the COVID-19 pandemic. Int Archiv Otorhinolaryngol. 2021;25:e141e149. doi:10.1055/s-0040-1722252
21. Martens C, Goplen FK, Aasen T, Nordfalk KF, Nordahl SHG. Dizziness handicap and clinical characteristics of posterior and lateral canal BPPV. Eur Arch Otorhinolaryngol. 2019;276:21812189. doi:10.1007/s00405-019-05459-9
22. Kim MJ, Kim KS, Joo YH, Park SY, Han GC. The dizziness handicap inventory and its relationship with vestibular diseases. J Int Adv Otol. 2012;8:6977.
23. Cakir BO, Ercan I, Cakir ZA, Civelek S, Sayin I, Turgut S. What is the true incidence of horizontal semicircular canal benign paroxysmal positional vertigo? Otolaryngol Head Neck Surg. 2006;134:451454. doi:10.1016/j.otohns.2005.07.045
24. Parnes LS, Agrawal SK, Atlas J. Diagnosis and management of benign paroxysmal positional vertigo (BPPV). Cmaj. 2003;169:681693.
25. Marciano E, Marcelli V. Postural restrictions in labyrintholithiasis. Eur Arch Otorhinolaryngol. 2002;259:262265. doi:10.1007/s00405-001-0445-7
26. Wolf JS, Boyev KP, Manokey BJ, Mattox DE. Success of the modified Epley maneuver in treating benign paroxysmal positional vertigo. Laryngoscope. 1999;109:900903. doi:10.1097/00005537-199906000-00011
27. Katsarkas A. Benign paroxysmal positional vertigo (BPPV): idiopathic versus post-traumatic. Acta Otolaryngol. 1999;119:745749. doi:10.1080/00016489950180360
28. Korres S, Balatsouras DG, Kaberos A, Economou C, Kandiloros D, Ferekidis E. Occurrence of semicircular canal involvement in benign paroxysmal positional vertigo. Otol Neurotol. 2002;23:926932. doi:10.1097/00129492-200211000-00019
29. Honrubia V, Baloh RW, Harris MR, Jacobson KM. Paroxysmal positional vertigo syndrome. Am J Otol. 1999;20:465470.
President Biden responded to a heckler while delivering remarks in Milwaukee on Monday, saying, Everybodys entitled to be an idiot.
Biden traveled to Wisconsin on Labor Day to deliver a speech at Milwaukee Laborfest, where he spoke about his support for unions and lauded Democratic legislative victories such as last years coronavirus relief package and a bill to invest in domestic semiconductor manufacturing that he signed into law last month.
At one point, someone in the audience could be heard trying to disrupt the speech.
No, no, no, dont let him go. Hes, look, everybodys entitled to be an idiot, Biden said.It was not immediately clear what prompted the heckling or what the person was saying.
Biden also responded to protesters while delivering a prime-time speech at Independence Hall in Philadelphia on Thursday. Hecklers shouted F Joe Biden and the anti-Biden phrase Lets go, Brandon.
Theyre entitled to be outrageous. This is a democracy, Biden said during that speech, also saying, Good manners is nothing theyve ever suffered from.
Bidens stop in Wisconsin comes two months ahead of the November midterms. Wisconsin Gov. Tony Evers (D) and Democratic Senate nominee Mandela Barnes are gearing up for high-profile contests against Republican gubernatorial candidate Tim Michels and Sen. Ron Johnson (R-Wis.), respectively.
Please select whether you belong to a Medical Aid:
Your Medical Aid will pay the Government directly for this vaccine. This will not influence your day-to-day, savings or any other benefit.
You will not be required to pay for this vaccine and no co-payment/levy will be required.
CDC Approves Updated Boosters Shots of COVID-19 Vaccine - City and County of Denver
opens in new tab or window
Published on September 02, 2022
DENVER The Centers for Disease Control and Prevention (CDC) approved two new booster shots by Pfizer-BioNTech and Moderna that take aim at the latest strains and variants of COVID-19. The bivalent formulations of the vaccines were approved for use as a single booster dose at least two months following primary or booster vaccination. The vaccines are safe and have been tested to meet the Food and Drug Administration (FDA) and CDCs rigorous scientific standards. The vaccines were formally approved for use by the FDA on Aug. 31.
Until now, COVID-19 vaccines have targeted the original SARS-CoV-2 virus, while both new U.S. boosters are combination, or bivalent, shots. They contain half the original vaccine formula and half protection against the newest omicron variants, BA.4 and BA.5, considered the most contagious yet. The updated boosters are only for people who have already completed their primary vaccination series using the original vaccines. Age eligibility requirements are different for each booster:
Moderna COVID-19 Vaccine, Bivalent: Individuals 18 years of age and older are eligible for a single booster dose if it has been at least two months since they have completed primary vaccination or have received the most recent booster dose with any authorized or approved monovalent COVID-19 vaccine.
Pfizer-BioNTech COVID-19 Vaccine, Bivalent: Individuals 12 years of age and older are eligible for a single booster dose if it has been at least two months since they have completed primary vaccination or have received the most recent booster dose with any authorized or approved monovalent COVID-19 vaccine.
"As we continue to navigate the endemic phase of COVID-19, we have been consistent in our messaging that vaccinations and boosters are the way for our Denver community to stay as safe as possible, said Bob McDonald, DDPHE executive director. This updated vaccine is an additional tool to use to stay protected. As we head into fall, we expect to see a surge in COVID-19 cases, as is typical for respiratory illnesses. Getting the approved bivalent vaccine is essential in staying protected from the newer variants of COVID-19.
The bivalent vaccines should not be used for initial vaccinations. The COVID-19 vaccines, including boosters, continue to save lives and prevent hospitalization and death. Heading into fall, as people begin to spend more time indoors, the Denver Dept. of Public Health & Environment (DDPHE) strongly encourages anyone who is eligible to consider receiving a booster dose with a bivalent COVID-19 vaccine to provide better protection against currently circulating variants.
DDPHE is in close coordination with the Colorado Department of Public Health & Environment on the rollout of the updated boosters.
Schedule your COVID-19 vaccine at the Kansas City Health Department | KCMO.gov - City of Kansas City, MO
Please enable JavaScript in your browser for a better user experience.
City Hall Departments Health COVID-19 (Coronavirus) - KCMO Information and Response
Choose a day:
New Booster to Protect Against Omicron Variant- We await shipment of the FDA & CDC approved Bivalent Vaccine Boosters (aka 'the updated boosters.') The Bivalent Boosters provide better protection against the Omicron variant.
Because these boosters are now approved, we will no longer be able to provide the original boosters. We expect to resume booster doses the week of September 12.
COVID Vaccines for Children- The Kansas City Health Department has pediatric vaccine of Pfizer and Moderna for children six months and older.
What vaccinations does KCHD offer?
See chart below.
Boosters
+Awaiting shipment of 'Updated Boosters' approved 9/1/2022
+Single dose for 12 yrs+
+To be given at least 2 months after last dose
+Single dose for 18 yrs+
+To be given at least 2 months after last dose+
2 months after initial dose for 18+
**From CDC: Waiting eight weeks between first and second Pfizer & Moderna doses may be better for some people 12 years and older, especially for males ages 12 to 39 years.
2-shot series: 2 doses, 4 weeks apart
Do I need an appointment?Appointments are preferred, but walk-ins are welcome. If you have family and friends who need help filling out the sign-up form, please tell them to call 311, and a member of our team will help them.
Where is the Kansas City Health Department Clinic located?The address is: 2400 Troost Ave, KCMO 64108
Hours for COVID Vaccination ClinicMonday - Thursday8:00 a.m. - 6:00 p.m.(Closed from 12:00 - 12:30 p.m. for lunch)Check-in by 5:15 p.m.
Friday8:30 a.m. - 11:15 a.m.1:00 p.m. - 4:00 p.m.
