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In a recent study published in Nutrients, researchers investigated whether vitamin D supplementation before the onset of coronavirus disease 2019 (COVID-19) could provide benefits.
Study:Preventive Vitamin D Supplementation and Risk for COVID-19 Infection: A Systematic Review and Meta-Analysis. Image Credit:FotoHelin/Shutterstock.com
Vitamin D is fat-soluble and synthesized in the epidermis; metabolic processes are required for its activation. 1,25-hydroxyvitamin D is the primary end product of these processes.
It binds to the vitamin D receptor (VDR) that mediates a majority of the vitamins effects, promoting the expression of genes with specific sequences.
The interplay between VDR, vitamin D, and repressor/promoter proteins has a crucial impact on bone mineral density.
Around 3% of the human genome is controlled by 1,25-dihydroxyvitamin D; as such, vitamin D is speculated to regulate muscle function, metabolism, immune responses, and oncogenesis, among others. The effects of vitamin D in disease, including COVID-19, are under scrutiny.
Available data support that adequate vitamin serum levels may be protective against COVID-19 incidence and mortality; however, this has not been validated.
The present study examined whether prophylactic vitamin D supplementation pre-COVID-19 could yield beneficial outcomes.
They searched the MEDLINE/PubMed, Scopus, Google Scholar, and Cochrane databases for randomized controlled trials (RCTs) and quasi-experimental, case-control, cross-sectional, and cohort studies with relevant quantitative data on vitamin D supplementation before COVID-19 diagnosis and its role against the disease.
The study population comprised patients or healthcare workers (HCWs). The primary outcome was COVID-19 incidence; secondary outcomes were COVID-19-related admission to the intensive care unit (ICU) and mortality.
The researchers excluded studies with insufficient data and those that did not meet the population, intervention, comparison, outcome, and study design (PICOS) criteria. There were no restrictions on the language or year of publication.
Two authors screened the literature, and studies were included after a full-text review. Data on relevant parameters were extracted. The team computed odds ratios and corresponding 95% confidence intervals as effect measures.
Study quality and bias were evaluated using distinct assessment tools specific to the type of study. Statistical heterogeneity was assessed using 2 and I2 statistics. Publication bias was assessed using funnel plots and Eggers linear regression.
Overall, the team selected 16 publications for analysis. Seven studies were RCTs, and eight were analytical studies. Five RCTs included HCWs, and two included patients. RCTs compared vitamin D supplementation with no treatment or high- vs. low-dose regimens.
COVID-19 incidence was assessed in 13 studies, ICU admission in three, and mortality in 11. The frequency of supplementation varied across studies.
Fifteen studies reported the precise dose of vitamin D. Controls received a placebo, low-dose vitamin D, or none. In RCTs, vitamin D supplementation was associated with a lower risk of infection despite the substantial degree of heterogeneity.
In RCTs on HCWs, the risk reduction with supplementation was approximately 80%, with negligible heterogeneity. The prevalence of vitamin D insufficiency and deficiency was consistent across these studies.
In RCTs on non-HCW populations, vitamin D supplementation did not affect the COVID-19 infection rate. Notably, the treatment group received a lower-dose regimen compared to other studies.
The researchers speculate that the low dose and low prevalence of vitamin D deficiency might have contributed to the lack of an effect. There was a protective role of supplementation among analytical studies, albeit the heterogeneity was high.
Only one RCT evaluated COVID-19 mortality and reported that vitamin D recipients had significantly reduced mortality.
Further, no association was observed between vitamin D supplementation and COVID-19 mortality in analytical studies. Moreover, vitamin D supplementation was protective against COVID-19-related ICU admission.
The study assessed the protective effects of vitamin D supplemented before COVID-19 onset on disease incidence, ICU admission, and mortality.
RCTs and analytical studies reported a decline in COVID-19 in vitamin D recipients, especially in populations with increased incidence of vitamin D insufficiency and deficiency. Notably, the number of studies analyzed was smaller than prior meta-analyses.
However, unlike the current study, they focused on other aspects, viz., supplementation during COVID-19. Besides, several studies in this analysis lacked data on the prevalence of vitamin D insufficiency and deficiency and the vitamin D formulation, i.e., calcitriol, cholecalciferol, etc.
Overall, the findings support the use of vitamin D in preventing COVID-19 and associated complications, particularly in individuals with vitamin D deficiencies.
COVID-19 is known to cause loss of smell in certain patients. While this symptom is generally temporary, approximately 10% of patients may suffer from it for 6 months or more.
Earlier research carried out by a team of researchers from INRAE and ENVA observed that the SARS-CoV-2 infected olfactory mucosa is invaded by immune cells leading to its destruction and prolonged inflammation. Based on these observations, the same team decided to assess the effectiveness of corticosteroids--known for their anti-inflammatory properties-;in restoring the sense of smell.
Their results support the existence of a direct link between the loss of smell caused by the virus and a decrease in the olfactory neuron population in the nasal mucosa. In addition, they show that early treatment with dexamethasone, a commonly used corticosteroid, improves the recovery of olfactory abilities in animals.
The improvement of the olfactory capacities is associated with a reduction of the immunity cells in the mucosa, and an increased level of regeneration of the olfactory neuron population. These results suggest that the corticosteroid treatments currently used-;which have not been very successful in the treatment of prolonged anosmia-;could be more effective if prescribed early, at the onset of symptoms of loss of smell.
Source:
Journal reference:
Merle-Nguyen, L., et al. (2024). Early corticosteroid treatment enhances recovery from SARS-CoV-2 induced loss of smell in hamster.Brain, Behavior, and Immunity. doi.org/10.1016/j.bbi.2024.02.020.
BOSTON (AP) Four years after the COVID-19 pandemic closed schools and upended child care, the CDC says parents can start treating the virus like other respiratory illnesses.
Gone are mandated isolation periods and masking. But will schools and child care centers agree?
In case youve lost track: Before Friday, all Americans, including school children, were supposed to stay home for at least five days if they had COVID-19 and then mask for a set period of time, according to the Centers for Disease Control and Prevention.
Now, with COVID deaths and hospitalizations dropping, the CDC says children can go back to school when their overall symptoms improve and theyre fever-free for 24 hours without taking medication. Students are encouraged to wear a mask when they return.
Still, the change may not affect how individual schools urge parents to react when their children fall sick. Schools and child care providers have a mixed record on following CDC recommendations and often look to local authorities for the ultimate word. And sometimes other goals, such as reducing absences, can influence a state or districts decisions.
The result can be a confusing array of policies among states and districts, not to mention workplaces confounding parents whose lives have long been upended by the virus.
This is so confusing, said Gloria Cunningham, a single mom in the Boston area. I just dont know what I should think of COVID now. Is it still a monster?
Cunningham, who manages a local store for a national restaurant chain, said her company requires her to take off 10 days if she gets COVID-19. And the school system where her son is in second grade has still been sending home COVID test kits for kids to use before returning to school after long breaks.
I feel like we should just do away with anything that treats COVID differently or keep all of the precautions, she said.
The public education system has long held varying policies on COVID. During the 2021-2022 school year, only 18 states followed CDC recommendations for mask-wearing in class. When the CDC lifted its masking guidelines in February of 2022, states like Massachusetts followed suit, but California kept the mask requirement for schools.
And in the child care world, some providers have long used more stringent testing and isolation protocols than the CDC has recommended. Reasons have ranged from trying to prevent outbreaks to keeping staff healthy both for their personal safety and to keep the day care open.
Some states moved to more lenient guidelines ahead of the CDC. California and Oregon recently rescinded COVID-19 isolation requirements, and many districts followed their advice.
In an attempt to minimize school absences and address an epidemic of chronic absenteeism, California has encouraged kids to come to school when mildly sick and said that students who test positive for coronavirus but are asymptomatic can attend school. Los Angeles and San Diegos school systems, among others, have adopted that policy.
But the majority of big-city districts around the country still have asked parents to isolate children for at least five days before returning to school. Some, including Boston and Atlanta, have required students to mask for another five days and report positive COVID-19 test results to the school.
Some school leaders suggest the CDCs previous five-day isolation requirement was already only loosely followed.
Official policy in Burlington, Massachusetts, has been to have students stay home for five days if they test positive. But Superintendent Eric Conti said the real policy, in effect, is: Its a virus. Deal with it.
Thats because COVID is managed at home, using the honor system.
Without school-based testing, no one can enforce a five-day COVID policy, he said via text message.
Ridley School District in the Philadelphia suburbs was already using a policy similar to the new CDC guidelines, said Superintendent Lee Ann Wentzel. Students who test positive for COVID must be fever-free without medication for at least 24 hours before returning to school. When they come back, they must mask for five days. Wentzel said the district is now considering dropping the masking requirement because of the new CDC guidance.
A school or day cares specific guidelines are consequential for working parents who must miss work if their child cant go to school or child care. In October 2023, during simultaneous surges of COVID, respiratory syncytial virus and influenza, 104,000 adults reported missing work because of child care issues, the highest number in at least a decade. That number has fallen: Last month, child care problems meant 41,000 adults missed work, according to the Bureau of Labor Statistics.
Melissa Colagrossos child care center in West Virginia dropped special guidelines for COVID about a year ago, she said. Now, theyre the same as other illnesses: A child must be free of severe symptoms such as fever for at least 24 hours before returning to the center.
We certainly are treating COVID just like we would treat flu or hand, foot and mouth disease, said Colagrosso, CEO of A Place To Grow Childrens Center in Oak Hill.
As for kids without symptoms who test positive for COVID? Most parents have stopped testing kids unless they have symptoms, Colagrasso said, so its a quandary she has not encountered.
Still, some parents worry the relaxed rules put their communities at greater risk. Evelyn Alemn leads a group of Latino and Indigenous immigrant parents in Los Angeles County. The parents she represents, many of whom suffer from chronic illnesses and lack of access to health care, panicked when California did away with isolation requirements in January.
I dont think theyre considering what the impact will be for our families, she said of California officials. It feels like they dont care that were almost expendable.
Other impacts of the pandemic linger, too, even as restrictions are lifted. In Ridley, the Philadelphia-area district, more students are reclusive and struggle to interact in-person with peers, said Wentzel, the superintendent. Interest in school dances has plummeted.
Emotionally, Wentzel said, theyre having trouble.
Balingit reported from Washington.
The Associated Press education coverage receives financial support from multiple private foundations. AP is solely responsible for all content. Find APs standards for working with philanthropies, a list of supporters and funded coverage areas at AP.org.
New York to follow CDC's updated COVID-19 isolation guidance
by Steven Pappas
Four years after COVID-19 shut down much of the world, the CDC is making changes to its COVID-19 isolation guidance. (File photo)
Four years after COVID-19 shut down much of the world, the CDC has now made changes to its COVID-19 isolation guidance.
People who test positive for the virus will no longer have to isolate at home for five days. Instead, the CDC says you can return to normal activities after you're fever-free for 24 hours.
The rule change marks the first time the agency has revised its COVID guidelines since 2021.
On Friday, The New York State Department of Health announced it will follow the CDC's new directives.
Regardless of the CDC rules, experts say people should still use common sense when dealing with COVID-19.
If you are sick stay home. Stay home until you are feeling better for about 24 hours, said Kate Ott, Ontario County's Health Director. I think what the CDC is saying makes very good sense, but it does not negate the risk of transmission."
Ott also suggests being aware of personal space, and washing your hands.
For those who are over the age of 65 or maybe immunocompromised, it is still recommended that you get tested if symptoms develop.
If you have older folks in your family, parents, grandparents, great-grandparents, or people who have auto-immune illnesses or have had a transplant...these are some of the folk now that could really get severely ill from any of these viruses, cautioned Ott.
Strong and Highland hospitals announced that the new policy will not change their current requirement of a five day isolation.
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The emergence of the COVID-19 pandemic caused by the novel coronavirus, SARS-CoV-2, has evolved into a global health crisis. Initially focused on respiratory symptoms, it's now clear that COVID-19 presents a complex clinical picture affecting various organ systems32,33. Neurological manifestations have gained attention for their potential impact on both immediate clinical care and long-term health outcomes34,35. This systematic review and meta-analysis aimed to provide a comprehensive assessment of the abnormal neuroimaging findings in children with COVID-19.
Our findings reveal that a substantial proportion of pediatric COVID-19 patients with neurological symptoms exhibit abnormal neuroimaging findings, with 43.74% of children in the included studies demonstrating such abnormalities. These findings underscore the importance of considering neurological complications in the management of pediatric COVID-19 cases.
In a systematic review conducted by Choi et al. an extensive exploration was undertaken to comprehensively assess the spectrum of COVID-19-related neurological manifestations and associated abnormal neuroimaging findings in adults. Their meta-analysis unveiled that 42.6% of adult patients exhibited abnormal neuroimaging findings, as observed through brain CT or MRI36. With acute to subacute infarcts were the most common (24.0%), followed by cerebral micro hemorrhages (6.9%), acute spontaneous intracerebral hemorrhages (5.4%), and encephalitis/encephalopathy (3.3%)36. It is important to note that their investigation exclusively centered on specific COVID-19-related neuroimaging findings in the adult population and specifically considered MRI and CT as the imaging modalities of interest, although acknowledging that alternate modalities such as OCT, and TCD are also utilized.
In contrast, our study takes a unique approach, focusing exclusively on the pediatric group of COVID-19 patients, which is an area with limited research. Additionally, we aimed to cover a wide range of neuroimaging findings using diverse range of methods commonly used in pediatric cases. This broader scope is in response to the frequent use of various imaging techniques in pediatric clinical settings, extending the depth of our investigation.
In terms of specific neuroimaging abnormalities, our analysis categorized them into neurovascular findings, ADEM-like lesions, encephalitic pattern, myelitis, transient splenial lesions, and other findings. Neurovascular findings, encompassing findings like arterial or venous stroke, exhibited a pooled incidence of 8.22%. ADEM-like lesions showed a pooled incidence of 7.69%. Encephalitic pattern, including findings like Acute Hemorrhagic Necrotizing Encephalitis, showed a pooled incidence of 13.95%. Myelitis had a pooled incidence of 4.60%. Transient splenial lesions, encompassing findings like RESLES and MERS, exhibited a pooled incidence of 16.26%. Other abnormalities, such as PRES, neuritis, and brain edema, had a pooled incidence of 12.03%. These findings emphasize the diversity of neurological involvement in pediatric COVID-19 cases, spanning from inflammatory processes to vascular events.
In a recent systematic review led by Falsaperla et al. in 2023, undertook an exhaustive examination of COVID-19-related neurological manifestations in the pediatric population. Although this study primarily emphasized clinical symptoms, it did not include a meta-analytic assessment. Nevertheless, their conclusions align closely with our own findings, albeit with distinct categorization. Their results highlighted that encephalitis represented the most frequent diagnosis, accounting for 20.83% of cases, followed by seizures (10.42%), GBS (10.42%), cerebrovascular involvement (10.42%), ADEM (8.33%), and encephalopathy (8.33%). Additionally, a fraction of cases exhibited neurological signs secondary to central nervous system lesions (4.17%), and peripheral neuropathy (4.17%)37.
The cellular and molecular basis of SARS-CoV-2's ability to affect the nervous system is not fully understood. In light of this, several theoretical mechanisms have been posited to shed light on the acute and postacute neurological manifestations associated with COVID-19. Firstly, one hypothesis proposes that SARS-CoV-2 exhibits an affinity for infecting olfactory neurons, subsequently spreading through axons and across the synapse, thereby causing central nervous system infection38. Secondly, considering the viral-induced depletion of ACE-2, there is a perturbation in the renin-angiotensin system equilibrium. Consequently, a prothrombotic state may ensue, impairing both large vessel and microvascular blood flow. This vascular dysfunction heightens the risk of thrombotic and hemorrhagic stroke following SARS-CoV-2 infection39. Thirdly, perhaps the most pivotal mechanism at play is immune dysregulation, culminating in autoimmunity and hyperinflammatory responses. The aberrant immune response is recognized as a central contributor to neurological involvement in COVID-19 cases40. Lastly, the cytokine storm and systemic hyperinflammatory responses incited by the virus present an additional avenue through which neurological manifestations may occur. Elevated pro-inflammatory cytokine levels can disrupt normal neuronal function, impede neurotransmitter systems, and induce neuronal damage41,42. Understanding the mechanisms responsible for the neurological manifestations of COVID-19 is crucial for the development of potential therapeutic interventions. These mechanisms can operate independently or in concert within individual patients, giving rise to a range of clinical and neuroimaging presentations that, while varied, often exhibit overlapping features. This underscores the significance of investigating these mechanisms in our pursuit of effective treatments43.
The observed incidence of neurological abnormalities in pediatric COVID-19 patients raises several important clinical and research implications. First, it highlights the necessity for a high index of suspicion for neurological complications in children with COVID-19, especially those presenting with neurological symptoms. Timely neuroimaging assessments and consultations with pediatric neurologists may be essential for early diagnosis and appropriate management.
Second, the findings of this study emphasize the importance of continued research into the long-term consequences of COVID-19 in children. Even in cases where acute neurological symptoms resolve, it remains to be seen whether these children may be at risk of long-term cognitive or neurological sequelae. Longitudinal studies are needed to assess the evolution of these abnormalities and their potential impact on a child's development and quality of life.
To the best of our knowledge, this study represents the first systematic review and meta-analysis of neuroimaging findings in pediatric SARS-CoV-2 cases. Nonetheless, it is important to acknowledge several limitations of this study. Firstly, some of the studies included in our analysis exhibited substantial heterogeneity, attributed to variations in study designs, patient cohorts, and imaging protocols. This inherent diversity, though mitigated through statistical methods, somewhat limits the generalizability of our findings. Secondly, the potential presence of publication bias, although not overtly evident in our assessments, cannot be entirely dismissed. Thirdly, the relatively limited number of studies constrained our ability to conduct more detailed subgroup analyses and explore specific aspects comprehensively. Moreover, in this study, our research commenced on December 1, 2019. It is essential to acknowledge a limitation related to the evolving nature of information about COVID-19 during that early period. Detailed and comprehensive information about COVID-19, including its clinical manifestations and neurological implications, may not have been readily available at the beginning of our study. As a result, some aspects of our analysis may be based on limited data and evolving knowledge in the early stages of the pandemic. Furthermore, establishing a causal relationship between COVID-19 infection and the observed neuroimaging abnormalities remains an ongoing area of investigation. These abnormalities may be influenced by systematic confounding factors such as comorbidities, mechanical ventilation, and the complex pharmacological regimens administered for respiratory distress with hypoxia. These limitations underscore the necessity for future prospective studies that consider comorbidities and conduct more intricate analyses to affirm the potential association between COVID-19 and neuroimaging findings.
Even after your other symptoms from COVID-19 have gone away, you might experience sadness, fatigue, and other signs of depression. Scientists are still studying how COVID can affect the brain in some people and why this may put them at greater risk of depression.
Depression is one of the most common issues some people experience after a COVID infection, as part of long COVIDsometimes referred to as PASC (post-acute sequelae of COVID-19). According to one analysis, roughly 10% to 30% of people may still experience depression symptoms three months later, which may be severe in 3% to 12% of people.
This article explains more about the link between depression and COVID. It discusses how the virus that causes COVID directly affects the brain, other mental health effects of the pandemic, and tips on how to cope with depression after COVID.
FG Trade / Getty Images
Although scientists were initially most concerned about COVID-19 symptoms such as shortness of breath from lung infection, the virus causing COVID-19 (SARS-CoV-2) can also affect other body systems, including your brain.
People who have COVID have a higher rate of depression than people in the general population. You might be more prone to getting depression even after your other symptoms from COVID, like sore throat, are gone, and you no longer have an active viral infection.
People with severe COVID symptoms seem to have a greater risk of initial depressive symptoms. However, some studies have shown that people with mild COVID symptoms have a similar risk of post-COVID depression as people who had more severe infections that required hospitalization.
Long COVID broadly refers to symptoms still present at least three months after a COVID-19 infection.
Not everyone with long COVID has the same symptoms. Some people have shortness of breath, dizziness, or pain without a clear cause. However, others have symptoms that are very common in clinical depression.Others might have mild depressive symptoms.
For example, many people with long COVID have fatigue, apathy (lack of interest), sleep problems (too much or too little), or decreased mental sharpness (brain fog). Many people also experience increased anxiety or sadness. In some cases, depression might be part of a long COVID syndrome, with or without additional symptoms.
Scientists are still learning about what causes depression in people whove had COVID-19. They do know that circumstances contribute to COVID-related depression. For example, if youve lost income or have to cancel plans due to a COVID infection, you may naturally feel some sadness.
However, the virus that causes COVID also seems to directly affect the brain in ways scientists dont fully understand. Other infections may also trigger syndromes that can cause symptoms like depression, like the original SARS virus or Lyme disease.
Scientists theorize that inflammation plays a role in the development of depression with COVID-19. The virus that causes COVID can trigger immune-signaling molecules that can enter the brain and affect your mood, sleep, sense of motivation, and enjoyment. Scientists think inflammation plays a role in depression, even in people who have never had COVID.
However, the link between COVID and depression is complex. The virus that causes COVID binds to specific receptors in your brain, which might worsen depression. Some scientists speculate that low levels of the virus might be present in some people with long COVID, which could contribute to depression symptoms.
Alterations in the normal immune response (autoimmune disease) may also play a role, but more research on the relationship between autoimmune disease, COVID, and depression is needed.
Some people seem to be at greater risk of depression after COVID. For example, women have an increased risk compared to menwhich is true for depression in general, as well.People with a history of depression or other mental health issues also have an increased risk.
The pandemic significantly increased rates of anxiety and depression overall, even in people who didnt have the COVID-19. This was especially true early in the pandemic before vaccines and targeted treatments were available. Uncertainty about the virus was particularly stressful and profoundly affected peoples lives.
The pandemic also had broader effects, which varied based on individual circumstances. Some people were grieving from losing a loved one or managing the physical challenges of regaining their health, including from long COVID.
People were also dealing with the indirect impacts of the virus, such as job and income loss, social isolation, and burnout from increased responsibilities at home and/or work. Alcohol-related deaths and rates of suicide also increased.
Many of these trends improved as the impact of COVID lessened and disease outcomes became more predictable. Some scientists believe the overall effects on peoples mental health have been overestimated.
However, some people are still struggling with mental health issues that might have been triggered or worsened by circumstances related to the pandemic.
Depression after COVID-19 is relatively common, and symptoms decrease with time in most people.
If your depression is severely interfering with your life, reach out to a healthcare provider or mental health professional. Its especially critical to do so if you are having thoughts of self-harm or suicide. They can help you determine how to best navigate this time.
Even if your symptoms are less severe, getting some input from a mental health provider is often helpful. Depending on your situation and personal preferences, you might consider drug treatments for depression or therapy such as cognitive behavioral therapy (CBT).
Many people benefit from a holistic, multifaceted approach to depression treatment. Some considerations to help you cope include the following:
A holistic approach may also work best if you have depression in the context of other symptoms from long COVID. You may want to connect with a long COVID clinic (facilities specializing in long COVID care), where they can provide additional expertise and treatment approaches.
COVID-19 causes an increased risk of depression, both during active infection and for months following. Sometimes, this is part of a broader long COVID syndrome, which might include additional symptoms like pain, light-headedness, brain fog, and fatigue.
Social isolation and other factors surrounding COVID negatively affect many peoples mental health. But infection with the virus itself also seems to leave you more prone to depression, whether by inflammation or other unclear brain changes.
A holistic approach may work best in managing symptoms of depression related to COVID. Often, a combination of psychological therapy, medication, mind/body approaches, solid nutrition, and other lifestyle changes are needed.
The incidence of COVID-19 infection and poor outcomes in the last half of 2021 was consistently lowest among Canadians who completed a primary vaccination series and highest among the unvaccinated, with the most severe consequences among those aged 80 and older of any vaccination status, the Public Health Agency of Canada (PHAC) reports.
The researchers mined the National COVID-19 Case Dataset and the Canadian COVID-19 Vaccination Coverage Surveillance System for data on people aged 12 years and older in 12 of 13provinces and territories by vaccination status, COVID-19 outcomes, and demographic factors from December 2020 to January 2022.
During the study period, 1,194,694COVID-19 infections in patients with complete vaccination history (73.6% of all cases) were reported to PHAC. Most infected patients were unvaccinated, and the lowest percentage of infections was among those who received a primary COVID-19 vaccination series and one booster dose.
During the emergence of the SARS-CoV-2 Delta variant (May to July 2021), compared with vaccinated people, the unvaccinated were 6.8 times more likely to be infected, 11.4 times more likely to be hospitalized, and 17.5 times more likely to die. Amid Delta predominance (July to December 2021), those figures were 6.2, 21.0, and 15.4, respectively.
After the emergence of the Omicron variant (December 2021 to January 2022), the increased likelihoods for unvaccinated participants were 0.9, 7.1, and 11.3 for infection, hospitalization, and death, respectively.
"Case incidence in 2021 was consistently highest in unvaccinated individuals, with younger age groups having the highest incidence rates," the authors wrote.
"Starting in spring2021, there was an increase in vaccine breakthrough cases, consistent with studies showing that, although completion of a primary vaccination series was highly effective in preventing infection against the wild-type virus and Alpha variant, it was slightly less effective against the Beta, Gamma, and Delta variants."
Vaccination remains one of the most important public health interventions, particularly among older adults, to protect against COVID-19 severe outcomes as the pandemic evolves.
Rates of poor outcomes were consistently highest among those aged 80years and older, followed by those aged 60 to 79 for all vaccination statuses. Infection incidence was highest among adults aged 18 to 39, followed by those aged 40 to 59, from mid-2021 to late August2021. Infection incidence rates of in these older age-groups fell after vaccine uptake rose, until Omicron emergence.
"Vaccination remains one of the most important public health interventions, particularly among older adults, to protect against COVID-19 severe outcomes as the pandemic evolves," the study authors wrote. "Routine monitoring of COVID-19 outcomes by vaccination status can identify changes in COVID-19 epidemiology and inform public health action and policy."
CLEVELAND, Ohio You may be offered a reformulated one-shot COVID-19 vaccine this fall along with an updated flu shot, according to local health experts.
The updated COVID-19 vaccine will be reformulated months in advance, once researchers determine the most prevalent strain that will be circulating by fall, said Erika Sobolewski, medical director for Summit County Public Health.
While the public health emergency for COVID-19 has ended, the virus is still with us, Sobolewski said.
We are shifting from the pandemic phase to the endemic state of COVID-19, where it is found very commonly among the population, Sobolewski said. Getting vaccinated is still the best prevention from severe illness, hospitalization and death.
The COVID-19 vaccine is on peoples minds again because two recent moves by the U.S. Centers for Disease Control and Prevention regarding vaccine recommendations and isolation for those with the illness.
Vaccines: Americans 65 and older now are recommended to get an additional dose of the current one-shot COVID-19 vaccine, the CDC said Wednesday in updating its vaccine guidelines for the first time since the fall.
Older adults are at increased risk of severe disease from COVID-19, with more than half of COVID-19 hospitalizations from October to December 2023 occurring in adults 65 and older, the CDC said.
The one-shot COVID-19 vaccine first became available last fall, and was recommended for everyone age 5 and up to protect against serious illness.
Isolation: Then on Friday, the CDC issued new guidelines in isolation, saying Americans who test positive for the virus no longer need to stay away from others for at least five days.
The updated recommendations bring COVID-19 in line with the CDCs advice for other kinds of respiratory infections, including influenza and respiratory syncytial virus. Offering a single set of unified guidance will make people more likely to follow it, agency experts said in a news briefing Friday.
People who have the illness should stay home until theyve been fever-free without medication for at least 24 hours and their symptoms have been improving for 24 hours, the CDC said.
Most people under 65 can get a single COVID-19 vaccine yearly, according to current CDC recommendations, Sobolewski said. There are special allowances for additional doses for people who are moderately or severely immunocompromised, and initial vaccination in children 6 months to 4 years old.
People under 65 can get an additional vaccine shot two to three months after an infection, said Dr. Robert Salata, physician-in-chief at University Hospitals.
However, there are reasons to get a COVID-19 vaccine dose sooner, Sobolewski said. These include a persons risk of severe disease, risk of disease in a loved one or close contact, local COVID-19 hospital admission level, and the most common variant currently causing illness.
People who already had COVID-19 and do not get vaccinated after their recovery are more likely to get COVID-19 again, than those who get vaccinated after their recovery, Sobolewski said.
U.S. adult COVID-19 vaccination coverage
Here are facts about COVID-19 vaccine uptake among American adults from the CDC. Estimates of vaccination coverage are based on self reporting.
As of Feb. 17, 22.3% of adults reported having received an updated 2023-24 COVID-19 vaccine since Sept. 14, 2023.
An additional 11.1% reported that they definitely plan to get vaccinated.
Across states and the District of Columbia, vaccination coverage ranged from 10.1% in Mississippi to 45.5% in Vermont.
Vaccination coverage increased by age and was highest among adults 75 years and older.
White adults had higher vaccination coverage than adults in all other race and ethnicity groups. Coverage ranged from 14.5% among Hispanic adults to 26.0% among non-Hispanic White adults.
Vaccination coverage was lower among adults living in rural areas (17.8%) than among people in suburban (22.7%) and urban (23.5%) areas.
Vaccination coverage was higher among insured adults (24.4%) than uninsured adults (7.3%).
Julie Washington covers healthcare for cleveland.com. Read previous stories at this link.
When diagnosing external genital ulcers in women, both endo- and exogenous causes should be considered. The specialists should pay attention to both infectious and non-infectious reasons [9].Numerous factors such as infectious, inflammatory, immunological, neoplastic, traumatic, or medication-induced causes need to be taken into account [10].In adolescents the most common causes of AGU are: herpes simplex virus (HSV), Epstein-Barr virus, cytomegalovirus, human immunodeficiency virus (HIV), Behcets disease, Crohns disease (CD), ulcerative colitis, celiac disease, cyclic neutropenia, periodic fever syndromes and leukemia [9].
A thorough physical examination should be performed following detailed history-taking, because a patients childhood diseases can have a significant impact on their current health problems. Our patient was diagnosed with PFAPA syndrome in the past. This disease is a complex auto-inflammatory disorder diagnosed on the basis of clinical symptoms such as periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis. The course of the disease is characterized by alternating periods of relapses and remissions, and the main symptoms are often accompanied by gastrointestinal disorders [11]. Beside the chief complaint, our patient presented abdominal pain, nausea and vomiting.
PFAPA syndrome is associated with a polygenic predisposition to impaired functioning of the innate immune system. The interaction of genetic susceptibility and environmental factors, including infections, predisposes individuals to the occurrence of the disease and its recurrence in the autoimmune mechanism [11, 12]. People suffering from PFAPA display increased activation of CD4Th1 and Th17 lymphocytes [13]. This molecular susceptibility results in the dysfunction of antigen-presenting cells, e.g. monocytes, and in dysregulation of T cells. Monocytes produce higher levels of pro-inflammatory cytokine IL-12, which stimulates CD4 and CD8 lymphocytes to produce excessive amounts of IFN- and lipopolysaccharides (LPS) [14].Moreover, the expression of the IL-10 gene decreases, resulting in a reduction of anti-inflammatory IL-10 cytokine [13]. In addition, down regulation of CCR1 (CC motif chemokine receptor 1) predisposes to a reduced migration of monocytes [15]. Depletion of these cells in inflammatory diseases may lead to increased migration of microorganisms through the permeable mucous membrane, which results in ulceration [14]. In PFAPA, the classical complement pathway is activated, while the alternative pathway remains unchanged. During PFAPA flare-ups, the levels of T-cell chemokines (IP-10/CXCL10, MIG/CXCL9), G-CSF (granulocyte colony-stimulating factor), and pro-inflammatory cytokines IL-1, IL-6, IL-12, IL-18 are all increased, and the complement system is activated [11, 12]. PFAPA is a consequence of excessive intracellular protein complexes response with the participation of pro-inflammatory factors such as caspase-1, IL-6, IP-10 (interferon gamma-induced protein 10) and interleukin 1 receptor antagonist (IL1Ra), but the levels of other pro-inflammatory factors, such as TNF (tumor necrosis factor) and MCP-1 (monocyte chemoattractant protein-1), remain relatively steady.
During PFAPA attacks, the complete blood count shows increased levels of neutrophils and monocytes, with low levels of lymphocytes and eosinophils [12, 16]. The disease usually responds to treatment with corticosteroids [11]. The administration of antibiotics is not justified due to the autoimmune basis of the disease. Tonsillectomy provides a 7097% long-term remission of the PFAPA syndrome [17].
PFAPA syndrome may predispose to the occurrence of AGU [13, 18]. However, AGUs are a very rare and atypical manifestation of PFAPA. The presence of vulvar ulcers in PFAPA patients is influenced by reduced IL-10 (anti-inflammatory cytokine) and CCR1 levels [13, 14]. According to Scattoni et al. this atypical symptom should be regarded as a potential and useful indicator of PFAPA [18].
In the present study, we took into consideration the influence of the PFAPA syndrome on the development of labial ulceration in our patient. The immune and genetic determinants that caused the PFAPA syndrome could also lead to the appearance of ulcers after the occurrence of provoking factors. The patient's leukocyte, neutrophil, and eosinophil levels resembled those typically found in PFAPA syndrome. The vulvar lesions were accompanied by fever episodes, abdominal pain, nausea, and vomiting. Additionally, our patient did not undergo a tonsillectomy, a procedure reducing the risk of the PFAPA syndrome recurrence.
Furthermore, as emphasized by researchers, the incidence of PFAPA syndrome rose during the COVID-19 pandemic [14].
An effective vaccination against SARS-CoV-2 was a vital tool to halt the spread of the pandemic; however, some predisposed people may have presented adverse reactions to the vaccination. Several cutaneous side effects were observed, e.g. delayed large local reactions and eruptions.
Recently, cases of AGU associated with COVID-19 vaccinations have been reported [2, 5, 19]. Of the 94 cases of vulvovaginal ulceration reported in the female adolescent age group, there was evidence that at least 37 were AGUs. In addition, up to December 2022, there were approximately 12 case reports published in scientific literature on genital ulceration after COVID-19 vaccine administration in non-sexually active adolescent patients. In majority, the events occurred after the second dose, usually within 1week. Common symptoms included pain-related difficulty in urination, defecation, sitting and walking. Fever, vulvar swelling and fatigue were also noted. Despite a different approach, the ulcers were usually self-limiting and healed between 2 to 6weeks [20].
The most frequently reported altered effects of vaccines are pain and swelling. Mucosal changes (bleeding gums, oral sores and ulcers) may occur after administration of diphtheria, tetanus, acellular pertussis and polio vaccines [19]. Incidences of lichen planus, a chronic inflammatory disease which affects the stratified squamous epithelium and frequently involves the oral and genital mucosa, have been reported after hepatitis B vaccination. In all likelihood, the immune system recognizes epitopes similar/identical to proteins of the virus on keratinocytes and induces immunological response and apoptosis of these cells [21].
Once an mRNA vaccine is administered,the spike protein, a viral receptor-binding protein, is produced by ribosomes in muscle cells. Subsequently, it binds to the host receptor angiotensin-converting enzyme 2 and triggers a robust CD8+and CD4+cell mediated response, inducing the production of neutralizing antibodies and memory of B and T-cells. COVID-19 vaccinations induce an autoimmune response by several pathways, including the development of specific autoantibodies, the effects of certain vaccine adjuvants, and molecular mimicry [22].
The SARS-CoV-2 spike protein and lung surfactant proteins share 13 out of 24 pentapeptides and the respiratory system is the most frequently attacked system in the case of COVID-19 infection. A similar mechanism of cross-reactions between the virus proteins and a variety of human antigens could possibly lead to autoimmunity against other organs, including the formation of mucosal and skin lesions induced by the coronavirus invasion as well as COVID-19 vaccines [22].The side effects of a vaccination might as well be due to transient bursts of IFN-I expression, effective antibody production, oxidative stress and DNA-damage, which may stimulate hyperinflammatory conditions. Another explanation indicates that in the case of mRNA vaccines, mRNA presents as both antigen and adjuvant, and might be so identified by Toll-like receptors, which trigger inflammation and immunity [22]. Nevertheless, the pathophysiology of AGUs after vaccination remains poorly understood.
A rare problem following COVID-19 vaccination described in the literature is Behcet's disease, and it is also possible that AGUs after vaccination are the first manifestation of this condition [23].
Behcets disease (BD) should also be evaluated in our patients history of aphthous lesions in the mouth and genital ulceration. Behcets disease is a rare inflammatory disorder diagnosed based on clinical symptoms and specific characteristics. According to the new criteria, a patient who scores4 points is classified as having BD. Characteristic signs and symptoms include ocular lesions (2), genital aphthosis (2), oral aphthosis (2), skin lesions (1), neurological manifestations (1), vascular manifestations (1) and, optionally, a positive pathergy test (1) [24]. In addition, BD is often associated with the neutrophil to lymphocyte ratio (NLR) being increased while the hemoglobin (HB) level is decreased. Additionally, there is an increase in the erythrocyte sedimentation rate (ESR) and CRP, and the human leukocyte antigens (HLA-B51) test shows positive results [25].
The pathomechanism of BD may depend on neutrophil-mediated mechanisms, that is, neutrophil hyperactivation via both a massive reactive oxygen species (ROS) production and neutrophil extracellular traps (NETs) release. BD patients have higher serum concentrations of sTNFR, leptin, sCD40L, and IL-6. Tumor necrosis factor alpha (TNF-alpha), leading neutrophils to disrupt the oral mucosa, is elevated in patients with recurrent aphthae, and affects endothelial cell adhesion and neutrophil chemotaxis. This is believed to be one of the molecular factors that are responsible for aphthous ulcers. As mentioned above in the present article, aphthous ulcers may occur both as a rare side effect of COVID-19 vaccination and as a consequence of high serum concentrations of sTNFR in BD [26].
,PFAPA syndrome and Behcets disease are characterized by similar pathomechanism. For this reason, they are often considered in the differential diagnosis [10, 13]. It is postulated that the same HLA type, specifically, HLA-B5 and HLA-B51, is involved in the development of both diseases [13, 14].Thus, ulceration in the vaginal area can be a symptom of PFAPA syndrome and Behcets disease.
The vulva can be affected by a variety of microorganisms including bacteria, viruses, fungi and parasites. Commonly, those infections are transmitted by sexual contact. However, in non-sexually active adolescents, genital infections might develop as well. AGU is commonly described as associated with a variety of infections including cytomegalovirus, herpes zoster virus (HZV), influenza type A and B, mumps virus, salmonella, mycoplasma and, most commonly, Epstein-Barr virus [4].
EBV causing infectious mononucleosis syndrome has been reported as a most common cause of AGU. Serologic testing for EBV in patients with vulvar ulcers demonstrated evidence of acute as well as prior infections [3]. Most patients develop systemic symptoms of IMS, and lymphadenopathy distant from the site of ulceration is also common; however, in the presented case the enlargement of lymph nodes has not been noted. Acute CMV infection has also been detected in patients with AGU and CMV inclusions found in cells of the vulva and cervix [3, 27]. As for the vulvar HZV infection, it is uncommon and often causes pain or a burning sensation. Lesions usually appear in a specific dermatomal distribution.
Herpes simplex virus, causing genital herpes, remains the most common factor of genital ulcers among sexually active females. However, it might also be responsible for ulcers in non-sexually active adolescents [4, 28]. There are two types of HSV. HSV-2 is considered to be the main cause of AGU, whilst HSV-1 is mostly linked to oral cavity lesions.
American pediatric and adolescent gynecology care providers suspect an 80% of HSV etiology at the onset of AGU diagnosis, therefore aggressive diagnosis of lesions should be delayed [29].
Since there is no single infectious agent identified as a cause of AGU, clinical examination and detection of viral genetic material or serologic tests play a pivotal role in the diagnostic process.
We also considered the possibility of vulvar cancer, although the incidence of genital cancers are rare in young females [30]. However, the macroscopic appearance of the vulvar lesion as an ulcer raised suspicions of oncological concern. There are two types of vulvar intraepithelial neoplasia (VIN). One of them, defined as differentiated (dVIN), is often associated with lichen sclerosus. The other refers to vulvar high-grade squamous intraepithelial lesions (vH-SIL) [31]. It is an HPV-related oncology condition that is specific to younger women and refers to intraepithelial neoplasia and squamous cell vulvar carcinoma (SVC) [32]. Moreover, given the increase in HPV infections and an early age of sexual initiation, there is a significant risk of vulvar cancer in younger age groups [33]. However, biopsy from vulvar lesions in children is debatable among many researchers unless there is a recurrence or a non-infectious etiology is suspected [29]. Most cases of vulvar ulceration in young women are self-limiting and respond to topical and systemic corticosteroid therapy. For these reasons, some authors recommend reducing extensive diagnostics [34].In our study, due to the extensive area of necrosis as well as the specificity of a hospital also providing oncological treatment, it was decided to collect material for histopathological examination. Biopsy excluded neoplastic invasion, therefore we ruled out vulvar cancer.
