The Omicron BA.2.12.1 subvariant is now the dominant COVID-19 variant in the US, responsible for 58% of recorded new coronavirus cases in the last week alone. "I'm in Connecticut, and it's like 80% of all sequences that we see right now," says Anne Hahn, PhD., postdoctoral researcher at the Yale School of Public Health. Here are the five most dangerous spots to catch COVID-19, according to experts. Read on to find out moreand to ensure your health and the health of others, don't miss Already Had COVID? These Symptoms May "Never Go Away".
Indoor gatherings such as weddings and parties are still dangerous, warns the World Health Organization. "In the context of the COVID-19 pandemic, there is no 'zero risk' when it comes to any kind of gathering especially events that bring groups of people together," says the WHO. "Regardless of the size of the event, you are at risk from COVID-19 whenever you get together with people. The virus that causes COVID-19 spreads easily indoors, especially in poorly ventilated settings."
Planning a family cruise this summer? The CDC has lifted its warning on cruise ship travel, but virus experts are still recommending caution. "This means to prepare for the cruise, all four of you should be fully vaccinated and boosted," says Jessica Justman, infectious diseases specialist and epidemiologist at the Columbia University Irving Medical Center, who recommends travelers make sure their ship has opted into the CDC's Covid-19 Program for Cruise Ships. "I suggest completing all booster doses a few weeks, and at least one week, before the trip starts. I would also be interested in how many inpatient beds and medical personnel are on the cruise and compare that to the number of passengers. One might confirm that the cruise follows guidelines such as the cruise ship health care guidelines from the American College of Emergency Physicians."
Buffets are risky due to close contact with both customers and staff. "While common utensils theoretically could lead to transmission of COVID from hand to spoon to hand, we actually don't have any good examples in clusters of COVID illnesses that surfaces really matter as much as people all standing close to each other does," says Benjamin Chapman, Ph.D., professor and food safety specialist in the department of Agricultural and Human Sciences at North Carolina State University. "Managing social distancing and line-ups is really the hardest part. Or in situations where staff will serve patrons from a buffet, the staff and patron interaction is the riskiest part."
Indoor gyms are still highly problematic in terms of catching the virus, experts warn. "If you're not willing to get COVID don't go," says Dr. Michael Klompas, a hospital epidemiologist and infectious disease physician at Brigham and Women's Hospital. "At a time like now, when there's a lot of COVID around, it is a high risk proposition."
Social distancing is practically impossible in airports, with people standing next to each other in check in and security lines and sitting close together on planes. "Avoid common-touch surfaces, hand hygiene wherever possible, masks, distancing, controlled-boarding procedures, try to avoid face-to-face contact with other customers, try to avoid being unmasked in flight, for meal and drink services, apart from when really necessary," says David Powell, physician and medical adviser to the International Air Transport Association. "The greatest protection you can give yourself is to be vaccinated and boosted."6254a4d1642c605c54bf1cab17d50f1e
Follow the public health fundamentals and help end this pandemic, no matter where you liveget vaccinated or boosted ASAP; if you live in an area with low vaccination rates, wear an N95 face mask, don't travel, social distance, avoid large crowds, don't go indoors with people you're not sheltering with (especially in bars), practice good hand hygiene, and to protect your life and the lives of others, don't visit any of these 35 Places You're Most Likely to Catch COVID.
Ferozan Mast
The past two and a half years have been a global crash course in infection prevention. Theyve also been a crash course in basic math: Since the arrival of this coronavirus, people have been asked to count the meters and feet that separate one nose from the next; theyve tabulated the days that distance them from their most recent vaccine dose, calculated the minutes they can spend unmasked, and added up the hours that have passed since their last negative test.
What unites many of these numbers is the tendency, especially in the United States, to pick thresholds and view them as binaries: above this, mask; below this, dont; after this, exposed, before this, safe. But some of the COVID numbers that have stuck most stubbornly in our brains these past 20-odd months are now disastrously out of date. The virus has changed; we, its hosts, have as well. So, too, then, must the playbook that governs our pandemic strategies. With black-and-white, yes-or-no thinking, we do ourselves a disservice, Saskia Popescu, an epidemiologist at George Mason University, told me. Binary communication has been one of the biggest failures of how weve managed the pandemic, Mnica Feli-Mjer, of the nonprofit Ciencia Puerto Rico, told me.
Here, then, are five of the most memorable numerical shorthands weve cooked up for COVID, most of them old, some a bit newer. Its long past time that we forget them all.
2 doses = fully vaccinated
At the start of the vaccination campaign, getting dosed up was relatively straightforward. In the United States, a pair of Pfizer or Moderna shots (or just one Johnson & Johnson), then a quick two-week wait, and boom: full vaccination, and that was that. The phrase became a fixture on the CDC website and national data trackers; it spurred vaccine mandates and, for a time in the spring and summer of 2021, green-lit the immunized to doff their masks indoors.
Then came the boosters. Experts now know that these additional shots are essential to warding off antibody-dodging variants such as the many members of the Omicron clan. Some Americans are months past their fifth COVID shot, and the nations leaders are weighing whether vaccinated people will need to dose up again in the fall. To accommodate those additions, the CDC has, in recent public communications, tried to shift its terminology toward up to date. Katelyn Jetelina, an epidemiologist at the University of Texas Health Science Center at Houston, prefers that phrase, because it allows for flexibility as recommendations evolve. It also more effectively nods at the range of protection that vaccination affords, depending on how many doses someones gotten and when their most recent dose was.
But fully vaccinated has been hard to shake, even for the CDC. The agency, which did not respond to requests for comment, maintains that the original definition has not changed, and the term still features heavily on CDC websites. Maybe part of the stubbornness is sheerly linguistic: Up to date means something different to everyone, depending on age, eligibility, health status, and vaccine brand. Fully vaccinated is also grabby in a way that up to date is not. It carries the alluring air of completion, suggesting that youre actually done with the vaccine series, maybe even the pandemic overall, Jessica Malaty Rivera, an epidemiologist and adviser at the Pandemic Prevention Institute, told me. All of this may be partly why that uptake of boosterswhich sound optional, even trivial, compared with the first two shotsremains miserably low in the U.S.
< 6 feet + > 15 minutes = close contact
Since the pandemics early days, Americans have been taught to benchmark our risk of exposure to the virus by two metrics: proximity and duration. Get within six feet of an infected person for at least 15 minutes over a 24-hour period, and congratulationsyouve had a close contact. Even now, the CDC advises that this kind of encounter should trigger 10 full days of masking and, depending on your vaccination status and recent infection history, a test and/or a five-day quarantine.
Thresholds such as these made some sense when researchers werent yet savvy to the viruss main modes of transmission, and at least some efforts were made to contact trace, Jetelina told me. You needed some metric so you could call people. Nearly all contact-tracing attempts, though, have long since fizzled out. And scientists have known for years that SARS-CoV-2 can hitch a ride in bubbles of spittle and snot small enough to drift across rooms and remain aloft for hours, especially in poorly ventilated indoor spaces. Pathogens dont slam up against a magic wall at the six-foot mark, Malaty Rivera said. Nor will viruses bide their time for 14 minutes and 59 seconds before launching themselves noseward at 15 minutes on the dot. Exposure is a spectrum of high to low risk that factors in, yes, proximity and duration, but also venue, ventilation, mask quality, and more, Popescu said. Its not just exposed or not exposed.
The CDC acknowledges that SARS-CoV-2 can move beyond six feetbut the scientific justification behind its guidelines on preventing transmission was last updated in May 2021, just before the Delta variant bamboozled the nation. Since then, the coronavirus has gotten even more contagious and craftybetter at transmitting, better at dodging the antibodies that people raise. Even passing interactions and encounters have led to people becoming exposed and infected, Malaty Rivera said, especially if people are indoors and a ton of virus is being volleyed about. And yet, the mantra of six feet, 15 minutes has stayed. Schools have even cut the guidance in half, counting close contact only when children are less than three feet apart.
5 days = end of isolation
In the beginning, isolation numbers loomed large: Infected people had to wait at least 10 days after their symptoms began, or after their first positive test result, before they could reenter the world. Then, at the start of 2022, the CDC slashed the duration of isolation to just five days for people with mild or asymptomatic cases (regardless of vaccination status), as long as they kept masking and avoided travel through day 10. You didnt even need a negative test to go about your life.
This guideline has been perpetually behind the times. For much of 2021, truncating isolation might have made sense for vaccinated people, who clear the coronavirus faster than folks who havent gotten their shots, especially if negative tests confirmed the safety of exit. But only after the rise of Omicron did the guidance changeand it was based mostly on pre-Omicron data. The shift in guidance arrived just in time for the coronavirus to bust it wide open. After nearly two years of COVID symptoms starting around the time people first began to test positive, test positivity with Omicron and various iterations is now quite frequently lagging the onset of illness. Many people now report strings of negative results early in their symptom course, then positives that persist into their sixth, seventh, or eighth day of sickness or later, raising the possibility that they remain quite contagious past when formal isolation may end. I find it impossible to believe you can end isolation without testing, Malaty Rivera said.
Read: A negative COVID test has never been so meaningless
And yet, many workplaces have already embraced the five-day rule with no exit test, using that timeline as the basis for when employees should return. With masks largely gone, and paid sick leave so uncommon, defaulting to five days could drive more transmissionin some cases, likely inviting people back into public when theyre at their infectious peak.
Infection + 90 days = no retest
According to CDC guidelines, people who have caught SARS-CoV-2 dont need to test or quarantine if theyre exposed again within 90 days of their initial infection. This recommendation, which appeared in the pandemics first year, was designed in part to address the positives that can crop up on PCR tests in the weeks after people stop feeling sick. But the CDC also touts the low risk of subsequent infection for at least 6 months on one of its pages, last updated in October 2021. Reinfections can occur within 90 days, but thats early.
That framing might have once been pretty solid, before the era of widespread at-home antigen testingand before the rise of antibody-dodging variants, Popescu said. However, reinfections have gotten more common, and far closer together. They were happening even in the era of Delta; now, with so many immunity-evading Omicron offshoots at the helm, and masks and other mitigation matters mostly vanished, theyve become a quite-frequent fixture. The number of people who have caught the virus twice within just a matter of weeks has grown so much that we should forget these windows, Malaty Rivera said. Even the Department of Health and Human Services secretary recently tested positive twice in the same month.
Read: You are going to get COVID again and again and again
And yet, with these guidelines in place, many people have been lulled by the promise of rock-solid post-infection immunity, assuming that a new crop of symptoms are anything but COVID, Malaty Rivera said. That thinking is not only allowing a growing share of contagious coronavirus cases to go undetectedits also stymieing the study of reinfection dynamics writ large. Many studies, including those cited by the CDC in its guidance, wont even count reinfections earlier than 90 days. But the 90-day number, Malaty Rivera said, is no longer relevant. It has to be deleted from peoples minds.
200 cases + 10 hospital admissions per 100,000 = mask?
As obsolete as some of Americas COVID calculations may be, updates arent a universal win, either. Take the most recent iteration of mask recommendations from the CDC. The agency would like everyone to mask indoors if their county hits a high COVID community level, a threshold that is met only when the region logs 200 or more infections per 100,000 people in one week, and if local hospitals see more than 10 COVID-related admissions per 100,000 people in a week, or fill at least 15 percent of their inpatient beds. Currently, roughly 10 percent of U.S. counties are in the high category.
Read: The Biden administration killed Americas collective pandemic approach
But waiting to just suggest masks at those levels of transmission and hospitalizationnot even require themleaves far too much time for widespread disease, disability, even death, experts told me. A bar that high still lets long COVID slip through; it continues to imperil the vulnerable, immunocompromised, and elderly, who may not get the full benefit of vaccines. Case rates, Malaty Rivera pointed out, are also a terrible yardstick right now because so many people have been testing at home and not reporting the results to public-health agencies.
In Puerto Rico, Feli-Mjer and her colleagues have been struggling to reignite enthusiasm for mask wearing as their community battles its second-largest case wave since the start of the pandemic. A better system would flip on protections earliertaking a preventive approach, rather than scrambling to react. But thats a difficult stance for jurisdictions to assume when the official map looks so green and a little yellow, Feli-Mjer said. Its the problem of thresholds striking once again: No one cares to take up arms anew against the virus until the damage is already done. Thats made the pandemic that much easier to tune outits either here in full force, the thinking goes, or its totally gone. If only the calculus were that simple.
A syringe is prepared with the Pfizer COVID-19 vaccine at a vaccination clinic at the Keystone First Wellness Center in Chester, Pa. (AP file photo/Matt Rourke)
U.S. health authorities are facing a critical decision: whether to offer new COVID-19 booster shots this fall that are modified to better match recent changes of the shape-shifting coronavirus.
Moderna and Pfizer have tested updated shots against the super-contagious omicron variant, and advisers to the Food and Drug Administration were set to debate Tuesday if its time to make a switch setting the stage for similar moves by other countries.
This is science at its toughest, FDA vaccine chief Dr. Peter Marks told The Associated Press, adding that a final decision is expected within days of the advisory panels recommendation.
Current COVID-19 vaccines saved millions of lives around the world in just their first year of use. And the Moderna and Pfizer shots still offer strong protection against the worst outcomes severe illness and death especially after a booster dose.
But those vaccines target the original coronavirus strain and between waning immunity and a relentless barrage of variants, protection against infections has dropped markedly. The challenge is deciding if tweaked boosters offer a good chance of blunting another surge when theres no way to predict which mutant will be the main threat.
In an analysis prepared for Tuesdays meeting, FDA officials acknowledged targeting last winters version of omicron is somewhat outdated since it already has been replaced by its even more contagious relatives.
We would obviously like to get it right enough, Marks said, so that with one more shot we get a full season of protection.
Many experts say updated boosters promise at least a little more benefit.
It is more likely to be helpful than simply giving additional doses of todays vaccine, said epidemiologist William Hanage of the Harvard T.H. Chan School of Public Health.
Thats assuming the virus doesnt throw another curve ball.
Were following rather than getting ahead which is so vexing that we havent come up with a better variant-proof vaccine, said Dr. Eric Topol, head of the Scripps Research Translational Institute, who has urged a major government push for next-generation immunizations.
Adding to concern about a winter COVID-19 wave is that about half of Americans eligible for that all-important first booster dose never got it. An updated version might entice some of them.
But we do need to change our expectations, said Dr. William Moss of the Johns Hopkins Bloomberg School of Public Health, who noted that studies early in the pandemic raised unrealistic hopes of blocking even the mildest infections. Our strategy cant be booster doses every couple of months, even every six months, to prevent infections.
The top candidates are what scientists call bivalent shots a combination of the original vaccine plus omicron protection.
Thats because the original vaccines do spur production of at least some virus-fighting antibodies strong enough to cross-react with newer mutants in addition to their proven benefits against severe disease, said University of Pennsylvania immunologist E. John Wherry.
Being able to push the boost response a little bit in one direction or the other without losing the core is really important, he said.
Moderna and Pfizer found their combo shots substantially boosted levels of omicron-fighting antibodies in adults whod already had three vaccinations, more than simply giving another regular dose.
Recipients also developed antibodies that could fight omicrons newest relatives named BA.4 and BA.5, although not nearly as many. Its not clear how much protection that will translate into, and for how long.
Antibodies are a key first layer of defense that form after vaccination or a prior infection. They can prevent infection by recognizing the outer coating of the coronavirus the spike protein and blocking it from entering your cells.
But antibodies naturally wane and each new variant comes with a different-looking spike protein, giving it a better chance of evading detection by remaining antibodies. Separate studies published this month in Nature and the New England Journal of Medicine show the newest omicron relatives are even better at dodging antibodies both in the vaccinated and in people who recovered from the original omicron.
That first booster people were supposed to get strengthened immune memory, helping explain why protection against hospitalization and death is proving more durable. If the virus sneaks past antibodies, different defenders called T cells spring into action, attacking infected cells to curb illness.
T cells recognize the virus in a fundamentally different way, not hunting for disguised spike protein but for parts of the virus that so far havent been altered as much, said Penns Wherry.
Still, as people get older, all parts of their immune system gradually weaken. Theres little data on how long T cell protection against COVID-19 lasts or how it varies with different mutations or vaccines.
Wherry and dozens of other scientists recently petitioned the FDA to quit focusing solely on antibodies and start measuring T cells as it decides vaccination strategy.
The Biden administration has made clear that it needs Congress to provide more money so that if the FDA clears updated boosters, the government can buy enough for every American who wants one. And Dr. Anthony Fauci, the governments top infectious disease expert, told Congress last week more research funding also is critical to create better next-generation vaccines, such as nasal versions that might better block infection in the nose or more variant-proof shots.
The virus is changing and we need to keep up with it, Fauci, said.
The West Virginia Department of Health and Human Resources (DHHR) reports as of June 28, 2022, there are currently 1,993 active COVID-19 cases statewide. There has been one death reported since the last report, with a total of 7,057 deaths attributed to COVID-19.
DHHR has confirmed the death of a 65-year old female from Kanawha County.
We are saddened to report the loss of another West Virginian, and extend our sympathies to the family, said Bill J. Crouch, DHHR Cabinet Secretary. Please utilize the vaccine calculator to ensure you are up to date on your COVID vaccine.
CURRENT ACTIVE CASES PER COUNTY: Barbour (8), Berkeley (119), Boone (28), Braxton (16), Brooke (19), Cabell (104), Calhoun (8), Clay (11), Doddridge (6), Fayette (69), Gilmer (5), Grant (14), Greenbrier (59), Hampshire (21), Hancock (26), Hardy (14), Harrison (84), Jackson (18), Jefferson (75), Kanawha (197), Lewis (12), Lincoln (12), Logan (38), Marion (86), Marshall (29), Mason (26), McDowell (30), Mercer (73), Mineral (30), Mingo (16), Monongalia (110), Monroe (23), Morgan (15), Nicholas (34), Ohio (35), Pendleton (1), Pleasants (5), Pocahontas (5), Preston (23), Putnam (77), Raleigh (90), Randolph (21), Ritchie (8), Roane (30), Summers (15), Taylor (18), Tucker (9), Tyler (6), Upshur (47), Wayne (29), Webster (4), Wetzel (22), Wirt (3), Wood (86), Wyoming (24). To find the cumulative cases per county, please visit coronavirus.wv.gov and look on the Cumulative Summary tab which is sortable by county.
West Virginians ages 6 months and older are recommended to get vaccinated against the virus that causes COVID-19. Those 5 years and older should receive a booster shot when due. Second booster shots for those age 50 and over who are 4 months or greater from their first booster are recommended, as well as for younger individuals over 12 years old with serious and chronic health conditions that lead to being considered moderately to severely immunocompromised.
Visit the WV COVID-19 Vaccination Due Date Calculator, a free, online tool that helps individuals figure out when they may be due for a COVID-19 shot, making it easier to stay up-to-date on COVID-19 vaccination. To learn more about COVID-19 vaccines, or to find a vaccine site near you, visit vaccinate.wv.gov or call 1-833-734-0965.
To locate COVID-19 testing near you, please visit https://dhhr.wv.gov/COVID-19/pages/testing.aspx.
Commentary
The first case of the Corona Virus Disease-2019 (COVID-19) in Afghanistan was detected on 22 February 2020 in a person who had returned from Qom city, Iran.1 As of 30 May 2022, a total of 180,176 confirmed cases, including 7701 deaths, were reported to the World Health Organization (WHO). The recovery rate is reported to be around 90% and Case Fatality Rate to be 4.29%.2 However, it is said that the actual figures of the infected cases might be much higher than the reported numbers.3
Meanwhile, a total of 6,118,557 doses of the COVID-19 vaccine have been administered to the residents in the country.2 Afghanistan is the lowest among many nations in terms of the COVID-19 vaccine coverage. As per the official reports, around 10% of the total population are vaccinated thus far, which is way behind the proposed target for 2022, ie 60%.
Since the beginning of the pandemic, the COVID-19 has spread throughout the country in four waves. The first wave was reported to span from the end of April to June 2020; the second wave began by October 2020 and lasted until the end of December 2020; the third wave reportedly began by April 2021 and lasted until mid-August 2021.2
An analysis of the recent data uploaded by the District Health Information Software-2 (DHIS2) reveals that the fourth wave of the COVID-19 passed in March 2022. As shown in Figure 1, the peak numbers were reported during the month of February 2022 with highest confirmed cases in the first and second weeks, ie 3850 and 3847 cases, respectively. By March 2022, the cases began to decline until the curve almost fattened in April 2022.
Figure 1 The trend of the COVID-19 confirmed cases during JanApr 2022 (fourth wave).
The COVID-19 pandemic hit Afghanistan at a time when the country was politically undergoing changes, with a fragile healthcare system which was unable to respond to the emergence of COVID-19 and to the needs of the most vulnerable people. The government lacked the means to communicate adequately with the citizens, trace contacts, collect and test samples. In the beginning of the fight against COVID-19, the government had only one dedicated hospital, the Afghan Japan Hospital, for the provision of COVID-19 related services, including sample collection. A few months later, Ali Jinnah Hospital was also designated to treat COVID-19 patients in Kabul. In both these hospitals, the outpatient and inpatient clients were very high, making it almost impossible to provide the needed health services and case detection.
Before August 15, 2021, overall, a total of 38 COVID-19 hospitals were operating throughout the country, all of them funded by international donors. Alongside these, Rapid Response Teams (RRTs) and District Centers (DCs) were also established as part of the Emergency Response to COVID-19 to conduct risk communication sessions, collect samples of suspected cases, trace contacts and advice on mild and moderate cases to be treated at home. These actions were vital in helping to reduce the burden of the COVID-19 designated hospitals, and thus enabled them to focus on the management of severe and critical cases. After the collapse of the previous government, all funding and supports to the COVID-19 emergency response were reduced and most of the hospitals were forced to stop their operations due to lack of funds, doctors, medicine, and even heating.4
The lack of healthcare personnel to collect the samples of suspected individuals and the shortage of kits for laboratory diagnostic tests are still the major challenges in most districts of Afghanistan. High levels of financial insecurity in several parts of the country have had a large and direct negative effect on the provision and coverage of healthcare services for the general public.5 Unfortunately, many people who have received their first shots of the COVID-19 vaccine have not received the next dose due to shortage or unavailability of vaccine.6
Although the fourth wave of the COVID-19 passed with no clear and accurate data of the mortality and morbidities, it is assumed that the next wave might not be too far. Challenges such as the lack of or insufficient donor funds, unstable political situation, inadequate healthcare services, insufficient healthcare workers and diagnostic capacity, illiteracy of people, poor economy and shortage of the COVID-19 vaccine are threatening to push the nation towards a devastating stage. The de facto authority also does not seem to have a clear plan to fight against the pandemic. Therefore, the international community, civil societies, healthcare workers and other stakeholders should pool their efforts immediately to improve and restore the health system.
Fortunately, many COVID-19 hospitals resumed their operations with the funds provided by international donors; however, for the long term, the COVID-19 services should be integrated in the countrys existing healthcare services framework, ie the Sehatmandi project. Moreover, awareness campaigns should be continued to keep the most vulnerable groups safe and protected. Vaccination services also need to be speeded up to have a significant portion of people immunized. Public willingness towards getting the vaccine should be increased through awareness campaigns mostly conducted by social media volunteers and healthcare workers.
The authors would like to sincerely thank Dr. Pakeer Oothuman, a former professor of parasitology at the University Kebangsaan Malaysia and International Islamic University Malaysia, for editing the manuscript.
The authors declare no conflicts of interest in relation to this work.
1. Mousavi SH, Shah J, Giang HTN, et al. The first COVID-19 case in Afghanistan acquired from Iran. Lancet Infect Dis. 2020;20(6):657658. doi:10.1016/S1473-3099(20)30231-0
2. World Health Organization. COVID-19 dashboards - Afghanistan situation. Available from: https://covid19.who.int/region/emro/country/af. Accessed May 31, 2022.
3. Nemat A, Asady A. The third wave of the COVID-19 in Afghanistan: an update on challenges and recommendations. J Multidiscip Healthc. 2021;14:20432045. doi:10.2147/JMDH.S325696
4. Al-Jazeera. COVID surge batters Afghanistans crumbling healthcare. Available from https://www.aljazeera.com/gallery/2022/2/10/photos-covid-surge-batters-afghanistans-crumbling-healthcare. Accessed February 11, 2022.
5. Shah J, Karimzadeh S, Al-Ahdal TMA, et al. COVID-19: the current situation in Afghanistan. Lancet Global Health. 2020;8(6):e771e772. doi:10.1016/S2214-109X(20)30124-8
6. World Health Organization (WHO) Regional Office for the Eastern Mediterranean. COVID-19 vaccines shipped by COVAX arrive in Afghanistan, Available from: http://www.emro.who.int/afg/afghanistan-news/covid-19-vaccines-shipped-by-covax-arrive-in-afghanistan.html.Accessed June 23, 2022.
Introduction
The coronavirus disease 2019 (COVID-19) pandemic has had a substantial impact on medical practice,1,2 and the use of electroconvulsive therapy (ECT) as a general anesthetic procedure has been no exception. From the outset of the global pandemic, concerns have arisen worldwide about the disadvantages for patients who needed but were not able to receive ECT. In several countries with severe outbreaks of COVID-19, the number of ECT cases declined in 2020, and some facilities stopped ECT completely.3,4 In April 2020, a group of psychiatrists in the United States appealed vigorously to the medical community to support that ECT is an essential treatment modality, even with limited medical resources, and that some patients can only be effectively treated by ECT.5 Specialists in ECT then developed recommendations for the criteria to guide ECT introduction and infection control measures during the COVID-19 pandemic.6,7
In Japan, the total number of COVID-19 deaths was lower than that in most other countries, and the government did not enforce strict lockdowns throughout the pandemic.8,9 However, large increases in the number of COVID-19 infections occurred in five waves until October 2021 (Figure 1), which challenged the countrys ability to maintain essential medical services, including ECT. As in other countries, the rapid spread of COVID-19 infection caused confusion in clinical practice. The Japanese Society of General Hospital Psychiatry made its own recommendations regarding ECT during the pandemic,10 referring to the criteria proposed by ECT specialists as previously noted, and each facility decided on its criteria for introducing ECT and infection protection measures based on these domestic and international recommendations. However, the number of ECT cases and the degree of infection control required varied based on differences in infection status in different regions throughout Japan and at different time points throughout the pandemic, resulting in a wide range of approaches to the issue.
Figure 1 Number of new positive coronavirus disease 2019 (COVID-19) cases for patients hospitalized in Japan (based on the website of the Ministry of Health, Labour and Welfare, outbreaks in Japan, etc. https://www.mhlw.go.jp/stf/covid-19/kokunainohasseijoukyou.html, accessed December 14, 2021). The first survey was conducted in August 2020 and the second survey in August 2021. The number of electroconvulsive therapy (ECT) cases from April to June 2020 was compared with that from April to June 2021, which approximately corresponds to the first and fourth waves, respectively, of the COVID-19 pandemic.
ECT is widely used in Japan as well as other countries, and the number of ECTs being administered is increasing, with about 96,000 ECTs (0.76 per 1000 population) performed in 2019.11 The estimated number of ETCs performed in Canada is approximately 67,000 (2.112.13 per 1000 population). To the best of our knowledge, to date no studies have investigated how ECT practice in Japan has changed in response to the COVID-19 pandemic, the degree to which the impact of COVID-19 on ECT practices varied by region, and how the infection control measures of each facility changed in response to shifts in infection during the pandemic. Our study describes how facilities offering ECT have struggled during the COVID-19 pandemic in Japan. We surveyed healthcare institutions, primarily university and general hospitals, regarding the changes in the numbers of ECT cases and in their decisions related to ECT in each facility throughout the pandemic, from the first wave in April 2020, through the fourth wave in AprilJune 2021, to the fifth wave in August 2021. Based on these survey results, we discuss the best way to deliver the necessary treatment to patients who require ECT with appropriate protective measures and with an awareness of a next wave of pandemic in the future.
Two surveys were administered for this study. In the first survey, in August 2020, we used a mainly selective and partly descriptive questionnaire using Google forms12,13 (see Supplemental Digital Content 1). The questions were related to: 1) ECT delivery before the spread of COVID-19 infection; 2) protection measures for COVID infection for low- and high-risk cases; and 3) ECT delivery during COVID-19 pandemic. In these questions, the criteria for determining whether each case was at high risk for infection were determined by each facility. In the second survey conducted in August 2021, new questions were added, focusing on the changes in the situation after the first survey. To understand the changes between the early and recent stages of the pandemic, the numbers of patients who underwent ECT from April 2020 to March 2021 (during the pandemic) and from April 2019 to March 2020 (before the pandemic) were compared. Similarly, the number of patients undergoing ECT from April to June 2020 was compared with the number from April to June 2021.
The participants were ECT training facilities accredited by the Japanese Society of General Hospital Psychiatry (JSGHP) and facilities belonging to the members of the JSGHP ECT Committee. In both the first and second surveys, university and general hospitals accounted for more than 90% of the respondents. Of the 60 facilities contacted for the first survey, responses were collected from 46 facilities, of which 28 were university hospitals, 15 were general hospitals with beds, 2 were psychiatric hospitals, and 1 was a general hospital without beds. Out of the 61 facilities contacted for the second survey, responses were collected from 32 facilities, of which 21 were university hospitals, 9 were general hospitals with beds, 1 was a psychiatric hospital, and 1 was a general hospital without beds. A total of 28 facilities, comprising 20 university hospitals, 7 general hospitals with beds, and 1 general hospital without beds, responded to both the first and second surveys.
In addition, we compared the ECT cases throughout the pandemic waves in urban areas, where the impact of the pandemic was significant, with other non-urban areas. Facilities in urban areas were those located in the eight prefectures (Tokyo, Osaka, Kanagawa, Saitama, Aichi, Chiba, Hyogo, and Fukuoka) with more than 70,000 infected people as of December 13, 2021.13
This study has been granted an exemption by the Ethics Committee of Kyoto University Graduate School and Faculty of Medicine, and was conducted in compliance with the ethical standards set forth in the 1964 Declaration of Helsinki and its subsequent revisions.
Changes in the number of patients undergoing ECT throughout the COVID-19 pandemic are shown in Figure 2. The number of patients undergoing ECT decreased in 34.4% of facilities from April 2020 to March 2021 compared with the number from April 2019 to March 2020, whereas the number of patients undergoing ECT increased in 37.5% facilities from April to June 2021 compared with the number from April to June 2020. Urban areas had more facilities with a decrease in the number of patients between 2019 and 2020 than non-urban areas, whereas non-urban areas had more facilities with an increase between 2020 and 2021 than urban areas.
Figure 2 Change in the number of electroconvulsive therapy (ECT) cases. The number of ECT cases was compared from April 2020 to March 2021 (during the pandemic) with that from April 2019 to March 2020 (before the pandemic). Similarly, the number of ECT cases from April to June 2020 (the early stage) was compared with that from April to June 2021 (the recent stage).
In terms of the types of hospital, of the 21 university hospitals, the number of patients undergoing ECT decreased in 10 facilities (47.6%) from April 2020 to March 2021 compared with those from April 2019 to March 2020, whereas the number of patients undergoing ECT decreased in 8 facilities (38.1%) from April to June 2021 compared with those from April to June 2020. Of the 10 general hospitals, the number of patients undergoing ECT decreased in 2 facilities (20.0%) from April 2020 to March 2021 compared with those from April 2019 to March 2020, whereas the number of patients undergoing ECT decreased in 2 facilities (20.0%) from April to June 2021 compared with the number from April to June 2020. Trends in psychiatric hospitals could not be ascertained because only 1 facility responded.
In terms of ECT restrictions, 20 facilities (62.5%) had never restricted ECT; 12 (37.5%) had temporary restrictions, and 3 (9.4%) had ongoing restrictions. Comparison between urban and non-urban areas showed that 9 (64.3%) in urban areas were temporarily restricted versus 3 (16.7%) in non-urban areas. As shown in Table 1, in August 2021 there were no longer any facilities that did not offer ECT to patients with a low risk of infection, and there was a slight increase in the number of facilities offering ECT to patients with a high risk of infection. Regarding the change in the decision to use ECT, in August 2020, 13 facilities (28.2%) used ECT only in severe patients requiring this treatment, whereas 4 (12.6%) did so in August 2021. Regarding the change in maintenance of patients undergoing ECT in the first wave of the pandemic in April 2020, the number of patients remained constant in 28 facilities (75.7%) and decreased in 7 (18.9%), whereas therapy was no longer offered in 2 facilities (5.4%). In the fourth wave in AprilJune 2021, the number of patients undergoing ECT remained constant in 23 facilities (82.1%) and decreased in 3 facilities (10.7%), whereas therapy was no longer offered in 2 facilities (7.1%).
Table 1 Administration of Electroconvulsive Therapy in Cases with Low or High Risk for Coronavirus Disease 2019 Infection
At the time of the second survey in August 2021, all facilities had established infection control standards, and 28 facilities (87.5%) had hospital-wide standards. To develop infection control standards, one facility referred to the Guide to the Treatment of New Coronavirus Infections, COVID-19 that was prepared by the Ministry of Health, Labor and Welfare and another referred to the Use of Modified Electroconvulsive Therapy During the COVID-19 Pandemic by the JSGHP ECT Committee.
Table 2 shows the infection control measures used by psychiatrists during administration of ECT in low-risk patients. An increased use of eye shields was noted in 2021 compared with 2020. The most common type of equipment used was a combination of surgical masks (non-N95 masks) and eye shields. The equipment used by anesthesiologists and other medical staff was similar to that of the psychiatrists (see Supplemental Digital Content 2). In addition, most respondents reported that their patients undergoing ECT wore a surgical mask to protect them from infection. Also mentioned were the infection control approaches of covering the upper part of the body with plastic and using a head chamber. As shown in Table 3, the other most common infection prevention measures were polymerase chain reaction (PCR) testing and limiting the number of medical staff during ECT administration.
Table 2 Infection Control Measures Used by Psychiatrists for Electroconvulsive Therapy Cases with Low Risk of Coronavirus Disease 2019 Infection
Table 3 Infection Control Measures Other Than PPE for ECT Patients
The COVID-19 tests performed on admission at the time of the second questionnaire are shown in Table 4. More than 50% of the facilities performed PCR tests in all cases. In contrast, only a limited number of the facilities performed antigen and antibody tests. Moreover, some facilities required pre-hospital self-isolation for patients, which means staying indoors and completely avoiding contact with other people before their admission for ECT to avoid infection. At the time of the second survey, 6 facilities (18.7%) had a pre-hospital self-isolation requirement period, of which 4 (12.5%) mandated a period of 14 days.
Table 4 Tests for COVID-19 Performed on Admission (August 2021)
The number of ECT procedures was less affected in Japan than that in several other countries.3,4,1416 According to a previous paper from Canada, between mid-March and mid-May 2020, the number of ECT procedures in that country decreased in 64% of facilities, with procedures completely stopped in 27% of facilities.3 In the United Kingdom and Ireland in April 2020, 88% of facilities reported a decrease in the number of ECT procedures and 24% had stopped completely, and in July 2020, 78% of facilities still reported a decrease in the number of procedures.4 The lower impact of the pandemic on ECT practices in Japan may be due to the relatively small number of infected people and few restrictions on movement in the society such as lockdowns. Each time that the COVID-19 infection spread, the Japanese government introduced a state of emergency, but the stay-at-home guidelines were voluntary. Non-essential businesses were asked to close, but rarely faced penalties for not complying.17
A comparison of urban and non-urban areas in Japan shows a marked decline in the number of patients undergoing ECT and enforcement restrictions in urban areas. The recovery in the number of patients undergoing ECT in urban areas during the fourth wave in AprilJune 2021 was slower than in the first wave in April 2020, suggesting that the impact of the pandemic may be prolonged in urban areas.
In August 2021, more than 80% of facilities were using maintenance ECT at the same rate as before, but some were still restricted in their use. There is an urgent need to resume maintenance ECT to reach pre-pandemic levels, with priority given to patients at high risk of relapse. In a follow-up study of 81 patients for whom maintenance ECT was abruptly discontinued because of the COVID-19 pandemic, 36 patients (44.44%) relapsed within a 6-month observation period.18 In another study, the relapse rate also increased when the treatment was continued with a decreased frequency.19 Patients at higher risk of relapse were those with diagnoses other than major depressive disorder (ie, bipolar disorder, schizophrenia, schizoaffective disorder) and those with shorter intervals between maintenance ECT treatments. These findings clearly indicate that maintenance ECT is an essential treatment for which the accessibility to and frequency of administration should be stable, even in the pandemic.
Most facilities considered PCR testing before ECT if a patient was suspected to be infected with COVID-19. This strategy is recommended by several past reports.6,10,20 Furthermore, many facilities required all staff to wear surgical masks and eye shields during ECT. Some studies recommend the use of gloves, gowns, or head covers, in addition to masks and eye shields,6,10,2026 so it may be necessary to consider their use in Japan for future responses to infection and pandemic.
Another less common, but potentially effective, strategy is to cover the upper bodies of patients or to use ECT head chambers for them. Some reports suggest that if bag-mask ventilation (BMV) is needed for a significant desaturation, it may be helpful to cover the patients head with a plastic sheet2224 and to place a breathing circuit filter between the mask and valve.24,25 Because BMV is a known aerosolizing procedure,26 routine BMV should not be provided prior to ECT.23 In one chart review study, when patients were pre-oxygenated with a non-rebreather mask for 35 minutes, more than 50% of them did not require BMV and electroencephalography seizure duration did not decrease significantly.27
Our study revealed an increase in the use of ECT in patients who were not at low risk of infection in 2021. This finding may be explained by widespread awareness of the safety of ECT using proper infection control. It is conceivable that urgent cases for ECT included these patients groups: those at high risk of suicide, those rapidly deteriorating physically due to psychiatric symptoms, older adults with co-morbidities, or those with respiratory disease who have severe psychiatric symptoms but for whom pharmacotherapy is difficult, and other patients who, without ECT, are at risk of serious harm to themselves or others, including COVID-19 infection.10,28,29 Successful cases of ECT for urgent patients not at low risk of infection and even for infected patients have been reported.3034 For example, ECT in symptomatic patients has been reported in the United Kingdom in a 67-year-old man diagnosed with a major depressive episode with catatonic features. The patient presented with fever and decreased oxygen saturation prior to ECT and was found to be COVID-19 positive. Treatment for pneumonia was initiated, and 4 later the patient underwent ECT twice weekly for a total of six sessions. Infection control measures for this case included all staff wearing N95 masks, caps, visors, gowns, plastic aprons, shoe covers, and three pairs of gloves, and equipment was thoroughly disinfected before the next procedure. Glycopyrronium was also administered prior to treatment to inhibit respiratory secretion. During the procedure, BMV was avoided, intubation was performed after the use of an oxygen mask, and the psychiatrist and psychiatric nurse left the room during intubation and extubation.32 The infection control procedures in this case were practiced as recommended in other papers.35,36 To our best knowledge, no cases of ECT have been reported for infected people in Japan as of December 2021. In situations for which ECT must be performed in infected patients, it is necessary to implement ECT while taking sufficient infection control measures, referring to prior approaches used for cases globally.
In the COVID-19 pandemic, some cases of unfortunate outcomes occurred due to the inability to perform ECT.37,38 Of note, there was one case in which ECT was effective for neuropsychiatric symptoms in COVID-19.39 All these reports reaffirm the importance of ECT. We must continue to provide ECT to as many eligible patients as possible with appropriate infection control measures. It is not possible to predict how the widespread use of vaccines,40,41 the development of oral drugs,42 and the emergence of mutant43,44 strains for COVID-19 will affect the pandemic in the future. Therefore, it may still take some time before we will be able to offer ECT in the same way we did pre-pandemic.
This report has certain noteworthy limitations. The survey results may have been biased because this questionnaire only covered JSGHP training facilities and ECT committee members facilities. These facilities were relatively experienced in ECT practice, and most of them were general hospitals, including university hospitals. In a nationwide survey of psychiatric institutions in 2010, ECT was performed in 356 facilities and 217 facilities were psychiatric hospitals.45 We have not fully assessed the status of ECT implementation in psychiatric hospitals. In addition, the criteria regarding whether each case was at high risk for infection were not uniform, as they were based on each facilitys standards throughout the survey. Moreover, the exact number of ECT cases could not be determined because the question regarding the number of cases offered answer options with a number range, such as 15 cases, for ease of answering the questionnaire. Furthermore, the second survey covered the beginning of the fifth wave of the COVID-19 pandemic, which had the largest number of infections. Therefore, it is not possible to make a simple comparison with the first questionnaire, which was conducted during the period of convergence of the COVID-19 infection. Finally, it was unclear whether there was a shortage of anesthesiologists in Japan during the study period. Other countries reported that several cases of ECT were stopped due to a shortage of anesthesiologists, especially in the early stages of infection,3,37 and a survey that includes the perspective of anesthesiologists is needed in the future.
To the best of our knowledge, this study is unique because it analyzes the course of more than 1 year during the COVID-19 pandemic from 2020 to 2021. This survey showed that ECT was heavily affected by the pandemic in 2020, but by the summer of 2021, the number of ECT cases and the decisions to use ECT were returning almost to previous levels, with infection control measures in place.
Dr Hirotsugu Kawashima reports I received lecture fees from Otsuka, Dainippon-Sumitomo, Eisai, Meiji-Seika Pharma. Dr Takashi Tsuboi reports personal fees from Dainippon Sumitomo, personal fees from Takeda Pharmaceutical, personal fees from Pfizer, personal fees from Yoshitomi Yakuhin, personal fees from Tsumura, personal fees from Otsuka Pharmaceutical, personal fees from Mochida Pharmaceutical, personal fees from Kyowa Pharmaceutical, personal fees from Meiji-Seika Pharma, personal fees from Eisai, personal fees from Mitsubishi Tanabe Pharma, personal fees from MSD, personal fees from Shionogi, outside the submitted work; The authors declare no other conflicts of interest in this work.
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AUSTIN, Texas Austin Public Health (APH) is monitoring widespread transmission and declining immunity, including reinfections. Health officials recommendpreventive measuresto help minimize the spread of COVID-19 during Independence Day celebrations. Last week Travis CountysCOVID-19 Community Levelwas upgraded to medium.
With so many gathering and traveling to celebrate the holiday,indoor maskingis recommended, especially if youreat riskfor serious illness from COVID-19. Stay home if youre experiencingsymptoms, even if its just a scratchy throat or you think its just allergies. Before gathering, getup to datewith your COVID-19 vaccines, including anyrecommended booster doses, to protect yourself and your community.
"Were seeing concerning trends with our disease indicators which is especially worrisome as we head into a holiday weekend. The new omicron sublineages BA.4 and BA.5 are overtaking BA2.12 and are causing reinfections that are more likely to cause lung problems in at-risk people and may lead to hospitalization and the need for ICU care. People of all ages and risk levels will be gathering and should be mindful of each other, said Dr. Desmar Walkes, Austin-Travis County Health Authority. Test now, get up to date with your vaccines, and try to celebrate this weekend outdoors. Taking these steps will help protect loved ones and our hospital systems.
A key surveillance metric, new cases per 100K population in the last 7 days,climbed above 200a threshold signaling increased risk. Additionally, new COVID-19 hospital admissions per 100K population for the last week rose to 5.8, and the percent of staffed inpatient beds occupied by COVID-19 patients the last week rose to 2.5%.
We have highly-trained staff at our testing and vaccine sites that are here to help make sure you have a safe weekend with family and friends, said APH Director Adrienne Sturrup. We encourage families, especially those with young children, to come to our Old Sims clinic to start getting up to date with COVID-19 vaccines.
The Centers for Disease Control and Prevention (CDC) recommends COVID-19 vaccines for everyone 6 months and older. APH offers vaccine to all eligible age groups. While most children in Travis County get their vaccines from physicians offices, APH is prepared to fill in the gaps until supply is more widely available. Appointments arent required at the Old Sims Elementary Gymnasium clinic (1203 Springdale Rd., Austin, TX 78721).
TheShots for Tots programis also available for underserved communities.
Free N95 respirators
Wearing awell-fitting maskoffers protection for yourself and those around you. Free N95 respirators are available at some local pharmacies. Use afeature on the CDCs websiteto find a location near you.
Free COVID-19 tests
APH encourages testing before and after gatherings, especially if you plan to be in close contact with individuals who areat risk. Athird round of free mail-order COVID-19 test kitsis available through the federal government. You can also pick up free rapid antigen tests at APH's Metz Elementary testing site (84 Robert T. Martinez Jr. St., Austin, TX 78702).
Testing and Vaccination Information
Find vaccine providers usingVaccines.gov(Vacunas.govin Spanish) or by texting your zip code to 438829 (822862 in Spanish) to find a nearby clinic.
APH clinics offer COVID-19testingandvaccinationswithout an appointment, although creating an account online in advance saves time. COVID-19 vaccinations are free and require neither identification nor insurance. For more information and to schedule an appointment, call3-1-1or512-974-2000or visitwww.AustinTexas.gov/COVID19.
A list of Travis County vaccine distribution events can befound online.
The APH Mobile Vaccination Program brings vaccine clinics to businesses, churches and more. APH is asking all organizations to fill outan online formto request a pop-up clinic.
About Austin Public Health
Austin Public Healthis the health department for the City of Austin and Travis County. Austin Public Health works to prevent disease, promote health and protect the well-being of all by monitoring and preventing infectious diseases and environmental threats and educating about the benefits of preventative behaviors to avoid chronic diseases and improve health outcomes.
A study suggests people who catch covid-19 at least twice have double the risk of dying from any cause and are three times as likely to be hospitalised in the next six months, compared with people who test positive just once
By Michael Le Page
A person waits at a drive-in covid-19 PCR test site in Miami, Florida, in May
Daniel A. Varela/Miami Herald/Tribune News Service via Getty Images
You have been vaccinated and recently had covid-19, so you dont have to worry about catching it again, right? Wrong. A large study suggests that every time a person is reinfected, they have additional health risks, both during their immediate illness and in the months afterwards.
Every reinfection is like rolling the dice again, says Ziyad Al-Aly at VA St. Louis Health Care System in Missouri. A second infection is still bad for you.
These findings
WIMBLEDON, England -- Matteo Berrettini, last year's runner-up at Wimbledon, dropped out of the grass-court Grand Slam tournament hours before he was scheduled to play his first-round match Tuesday, saying that he tested positive for COVID-19.
The All England Club announced Berrettini's withdrawal, and he posted about it on Instagram, saying that he was "heartbroken" and has been isolating "the last few days" after experiencing flu-like symptoms.
He's the second high-profile player to pull out of the draw within the first two days because of the illness caused by the coronavirus, joining 2014 U.S. Open champion and 2017 Wimbledon finalist Marin Cilic, who was seeded 14th. The bracket is now without five of the top 11 in the ATP rankings: No. 1 Daniil Medvedev (ban on Russians ), No. 2 Alexander Zverev (ankle surgery), No. 8 Andrey Rublev (ban on Russians), No. 10 Hubert Hurkacz (lost Monday) and No. 11 Berrettini.
An All England Club spokesperson did not respond to a question about what the level of concern is about COVID-19 at the event but did say in an email that organizers have been working with the British public health agency and local authorities.
"We have maintained enhanced cleaning and hand sanitizing operations, and offer full medical support for anyone feeling unwell. We are following U.K. guidance around assessment and isolation of any potential infectious disease," the statement said. "Our player medical team also continue to wear face masks for any consultation.''
After being canceled in 2020 because of the pandemic, then setting up a bubble-type environment and restricting attendance in 2021 to try to prevent the spread of COVID-19, Wimbledon has returned to normal in every way, with no mask-wearing requirement, full crowds and its famous queue back in action.
"Despite symptoms not being severe, I decided it was important to take another test this morning to protect the health and safety of my fellow competitors and everyone else involved in the tournament," Berrettini wrote in his post, which included a black-and-white photo of him hitting a serve at Wimbledon.
"I have no words to describe the extreme disappointment I feel," he said. "The dream is over for this year, but I will be back stronger."
The eighth-seeded Italian player spent time practicing with Rafael Nadal on Centre Court last week and also crossed paths with Novak Djokovic there.
Berrettini was supposed to play 44th-ranked Cristian Garin in the first round on Tuesday. Berrettini was replaced in the field by Elias Ymer, who lost in qualifying but now will take on Garin.
2 Related
Berrettini was considered a title contender for Wimbledon -- because of last year's run to his first Grand Slam final at the All England Club before losing to Djokovic and because of his recent form on grass.
"I mean, he is definitely [one of the] top two, three players in the world on grass in the last three years. I mean, his results are testament to that," Djokovic said on Monday about Berrettini. "Probably, this is his favorite surface. For his game, it's the most suitable surface. So there is a lot of expectations on his side that he should go far in this tournament."
Berrettini, a 26-year-old who relies on big serves and big forehands, won two tuneup tournaments on the surface this month, going 9-0 at Stuttgart, Germany, and at Queen's Club in London.
That was how he returned to action after being sidelined since March because of an operation on his right hand.
In all, since the start of 2019, he is 32-3 on grass. Two of those three losses came against six-time Wimbledon winner Djokovic and eight-time champion Roger Federer.
Two other singles players left the tournament Tuesday because of injuries: Danka Kovinic (lower back) and Wang Xiyu (left thigh). Kovinic was replaced in the field by Lesley Pattinama Kerkhove, who faces Sonay Kartal.
Three-time Grand Slam semifinalist Grigor Dimitrov also retired from his first-round match at Wimbledon, against American opponent Steve Johnson, after having a medical evaluation of his leg.
Eighteenth-seeded Dimitrov won the first set 6-4 and was trailing 5-2 in the second when he stopped playing on No. 2 Court.
Dimitrov, who is from Bulgaria, reached the last four at the All England Club in 2014, when he was 23.
