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Bulletin for 17 March 2023


Cochrane Library

Cochrane clinical answers

Evidently Cochrane





Other journals




Guidelines for reducing the environmental impact of perioperative care
Avoiding unnecessary resource use and controlling emissions are important approaches to reduce the environmental impact of perioperative care. Updated Canadian Anesthesiologists' Society guidelines re-emphasize specific strategies that include choosing reusable, reprocessable equipment rather than single-use disposable items, recycling materials when feasible, and responsibly using inhalation anesthetic agents (eg, low fresh gas flow during delivery; minimizing use of desflurane and nitrous oxide; selecting alternative techniques such as total intravenous anesthesia [TIVA] or neuraxial or regional anesthetic approaches when appropriate) [14]. (See "Environmental impact of perioperative care", section on 'Managing supplies, equipment, and medications'.)

Toxicity with combined acetaminophen/opioid products
Patients taking combined acetaminophen/opioid formulations are at risk for unintentional acetaminophen overdose and hepatotoxicity. As a consequence, in 2011 the US Food and Drug Administration announced a mandate (effective in 2014) limiting acetaminophen to 325 mg in combined opioid formulations. An interrupted time-series analysis of a large hospitalization database and multicenter liver failure study group (nearly 40,000 and 465 cases of combined acetaminophen/opioid toxicity, respectively) found that since 2011 there has been a significant decrease in hospitalizations and percentage of acute liver failure cases caused by combined acetaminophen/opioid products [28]. In patients taking medications containing acetaminophen and in those who present with unexplained liver injury, it is important to review the total daily acetaminophen dose to prevent hepatoxicity and to investigate a cause for hepatoxicity, respectively. (See "Acetaminophen (paracetamol) poisoning in adults: Pathophysiology, presentation, and evaluation", section on 'Epidemiology'.)

Extending low molecular weight heparin until closer to delivery
Most obstetricians replace low molecular weight (LMW) heparin with unfractionated heparin at 36 to 37 weeks of gestation to improve the patient's chances of receiving neuraxial anesthesia for labor and delivery, if desired. However, an analysis of data from the Highlow trial of LMW heparin prophylaxis in pregnancy found that most patients were eligible for neuraxial anesthesia at the unplanned onset of labor, including 82 percent of patients on low-dose and 61 percent of patients on intermediate-dose LMW heparin [15]. Numbers of eligible patients were higher for planned labor (93 and 81 percent). These results support extended use of LMW heparin prophylaxis to 38 to 39 weeks or even until delivery in selected individuals. (See "Use of anticoagulants during pregnancy and postpartum", section on 'Switch to unfractionated heparin'.)

Combination medical therapy not superior to methotrexate alone for treating ectopic pregnancy
Ectopic pregnancy is usually treated with surgery or methotrexate (MTX) alone, but use of MTX with another medication (eg, gefitinibmifepristone) has been described. In a randomized trial comparing a single dose of MTX plus seven days of either gefitinib or placebo in over 300 patients with tubal ectopic pregnancy, both groups had similar rates of surgical intervention, time to pregnancy resolution, subsequent doses of MTX, and serious complications [23]. However, more patients in the gefitinib group experienced diarrhea and rash. In our practice, we do not use combination medical therapy as MTX alone is effective, and combination therapy increases side effects and cost. (See "Ectopic pregnancy: Methotrexate therapy", section on 'Role of combined drug therapy'.)

Elevated risk of superficial siderosis associated with spontaneous intracranial hypotension
Persistent cerebrospinal fluid (CSF) leak may be associated with morbidity, including a long-term risk of superficial siderosis. In a single-center registry of nearly 1600 patients with spontaneous intracranial hypotension (SIH), superficial siderosis was identified in 3.6 percent [13]. The prevalence was higher among patients with ventral spinal CSF leaks (10.3 percent) compared with those with other spinal leaks, including dural ectasia (3.9 percent), CSF-venous fistulas (2.6 percent), or meningeal diverticula (0.9 percent). The median interval from onset of SIH to the development of superficial siderosis was approximately 10 years. Timely identification of sources of SIH are warranted to treat symptoms and to reduce risk of long-term complications such as superficial siderosis. (See "Spontaneous intracranial hypotension: Treatment and prognosis", section on 'Prognosis'.)

Tucatinib in advanced HER2-positive breast cancer with brain metastases
Newer anti-HER2-directed tyrosine kinase inhibitors such as tucatinib are being used for patients with advanced, HER2-positive breast cancer, but data in those with brain metastases are emerging. In an updated analysis of the HER2CLIMB trial, which included patients with heavily pretreated HER2-positive metastatic breast cancer, the addition of tucatinib to capecitabine and trastuzumab improved median overall survival among patients with brain metastases (22 versus 13 months), including in the subset with active brain metastases (21 versus 12 months) [30]. For patients with advanced HER2-positive breast cancer, we consider the tucatinib, capecitabine, and trastuzumab combination to be an effective subsequent-line systemic treatment option, including for those with brain metastases. (See "Brain metastases in breast cancer", section on 'Tucatinib, capecitabine, and trastuzumab'.)


Cochrane Library

Consumers’ and health providers’ views and perceptions of partnering to improve health services design, delivery and evaluation: a co‐produced qualitative evidence synthesis
Successful formal group partnerships with consumers require health providers to continually reflect and address power imbalances that may constrain consumers' participation. Such imbalances may be particularly acute in recruitment procedures, meeting structure and content and decision‐making processes. Formal group partnerships were perceived to improve the physical environment of health services, the person‐centredness of health service culture and health service design and delivery. Implementing the best practice principles may help to address power imbalances, strengthen formal partnering, improve the experiences of consumers and health providers and positively affect partnership outcomes. Cochrane Database of Systematic Reviews – Qualitative 14 March 2023

Spinal cord stimulation for low back pain
Data in this review do not support the use of SCS to manage low back pain outside a clinical trial. Current evidence suggests SCS probably does not have sustained clinical benefits that would outweigh the costs and risks of this surgical intervention. Cochrane Database of Systematic Reviews  – Intervention 7 March 2023

Antibiotics versus placebo for acute bacterial conjunctivitis
The findings of this update suggest that the use of topical antibiotics is associated with a modestly improved chance of resolution in comparison to the use of placebo. Cochrane Database of Systematic Reviews – Intervention 13 March 2023

Personally tailored activities for improving psychosocial outcomes for people with dementia in long‐term care
Offering personally tailored activities to people with dementia in long‐term care may slightly reduce agitation. Cochrane Database of Systematic Reviews – Intervention 13 March 2023

Postnatal phenobarbital for the prevention of intraventricular haemorrhage in preterm infants
The evidence suggests that phenobarbital results in little to no difference in the incidence of IVH (any grade or severe) compared with control (i.e. no intervention or placebo). The evidence is very uncertain about the effects of phenobarbital on ventricular dilation or hydrocephalus and on neurodevelopmental impairment. The evidence suggests that phenobarbital results in little to no difference in death before discharge and all deaths during the study period compared with control. Cochrane Database of Systematic Reviews – Intervention 16 March 2023


Cochrane clinical answers

For people with mild to moderate dementia, what are the effects of cognitive stimulation?
High‐certainty evidence shows that for people with mild to moderate dementia, cognitive stimulation (using reality orientation, a treatment manual, or different protocols involving concentration and memory) results in a moderate improvement in communication and social interaction and a marginal increase in instrumental activities of daily living at median 10 weeks follow‐up when compared with control. Cochrane clinical answers 13 March 2023

What are the benefits and harms of opioid agonist treatment for people who are dependent on pharmaceutical opioids?
Low‐certainty evidence generally supports the use of opioid agonist treatment to help people quit using pharmaceutical opioids. Methadone may be more effective than buprenorphine. Evidence on safety and impact on health was mostly limited and inconclusive. Cochrane clinical answers 2 March 2023


Evidently Cochrane

Dementia and hearing conditions: what do we most need to know?
A new project aims to find out what are the top questions that need answering about dementia and hearing conditions, in the first Priority Setting Partnership (PSP) to look at two health areas together. Evidently Cochrane 13 March 2023

Preventing falls in older people: new evidence on what helps
Sarah Chapman from Cochrane UK shares new evidence on what can be done to reduce falls in older people at home by assessing hazards and making adaptations to the home environment and, importantly, who is likely to benefit most from these. Evidently Cochrane 10 March 2023

Physical exercise for people with Parkinson’s: do what you enjoy
In this blog for people living with Parkinson’s, and those who support them, older person’s doctor Charlotte Squires and sport and exercise medicine doctor Rebecca Gould, look at new evidence on how physical exercise can help people with Parkinson’s and share some of their experiences in supporting people to be more active. Lis Kirkness, who lives with Parkinson’s, writes about her experience of trying both old and new forms of exercise, and the benefits she has felt not only to her symptoms but also her overall well-being. Evidently Cochrane 15 March 2023



Mitigating the impacts of racism on Indigenous wellbeing through human rights, legislative and health policy reform
System‐wide racial discrimination and inequitable access to justice impedes Indigenous rights to health and wellbeing. MJA 6 March 2023

Australia's political engagement on health and climate change: the MJA–Lancet Countdown indicator and implications for the future
Urgent and sustained political engagement is needed to address the health impacts of climate change. MJA 6 March 2023

Different estimates of the prevalence of dementia in Australia, 2021
Estimates of the number of Australians living with dementia vary from fewer than 200 000 to more than 450 000. To understand these differences, the authors assessed the sources of the estimates. MJA 13 March 2023



Continuous glucose monitoring
What you need to know

  • Continuous glucose monitoring (CGM) is the preferred glucose monitoring method in most recent guidelines (ADA/EASD/ISPAD) for people with insulin-requiring diabetes, but it is also suitable for all people with diabetes
  • Accuracy of CGM is close to that of finger stick blood glucose testing
  • Often, conscious or unconscious bias and concerns about technical or data literacy prevent providers from discussing CGM/intermittently scanned CGM with people with diabetes
  • CGM is costly, which leads to inequity in terms of patient access and research around the topic

BMJ 3 March 2023

Maternal opioid treatment after delivery and risk of adverse infant outcomes: population based cohort study
Findings from this study suggest no association between maternal opioid prescription after delivery and adverse infant outcomes, including death. BMJ 15 March 2023

Ionising radiation and cardiovascular disease: systematic review and meta-analysis
Results provide evidence supporting a causal association between radiation exposure and cardiovascular disease at high dose, and to a lesser extent at low dose, with some indications of differences in risk between acute and chronic exposures, which require further investigation. The observed heterogeneity complicates a causal interpretation of these findings, although this heterogeneity is much reduced if only higher quality studies or those at moderate doses or low dose rates are considered. Studies are needed to assess in more detail modifications of radiation effect by lifestyle and medical risk factors. BMJ 8 March 2023

Molnupiravir and risk of hospital admission or death in adults with covid-19: emulation of a randomized target trial using electronic health records
The findings of this emulation of a randomized target trial suggest that molnupiravir might have reduced hospital admission or death at 30 days in adults with SARS-CoV-2 infection in the community during the recent omicron predominant era who were at high risk of progression to severe covid-19 and eligible for treatment with molnupiravir. BMJ 7 March 2023

Aortic stenosis
What you need to know

  • Auscultate for a systolic murmur (it can be soft) when patients present with chest pain, breathlessness, presyncope, syncope, palpitations, or unexplained functional deterioration  
  • Clinically relevant aortic stenosis is underdiagnosed—consider transthoracic echocardiography and specialist assessment if there are cardiac or respiratory symptoms associated with an audible murmur
  • Arrange urgent cardiology assessment (within 2 weeks) or acute admission for syncope and/or rapidly deteriorating symptoms in suspected aortic stenosis
  • Transcatheter procedures are suitable for many patients who might previously have been deemed unfit for open valve replacement surgery

BMJ 15 March 2023

Cognitive impairment after cancer treatment: mechanisms, clinical characterization, and management
This review summarizes the recent advances in the mechanisms, clinical characterization, and novel management strategies of cognitive impairment associated with treatment of non-central nervous system cancers. BMJ 15 March 2023

Caring for young people with gender dysphoria
The priority for health professionals must be to offer the best possible care to their patients. Difficulties arise when the evidence base is preliminary or inconclusive. In that situation, when faced with a person seeking care, what is the best care to offer? The dilemma is more acute if the person seeking care is a child or adolescent. This is the complex and difficult challenge that specialists in gender dysphoria must master to provide the best possible care to young people. BMJ 9 March 2023



Phase 3 Trial of Sotatercept for treatment of Pulmonary Arterial Hypertension
In patients with pulmonary arterial hypertension who were receiving stable background therapy, sotatercept resulted in a greater improvement in exercise capacity (as assessed by the 6-minute walk test) than placebo. NEJM 6 March 2023

Outcomes after critical illness
The field of critical care has made enormous gains in its mission to save lives. Critical illness, however, changes a life trajectory and is often a traumatic experience for the entire family. The next challenge for critical care is to look beyond the ICU, hospital discharge, and survival at 30 and 90 days and to embrace the construct of ICU care as part of a continuum of care, with the goal of optimizing care transitions and long-term multidimensional functioning for surviving patients and their families. NEJM 9 March 2023

Fifteen-year outcomes after monitoring, surgery, or radiotherapy for prostate cancer
After 15 years of follow-up, prostate cancer–specific mortality was low regardless of the treatment assigned. Thus, the choice of therapy involves weighing trade-offs between benefits and harms associated with treatments for localized prostate cancer. NEJM 11 March 2023

Two phase 3 trials of Lebrikizumab for moderate-to-severe Atopic Dermatitis
In the induction period of two phase 3 trials, 16 weeks of treatment with lebrikizumab was effective in adolescents and adults with moderate-to-severe atopic dermatitis. NEJM 15 March 2023



Association of life expectancy with surveillance Colonoscopy findings and follow-up recommendations in older adults
In this cohort study, the likelihood of finding advanced polyps and CRC on surveillance colonoscopy was low regardless of life expectancy. Despite this observation, 58.1% of older adults with less than 5 years’ life expectancy were recommended to return for future surveillance colonoscopy. These data may help refine decision-making about pursuing or stopping surveillance colonoscopy in older adults with a history of polyps. JAMA 13 March 2023

Physical frailty, genetic predisposition, and incident Parkinson Disease
These findings indicate that physical frailty is a potential risk factor for PD and the assessment and management of frailty might have clinical significance in the at-risk population. JAMA 13 March 2023


Other journals

Machine learning identification of thresholds to discriminate osteoarthritis and rheumatoid arthritis synovial inflammation
H&E-stained images of TKR explant synovium can be correctly classified as OA or RA in 82% of samples. Cell density greater than 3400 cells/mm2 and the presence of mast cells and fibrosis are the most important features for making this distinction. Arthritis research and therapy 2 March 2023

The impact of family care visitation programme on patients and caregivers in the intensive care unit: A mixed methods study
What does this paper contribute to the wider global community?

  • Nursing for critically ill patients presented evidence for strengthening patient- and family-centred care (PFCC) away from healthcare professional-centred care.
  • Critical ill patients should be provided with mental health care, such as PFCC interventions.
  • Involving family in the caring of critically ill patients is an intervention that can lead to positive patient outcomes, such as improved respiration; the future direction of critical care nursing is suggested through the experience of family as being the centre of patient care and participating in nursing.

Journal of clinical nursing 7 March 2023

A novel smartphone application for the informal caregivers of cancer patients: Usability study
This study documents that caregivers are willing to complete frequent surveys about their loved ones and themselves. Based on the findings presented here and in other manuscripts, the authors hope to do further research to determine whether this app can help improve patient outcomes. Plos digital health 3 March 2023

Prevalence of Sjögren's syndrome according to 2016 ACR-EULAR classification criteria in patients with systemic lupus erythematosus
The prevalence of SS in SLE was 23% (AECG 2002) and 35% (ACR-EULAR 2016). The presence of glandular dysfunction, focal lymphocytic sialadenitis, and anti/Ro were predictors of SS in SLE. The greatest advantage of the new ACR-EULAR 2016 criteria is to enable an early diagnosis and identify the overlapping of these two diseases. ACR-EULAR 2016 criteria is not yet validated for secondary SS and this study is a pioneer in investigating prevalence based on the new criteria. Advances in rheumatology 14 March 2023

The study of nurses’ knowledge and attitudes regarding pain management and control in emergency departments
The current study revealed that pain management and control knowledge in most emergency nurses was low, and most of them had a moderate attitude. There is a need for more scientific and comprehensive pain management and control training courses to improve knowledge and attitude among health workers and nurses. BMC emergency medicine 13 March 2023

Mediterranean diet adherence is associated with lower dementia risk, independent of genetic predisposition: findings from the UK Biobank prospective cohort study
Higher adherence to a MedDiet was associated with lower dementia risk, independent of genetic risk, underlining the importance of diet in dementia prevention interventions. BMC medicine 13 March 2023

Water intake, hydration status and 2-year changes in cognitive performance: a prospective cohort study
Reduced physiological hydration status was associated with greater reductions in global cognitive function over a 2-year period in older adults with metabolic syndrome and overweight or obesity. Future research assessing the impact of hydration on cognitive performance over a longer duration is needed. BMC medicine 8 March 2023

Workflow interruption and nurses’ mental workload in electronic health record tasks: An observational study
Nursing interruptions occur frequently in EHR tasks, come from different sources and may lead to elevated mental workload and negative outcomes. By exploring the variables related to mental workload and performance, the authors offer a new perspective on quality improvement strategies. Reducing harmful interruptions to decrease task time can avoid negative outcomes. Training nurses to cope with interruptions and improve competency in EHR implementation and task operation has the potential to decrease nurses’ mental workload and improve task performance. Moreover, improving system usability is beneficial to nurses to mitigate mental workload. BMC nursing 9 March 2023

Three-month follow-up after severe COVID-19 infection: are chest CT results associated with respiratory outcomes and respiratory recovery in COVID-19 patients?
Patients surviving hospitalization for COVID-19-associated hyperinflammation with higher CT-SS have worse respiratory outcome, both in-hospital and at 3-months after hospitalization. Strict monitoring of patients with high CT-SS is therefore warranted. BMC pulmonary medicine 7 March 2023

Early adjunctive methylene blue in patients with septic shock: a randomized controlled trial
In patients with septic shock, MB initiated within 24 h reduced time to vasopressor discontinuation and increased vasopressor-free days at 28 days. It also reduced length of stay in ICU and hospital without adverse effects. This study supports further research regarding MB in larger randomized clinical trials. Critical care 13 March 2023

Professional interpreter services and the impact on hospital care outcomes: An integrative review of literature
Migration patterns have rapidly changed in Australia and elsewhere, which have contributed to increasingly culturally and linguistically diverse societies. This requires healthcare sectors to provide professional interpreter services for patients with a language barrier to eliminate healthcare disparities. This integrative review aimed to investigate the impact of professional interpreter services on hospital care outcomes and the associated cost of service provision. International journal of environmental research and public health 15 March 2023


Healthcare-associated Staphylococcus aureus bloodstream infections
This release shows 2020-21 data for healthcare-associated Staphylococcus aureus bloodstream infections in public hospitals and in private hospitals that choose to participate. The public hospital rate of 0.74 cases per 10,000 public hospital patient days is below the nationally agreed benchmark of 1 case per 10,000 patient days and the overall rates for each state/territory are also below the benchmark. The percentage of cases that were resistant to antimicrobial treatment bracket (MRSA cases) has decreased from 27% in 2010-11 to 17% in 2020–21. AIHW 15 March 2023

Acute rheumatic fever and rheumatic heart disease in Australia 2017-2021
Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) are preventable diseases disproportionately affecting Aboriginal and/or Torres Strait Islander people living in regional and remote areas. Incidence of ARF and RHD are highest in females and young people aged 5–14. These data highlight the important role of jurisdictional control programs and registers in New South Wales, Queensland, Western Australia, South Australia, and the Northern Territory. AIHW 16 March 2023



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Updated 30 March 2023

Audio interview: Ending the Covid-19 public health emergency
In this audio interview conducted on March 27, 2023, the editors discuss the upcoming end to the U.S. public health emergency as well as two new Covid-19 studies. NEJM 30 March 2023

Stroke, Myocardial Infarction, and Pulmonary Embolism after bivalent booster
The evaluated events included ischemic stroke (hazard ratio, 0.86; 95% confidence interval [CI], 0.58 to 1.27), hemorrhagic stroke (hazard ratio, 0.86; 95% CI, 0.46 to 1.61), myocardial infarction (hazard ratio, 0.92; 95% CI, 0.62 to 1.36), pulmonary embolism (hazard ratio, 0.83; 95% CI, 0.49 to 1.40), and all four events combined (hazard ratio, 0.87; 95% CI, 0.69 to 1.09). The results provide reassurance regarding the continued use of this bivalent vaccine. NEJM 29 March 2023

Estimated risk of adverse surgical outcomes among patients with recent COVID-19 infection using target trial emulation methods
These findings suggest that recent COVID-19 infection was not associated with risk of adverse postoperative outcomes, regardless of timing within the previous 60 days. A recent study found surgery within 8 weeks after a positive COVID-19 test result was associated with higher 90-day mortality vs matched controls.3 Another study found lower perioperative risk for vaccinated patients and for unvaccinated patients not given general anesthesia.4 These studies may shift the timing of surgery relative to recent infection. This study further rebalances the scale in favor of performing surgery in recently recovered patients. JAMA 28 March 2023

Drug repurposing and observational studies: The case of antivirals for the treatment of COVID-19
Remdesivir and molnupiravir received emergency use authorization on the basis of single trials launched after observed in vitro activity against SARS-CoV-2. For tenofovir disoproxil fumarate (TDF), little in vitro evidence was generated, and no randomized trials for early treatment were done. Yet, observational evidence suggested a lower risk for severe COVID-19 in TDF users compared with nonusers. The authors review the decision-making process for these 3 drugs and propose better use of available observational evidence for the repurposing of drugs during public health emergencies. Annals of internal medicine 28 March 2023

How covid-19 bolstered an already perverse publishing system
The pandemic turbocharged scientific publishing. While this was widely considered a collective triumph against a global threat, have the harms of pandemic publishing been overlooked? BMJ 28 March 2023

Risk of death following COVID-19 vaccination or positive SARS-CoV-2 test in young people in England
Several studies have reported associations between COVID-19 vaccination and risk of cardiac diseases, especially in young people; the impact on mortality, however, remains unclear. The authors use national, linked electronic health data in England to assess the impact of COVID-19 vaccination and positive SARS-CoV-2 tests on the risk of cardiac and all-cause mortality in young people (12 to 29 years) using a self-controlled case series design. Here, they show there is no significant increase in cardiac or all-cause mortality in the 12 weeks following COVID-19 vaccination compared to more than 12 weeks after any dose. However, they find an increase in cardiac death in women after a first dose of non mRNA vaccines. A positive SARS-CoV-2 test is associated with increased cardiac and all-cause mortality among people vaccinated or unvaccinated at time of testing. Nature communications 27 March 2023

Neutropenic fever–associated admissions among patients with solid tumors receiving chemotherapy during the COVID-19 pandemic
In this cohort study, among patients with solid tumors receiving chemotherapy with a risk of neutropenia, there was a significant reduction in Neutropenic fever (NF)-associated admission rates during the COVID-19 pandemic. Antimicrobial use and use of granulocyte colony-stimulating factor were unchanged between the study periods, so we infer from our results that the reduction in NF-associated admissions may be attributable to the use of nonpharmaceutical interventions (NPIs) and that NPIs may be beneficial in patients undergoing chemotherapy with a risk of neutropenia. Outpatient NF management was similar between the time periods. JAMA 27 March 2023

Expectations and prior experiences associated with adverse effects of COVID-19 vaccination
In this cohort study, several nocebo effects occurred in the first week after COVID-19 vaccination. The severity of systemic adverse effects was associated not only with vaccine-specific reactogenicity but also more negative prior experiences with adverse effects from the first COVID-19 vaccination, more negative expectations regarding vaccination, and tendency to catastrophize instead of normalize benign bodily sensations. Clinician-patient interactions and public vaccine campaigns may both benefit from these insights by optimizing and contextualizing information provided about COVID-19 vaccines. JAMA 27 March 2023

The relationship between SARS-CoV-2 neutralising antibody titres and avidity in plasma collected from convalescent non-vaccinated and vaccinated blood donors
Convalescent plasma (CP) treatment of COVID-19 has shown significant therapeutic effect when administered early (e.g. Argentinian trial showing reduced hospitalisation) but has in general been ineffective (e.g. REMAP-CAP trial without improvement during hospitalisation). To investigate whether the differences in CP used could explain the different outcomes, we compared neutralising antibodies, anti-spike IgG and avidity of CP used in the REMAP-CAP and Argentinian trials and in convalescent vaccinees. The authors found no difference between the trial plasmas emphasising initial patient serostatus as treatment efficacy predictor. By contrast, vaccinee convalescent plasma showed significantly higher titres and avidity, being preferable for future CP-treatment. Journal of infectious diseases 27 March 2023

Levels of complement components in children with acute COVID-19 or multisystem inflammatory syndrome
In this cross-sectional study, the complement system was associated with the pathogenesis of MIS-C and COVID-19 in children; complement inhibition could be further explored as a potential treatment option. JAMA 24 March 2023

Attitudes towards booster, testing and isolation, and their impact on COVID-19 response in winter 2022/2023 in France, Belgium, and Italy: a cross-sectional survey and modelling study
Simpler mandates for isolation may increase awareness and actual compliance, reducing testing costs, without compromising mitigation. High booster vaccination uptake remains key for the control of the winter wave. The lancet - regional health -Europe 23 March 2023

Update to living systematic review on prophylaxis against covid-19
Of the 16 prophylactic drugs analysed, none provided convincing evidence of a reduction in the risk of laboratory confirmed SARS-CoV-2 infection. For admission to hospital and mortality outcomes, no prophylactic drug proved different than standard care or placebo. Hydroxychloroquine and vitamin C combined with zinc probably increase the risk of adverse effects leading to drug discontinuation (moderate certainty evidence). BMJ 23 March 2023

Risk factors associated with Post−COVID-19 condition: A systematic review and meta-analysis
This systematic review and meta-analysis demonstrated that certain demographic characteristics (eg, age and sex), comorbidities, and severe COVID-19 were associated with an increased risk of PCC, whereas vaccination had a protective role against developing PCC sequelae. These findings may enable a better understanding of who may develop PCC and provide additional evidence for the benefits of vaccination. JAMA 23 March 2023

Association of treatment with Nirmatrelvir and the risk of Post–COVID-19 condition
This cohort study found that in people with SARS-CoV-2 infection who had at least 1 risk factor for progression to severe disease, treatment with nirmatrelvir within 5 days of a positive SARS-CoV-2 test result was associated with reduced risk of PCC across the risk spectrum in this cohort and regardless of vaccination status and history of prior infection; the totality of findings suggests that treatment with nirmatrelvir during the acute phase of COVID-19 may reduce the risk of post–acute adverse health outcomes. JAMA 23 March 2023

Sex-specific neurodevelopmental outcomes among offspring of mothers with SARS-CoV-2 infection during pregnancy
In this cohort study of offspring with SARS-CoV-2 exposure in utero, such exposure was associated with greater magnitude of risk for neurodevelopmental diagnoses among male offspring at 12 months following birth. As with prior studies of maternal infection, substantially larger cohorts and longer follow-up will be required to reliably estimate or refute risk. JAMA 23 March 2023

SARS-CoV-2 variants and multisystem inflammatory syndrome in children
The features of MIS-C at presentation were more often similar to the features of Kawasaki’s disease among patients hospitalized with SARS-CoV-2 infection during the more recent variant periods than among those during the earlier periods; however, without a definitive diagnostic test for either condition, it remains to be determined whether this represents a true change in phenotype or an increase in the number of patients with Kawasaki’s disease who meet the criteria for MIS-C through concurrent but unrelated SARS-CoV-2 infection. NEJM 23 March 2023

Covid-19 surveillance testing and resident outcomes in nursing homes
Greater surveillance testing of staff members at skilled nursing facilities was associated with clinically meaningful reductions in Covid-19 cases and deaths among residents, particularly before vaccine availability. NEJM 23 March 2023

The Fauci Phenomenon, Part 2
In this episode of “Intention to Treat,” Anthony Fauci sits down with host Rachel Gotbaum to discuss his long career in infectious disease and public health, what has motivated him, and the lessons he has learned and taught along the way. NEJM 23 March 2023

Effects of standard-dose prophylactic, high-dose prophylactic, and therapeutic anticoagulation in patients with Hypoxemic COVID-19 Pneumonia: The ANTICOVID randomized clinical trial
This randomized clinical trial found that compared with standard-dose prophylactic anticoagulation  (SD-PA), neither HD-PA nor therapeutic anticoagulation (TA) use improved the primary hierarchical outcome of all-cause mortality or time to clinical improvement in patients with hypoxemic COVID-19 pneumonia; however, high-dose prophylactic anticoagulation (HD-PA) resulted in significantly better net clinical outcome by decreasing the risk of de novo thrombosis. JAMA 22 March 2023

Understanding SARS-CoV-2 Delta and Omicron variant transmission and vaccine impact in schools and child-care settings in Australia: a population-based study
Vaccination reduced SARS-CoV-2 transmission rates in schools, although less so for omicron than delta variants. Despite higher community-based transmission rates, in-school transmission remained low and stable with high attendance, suggesting that community restrictions, rather than school closures, best mitigated COVID-19 impacts. The Lancet regional health Western Pacific 22 March 2023

Wastewater concentrations of human influenza, metapneumovirus, parainfluenza, respiratory syncytial virus, rhinovirus, and seasonal coronavirus nucleic-acids during the COVID-19 pandemic: a surveillance study
Wastewater-based epidemiology can be used to obtain information on circulation of respiratory viruses at a localised, community level without the need to test many individuals because a single sample of wastewater represents the entire contributing community. Results from wastewater can be available within 24 h of sample collection, generating real time information to inform public health responses, clinical decision making, and individual behaviour modifications. The Lancet microbe 22 March 2023

Correlates of protection against COVID-19 infection and intensity of symptomatic disease in vaccinated individuals exposed to SARS-CoV-2 in households in Israel (ICoFS): a prospective cohort study
Both IgG and neutralising antibodies are correlates of protection against SARS-CoV-2 infection. Our data suggest that IgG concentrations higher than 500 BAU/mL and neutralising antibody titres of 1024 or more are thresholds for immunological protection from SARS-CoV-2 delta variant infection. Potentially, updated protective thresholds against emerging variants of concern could be calculated, which could support decision makers on administration of new vaccination strategies and on the optimal period between vaccine doses. The Lancet microbe 21 March 2023

Heterogeneous treatment effects of therapeutic-dose Heparin in patients hospitalized for COVID-19
Among patients hospitalized for COVID-19, the effect of therapeutic-dose heparin was heterogeneous. In all 3 approaches to assessing heterogeneity of treatment effect (THE), heparin was more likely to be beneficial in those who were less severely ill at presentation or had lower BMI and more likely to be harmful in sicker patients and those with higher BMI. The findings illustrate the importance of considering HTE in the design and analysis of RCTs. JAMA 21 March 2023

Update alert 10: Risks and impact of Angiotensin-Converting Enzyme Inhibitors or Angiotensin-Receptor Blockers on SARS-CoV-2 infection in adults
On the basis of moderate-strength evidence, ARB initiation among adults with COVID-19 probably does not have a mortality benefit. Although the specific interventions varied (use of different ARBs and varying doses), results were consistent across 6 of the 7 trials with no serious methodological concerns. Event rates (deaths) were low across studies, making results imprecise. A recent meta-analysis of trials of ACEIs and ARBs continuation as well as initiation among adults with COVID-19 also found no difference in all-cause mortality. This meta-analysis included 5 of the same trials included in the author’s review, as well as results from 3 unpublished trials. Annals of internal medicine 21 March 2023

Effect of Thromboprophylaxis on clinical outcomes after COVID-19 hospitalization
The incidence of death or thromboembolism was low in this cohort of patients discharged after hospitalization with COVID-19. Because of early enrollment termination, the results were imprecise and the study was inconclusive. Annals of internal medicine 21 March 2023

Risk of SARS-CoV-2 infection, severe COVID-19 illness and COVID-19 mortality in people with pre-existing mental disorders: an umbrella review
As compared to the general population, there is strong evidence showing that people with pre-existing mental disorders suffered from worse physical health outcomes due to the COVID-19 pandemic and may therefore be considered a risk group similar to people with underlying physical conditions. Factors likely involved include living accommodations with barriers to social distancing, cardiovascular comorbidities, psychotropic medications and difficulties in accessing high-intensity medical care. BMC psychiatry 20 March 2023

Daily step counts before and after the COVID-19 Pandemic among All of Us research participants
These findings suggest a consistent, widespread, and significant decline in activity following the onset of COVID-19 in the US. Vulnerable populations, including individuals at a lower socioeconomic status and those reporting worse mental health in the early COVID-19 period, were at the highest risk of reduced activity. The authors found a statistically significant decline in daily step counts that persisted even after most COVID-19–related restrictions were relaxed, suggesting COVID-19 affected long-term behavioral choices. JAMA 20 March 2023

Suicide and COVID-19: a rapid scoping review
Despite suffering from a mental disorder is a risk factor for suicidal behavior per se, the advent of COVID-19 pandemic may exacerbate this relation. Annals of general psychiatry 17 March 2023

Projected COVID-19 mortality reduction from Paxlovid rollout
In this study, the authors estimated that had current Paxlovid uptake been achieved in January 2022, 4.8 thousand deaths would have been averted during the WOW. Their estimates suggest that 0.7 to 75.3 million symptomatic tests and 0.4 to 39.8 million courses of Paxlovid are needed for a future Omicron-like wave. JAMA 17 March 2023

Advances in developing ACE2 derivatives against SARS-CoV-2
The potential of ACE2 derivatives can be expanded with the additional participation of other SARS-CoV-2 targeting drugs. For instance, antivirals are one of the mainstream treatment options for COVID-19, and some of them (eg, remdesivir) have retained viral neutralisation efficacy due to the high conservation of their target protein during SARS-CoV-2 evolution. The Lancet microbe 16 March 2023

Analysis of previous infection, vaccinations, and anti–SARS-CoV-2 antibody titers and protection against infection with the SARS-CoV-2 Omicron BA.5 variant
In vaccine recipients (mainly 3-dose) who had experienced the Omicron BA.1/BA.2 wave, the authors found that higher antispike antibody titers were associated with a lower risk of Omicron BA.5 infection, and the association was enhanced by previous infection (mainly occurred during the Omicron BA.1/BA.2 epidemic). JAMA 16 March 2023

Obstetric and neonatal outcomes associated with implementation of a COVID-19 predelivery screening policy in a Taiwan hospital
The findings of this cohort study suggest that antiepidemic policies on hospitalization, elective labor induction, and epidural injection resulted in noticeable changes in obstetric practice. The authors observed that more women underwent elective labor induction; their newborns tended to be born earlier and were more likely to require intensive care. JAMA 16 March 2023

Audio interview: The future of Covid-19 research
In this audio interview conducted on February 28, 2023, the editors discuss necessary and promising areas of Covid-19 research. NEJM 16 March 2023

Effectiveness of nirmatrelvir–ritonavir in preventing hospital admissions and deaths in people with COVID-19: a cohort study in a large US health-care system
In a setting with high levels of COVID-19 vaccine uptake, nirmatrelvir–ritonavir effectively reduced the risk of hospital admission or death within 30 days of a positive outpatient SARS-CoV-2 test. The Lancet infectious diseases 15 March 2023

Comparative effectiveness of BNT162b2 versus mRNA-1273 covid-19 vaccine boosting in England: matched cohort study in OpenSAFELY-TPP
This matched observational study of adults estimated a modest benefit of booster vaccination with mRNA-1273 compared with BNT162b2 in preventing positive SARS-CoV-2 tests and hospital admission with covid-19 20 weeks after vaccination, during a period of delta followed by omicron variant dominance. JAMA 15 March 2023

Estimation of COVID-19 mRNA vaccine effectiveness and COVID-19 illness and severity by vaccination status during Omicron BA.4 and BA.5 sublineage periods
In this case-control study of COVID-19 vaccines and illness, vaccine effectiveness (VE) associated with protection against medically attended COVID-19 illness was lower with increasing time since last dose; estimated VE was higher after receipt of 1 or 2 booster doses compared with a primary series alone. JAMA 15 March 2023

Association of antenatal COVID-19–related stress with postpartum maternal mental health and negative affectivity in infants
The findings of this cohort study suggest that targeting pandemic-related stressors in the antenatal period may improve maternal and infant outcomes. Pregnant individuals should be classified as a vulnerable group during pandemics and should be considered a public health priority, not only in terms of physical health but also mental health. JAMA 14 March 2023

Intimate partner violence, mental health symptoms, and modifiable health factors in women during the COVID-19 pandemic in the US
Results of the study showed that IPV experiences at the start of the pandemic were associated with worse mental health symptoms and modifiable health factors for female participants younger than 60 years. Screening and interventions for IPV and related health factors are needed to prevent severe, long-term health consequences. JAMA 14 March 2023

Effectiveness of Molnupiravir and Nirmatrelvir–Ritonavir in hospitalized patients with COVID-19: A target trial emulation study
Molnupiravir and nirmatrelvir–ritonavir reduced all-cause mortality in both vaccinated and unvaccinated hospitalized patients. No significant reduction in ICU admission or the need for ventilatory support was observed. Annals of internal medicine 14 March 2023

Protective immunity of SARS-CoV-2 infection and vaccines against medically attended symptomatic omicron BA.4, BA.5, and XBB reinfections in Singapore: a national cohort study
Protection against XBB reinfection conferred by a previous omicron infection with vaccination was lower and waned faster than protection against BA.4 or BA.5 reinfection, which is indicative of the greater immune evasiveness of the XBB sublineage. Although severe COVID-19 is uncommon, populations remain vulnerable to future reinfection waves from emerging SARS-CoV-2 variants despite high rates of vaccination and infection, as reflected by substantially higher reinfection rates during Singapore's XBB wave than during the previous BA.5-driven wave. Policy makers could consider emerging public health interventions, such as omicron-adapted bivalent vaccines, to maintain population immunity against COVID-19. The Lancet infectious diseases 13 March 2023

Long COVID: Why isn't anyone listening?
Post-coronavirus disease 2019 (COVID-19) condition (“long COVID”) causes hundreds of symptoms across multiple organ systems, presenting a huge challenge to a health system already under unprecedented pressure from the COVID-19 pandemic. Many patients have the classic post-viral problems of fatigue and brain fog, but various possible symptom constellations exist. Some of the less well known symptoms our patients have raised include incontinence, digestive complaints, hair loss and dizziness. MJA insight 13 March 2023

Assessment of the risk of venous thromboembolism in non-hospitalized patients with COVID-19
In this cohort study of outpatients with COVID-19, the absolute risk of VTE was low. Several patient-level factors were associated with higher VTE risk; these findings may help identify subsets of patients with COVID-19 who may benefit from more intensive surveillance or VTE preventive strategies. JAMA 13 March 2023

COVID-19 policies, pandemic disruptions, and changes in child mental health and sleep in the United States
These findings suggest that public health authorities should consider the mental health impacts of pandemic-related disruptions when deciding mitigating policies. JAMA 13 March 2023

Prevalence of physical frailty, including risk factors, up to 1 year after hospitalisation for COVID-19 in the UK: a multicentre, longitudinal cohort study
Physical frailty and pre-frailty are common following hospitalisation with COVID-19. Improvement in frailty was seen between 5 and 12 months although two-thirds of the population remained pre-frail or frail. This suggests comprehensive assessment and interventions targeting pre-frailty and frailty beyond the initial illness are required. eClinicalMedicine 10 March 2023

Sarilumab plus standard of care vs standard of care for the treatment of severe COVID-19: a phase 3, randomized, open-labeled, multi-center study (ESCAPE study)
The efficacy of sarilumab in severe COVID-19 was not demonstrated both in the overall and in the stratified for severity analysis population. Exploratory analyses suggested that subsets of patients with lower CRP values or lower lymphocyte counts might have had benefit with sarilumab treatment, but this finding would require replication in other studies. The relatively low rate of concomitant corticosteroid use, could partially explain these results. eClinicalMedicine 10 March 2023

Subcutaneous anti-COVID-19 hyperimmune immunoglobulin for prevention of disease in asymptomatic individuals with SARS-CoV-2 infection: a double-blind, placebo-controlled, randomised clinical trial
These findings suggested that administration of subcutaneous human hyperimmune immunoglobulin C19-IG20% to asymptomatic individuals with SARS-CoV-2 infection was safe but did not prevent development of symptomatic COVID-19. eClinicalMedicine 10 March 2023

Long-term COVID-19 booster effectiveness by infection history and clinical vulnerability and immune imprinting: a retrospective population-based cohort study
Protection against omicron infection waned after the booster, and eventually suggested a possibility for negative immune imprinting. However, boosters substantially reduced infection and severe COVID-19, particularly among individuals who were clinically vulnerable, affirming the public health value of booster vaccination. The Lancet infectious diseases 10 March 2023

Effect of the COVID-19 pandemic on adolescent mental health and substance use up to March, 2022, in Iceland: a repeated, cross-sectional, population-based study
Population-level prevention targeting adolescent depressive symptoms should be prioritised in health policy in the wake of COVID-19. The Lancet child and adolescent health 10 March 2023

Exploring the influence of behavioural, normative and control beliefs on intentions to adhere to public health guidelines during the COVID-19 pandemic: a qualitative interview based study
Individual perceptions of risk, loss of control, access to resources (i.e., childcare), and societal expectations, shaped intentions to engage in disease preventative behaviours (i.e., social distancing) during the COVID-19 pandemic. BMC public health 10 March 2023

Estimated effectiveness of prior SARS-CoV-2 BA.1 or BA.2 infection and booster vaccination against Omicron BA.5 subvariant infection
Prior SARS-CoV-2 infection during the BA.1 and BA.2 periods was associated with greater protection from SARS-CoV-2 infection during BA.5 period, which is in line with a previous study. Moreover, protection against critical BA.5 infection was also associated with the number of booster doses, compared with the 2-dose vaccination. The 4-dose booster, irrespective of history of SARS-CoV-2 infection, was associated with higher protection against critical BA.5 infection, as shown in previous studies. JAMA 10 March 2023

Comparison of paediatric emergency department visits for attempted suicide, self-harm, and suicidal ideation before and during the COVID-19 pandemic: a systematic review and meta-analysis
The integration of mental health support within community health and the education system—including promotion, prevention, early intervention, and treatment—is urgently needed to increase the reach of mental health support that can mitigate child and adolescent mental distress. In future pandemics, increased resourcing in some emergency department settings would help to address their expected increase in visits for acute mental distress among children and adolescents. The Lancet psychiatry 9 March 2023

Comparison of symptoms associated with SARS-CoV-2 variants among children in Canada
The findings of this cohort study of SARS-CoV-2 variants suggest that the Omicron and Delta variants were more strongly associated with fever and cough than the original-type virus and the Alpha variant. Children with Omicron variant infection were more likely to report lower respiratory tract symptoms and systemic manifestations, undergo chest radiography, and receive interventions. No differences were found in undesirable outcomes (ie, hospitalization, intensive care unit admission) across variants. JAMA 9 March 2023

Immunologic effect of Bivalent mRNA booster in patients undergoing Hemodialysis
The findings are in accordance with results from clinical studies of bivalent mRNA vaccines in healthy persons that showed a significant rise in anti-spike IgG concentrations. In particular, patients who did not have previous breakthrough infection immunologically benefited from a bivalent mRNA booster: despite having lower anti-spike IgG concentrations before the fifth vaccination, they had a significant increase after the fifth vaccination, such that their concentrations matched those in persons with hybrid immunity due to omicron breakthrough infection. NEJM 9 March 2023

Case 7-2023: A 70-year-old man with Covid-19, respiratory failure, and rashes
A 70 – year old man who had recently undergone kidney transplantation was evaluated because of rashes that had developed during an admission for Covid-19, respiratory failure and bacteremia. What is his diagnosis? NEJM 9 March 2023

A hidden pandemic? An umbrella review of global evidence on mental health in the time of COVID-19
This is the first meta-review to synthesise the longitudinal mental health impacts of the pandemic. Findings show that probable depression and anxiety were significantly higher than pre-COVID-19, and provide some evidence that that adolescents, pregnant and postpartum people, and those hospitalised with COVID-19 experienced heightened adverse mental health. Policymakers can modify future pandemic responses accordingly to mitigate the impact of such measures on public mental health. Frontiers in psychiatry 8 March 2023

Comparison of mental health symptoms before and during the covid-19 pandemic: evidence from a systematic review and meta-analysis of 134 cohorts
High risk of bias in many studies and substantial heterogeneity suggest caution in interpreting results. Nonetheless, most symptom change estimates for general mental health, anxiety symptoms, and depression symptoms were close to zero and not statistically significant, and significant changes were of minimal to small magnitudes. Small negative changes occurred for women or female participants in all domains. BMJ 8 March 2023

Total and subgenomic RNA viral load in patients infected with SARS-CoV-2 Alpha, Delta, and Omicron variants
RNA viral loads were similar among hospitalized adults, irrespective of infecting variant and known risk factors for severe COVID-19. Total N and subgenomic RNA N viral loads were highly correlated, suggesting that subgenomic RNA measurements adds little information for the purposes of estimating infectivity. Journal of infectious diseases 8 March 2023

Efficacy of antivirals and bivalent mRNA vaccines against SARS-CoV-2 isolate CH.1.1
This data suggest that therapeutic options, such as the antiviral drugs remdesivir, molnupiravir, nirmatrelvir, and ensitrelvir, are still valid against the omicron sublineage CH.1.1, and that an additional vaccine dose with the bivalent mRNA (ancestral, BA.4, and BA.5) vaccine might be beneficial in preventing CH.1.1 infection. The Lancet infectious diseases 7 March 2023

Severe COVID-19 outcomes by cardiovascular risk profile in England in 2020: a population-based cohort study
Individuals without pre-existing CVD but with raised cardiovascular risk (by QRISK3 score) were more likely to experience severe COVID-19 outcomes and should be prioritised for prevention and treatment. Addressing cardiovascular risk factors could improve COVID-19 outcomes. The Lancet regional health – Europe 7 March 2023

Ambient air pollution exposure linked to long COVID among young adults: a nested survey in a population-based cohort in Sweden
Ambient long-term PM2.5 exposure may affect the risk of long COVID in young adults, supporting efforts for continuously improving air quality. The Lancet regional health – Europe 7 March 2023

SARS-CoV-2 omicron (B.1.1.529)-related COVID-19 sequelae in vaccinated and unvaccinated patients with cancer: results from the OnCovid registry
Unvaccinated patients with cancer remain highly vulnerable to COVID-19 sequelae irrespective of viral strain. This study confirms the role of previous SARS-CoV-2 immunisation as an effective measure to protect patients from COVID-19 sequelae, disruption of therapy, and ensuing mortality. The Lancet oncology 7 March 2023

Safety and immunogenicity of aerosolised Ad5-nCoV, intramuscular Ad5-nCoV, or inactivated COVID-19 vaccine CoronaVac given as the second booster following three doses of CoronaVac: a multicentre, open-label, phase 4, randomised trial
A heterologous fourth dose (second booster) with either aerosolised Ad5-nCoV or intramuscular Ad5-nCoV was safe and highly immunogenic in healthy adults who had been immunised with three doses of CoronaVac. The Lancet respiratory medicine 7 March 2023

Efficacy of antivirals and bivalent mRNA vaccines against SARS-CoV-2 isolate CH.1.1
Overall, this data suggest that therapeutic options, such as the antiviral drugs remdesivir, molnupiravir, nirmatrelvir, and ensitrelvir, are still valid against the omicron sublineage CH.1.1, and that an additional vaccine dose with the bivalent mRNA (ancestral, BA.4, and BA.5) vaccine might be beneficial in preventing CH.1.1 infection. The Lancet infectious diseases 7 March 2023

“If people are hesitant at all, you just want a really big front door”: a rapid qualitative interview study on the Luton COVID-19 vaccination outreach clinics
The COVID-19 mobile vaccination outreach clinics in Luton tested and developed a different model of service delivery and demonstrated a collaborative way of working: “taking the health service to the patient, not the patient to the health service”. Planning and local community engagement were seen as key to successful delivery of a mobile healthcare service. BMC public health 7 March 2023

Communication inequalities and health disparities among vulnerable groups during the COVID-19 pandemic - a scoping review of qualitative and quantitative evidence
This review supports the findings of studies on past public health crises. Public health institutions should specifically target their communication to people with low education to reduce communication inequalities. More research about communication inequalities and health disparities (CIHD) is needed on groups with migrant status, financial hardship, not speaking the language in the country of residence, sexual minorities, and living in deprived neighborhoods. Future research should also assess communication input factors to derive specific communication strategies for public health institutions to overcome CIHD in public health crises. BMC public health 7 March 2023

Molnupiravir and risk of hospital admission or death in adults with covid-19: emulation of a randomized target trial using electronic health records
The findings of this emulation of a randomized target trial suggest that molnupiravir might have reduced hospital admission or death at 30 days in adults with SARS-CoV-2 infection in the community during the recent omicron predominant era who were at high risk of progression to severe covid-19 and eligible for treatment with molnupiravir. BMJ 7 March 2023

Nursing home crowding and its association with outbreak-associated respiratory infection in Ontario, Canada before the COVID-19 pandemic (2014–19): a retrospective cohort study
Respiratory infection and mortality rates were higher in nursing homes with high crowding index than in homes with low crowding index, and the association was consistent across various respiratory pathogens. Decreasing crowding is an important safety target beyond the COVID-19 pandemic to help to promote resident wellbeing and decrease the transmission of prevalent respiratory pathogens. The Lancet healthy longevity 7 March 2023

COVID-19 hospitalisations in immunocompromised individuals in the Omicron era: a population-based observational study using surveillance data in British Columbia, Canada
Vaccinated clinically extremely vulnerable (CEV) population remains a higher risk group in the context of circulating Omicron variant and may benefit from additional booster doses and pharmacotherapy. The Lancet regional health – Americas 6 March 2023

“You'll come in and dose even in a global pandemic”: a qualitative study of adaptive opioid agonist treatment provision during the COVID-19 pandemic
Rigidity in the delivery of OAT has been an impediment to achieving health and wellbeing over past decades. To sustain health-promoting environments for people receiving OAT, the wider impacts of the complex system should be acknowledged beyond narrowly defined outcomes relating solely to the medication. Centring people receiving OAT in their own care plans will ensure adaptations in the complex system of OAT provision are responsive to the individual's risk environment. International journal of drug policy 6 March 2023

Aged care residents — and everybody else — would benefit from better control of COVID‐19 transmission
Encouraging public compliance with measures that limit community transmission would benefit everyone, with only minor inconvenience. MJA 6 March 2023

WHO keeps covid-19 a public health emergency of international concern
A sensible decision—the defining criteria still apply. On 30 January 2023 the director general of the World Health Organization, Tedros Adhanom Ghebreyesus, announced his decision that covid-19 remains a public health emergency of international concern (PHEIC), three years after the emergency was first declared. In doing so, Tedros acknowledged the advice of the covid-19 emergency committee that “the covid-19 pandemic is probably at a transition point.” There is considerable speculation about when the PHEIC will be terminated. BMJ 6 March 2023

Ethnic inequalities in COVID-19 infection, hospitalisation, intensive care admission, and death: a global systematic review and meta-analysis of over 200 million study participants
This study suggests that systematic ethnic inequalities in COVID-19 health outcomes exist, with large differences in exposure risk and some differences in prognosis following hospitalisation. Response and recovery interventions must focus on tackling drivers of ethnic inequalities which increase exposure risk and vulnerabilities to severe disease, including structural racism and racial discrimination. eClinicalMedicine 5 March 2023

Prevention of skin damages related to personal protective equipment among healthcare workers: Summary of best-evidence practiced strategies
What does this paper contribute to the wider global clinical community?

  • The COVID-19 pandemic has resulted in a significant rise in PPE use, which has elevated the risk of a number of cutaneous injuries and the aggravation of existing skin problems.
  • There are few previous studies on preventive measures for PPE-related skin injuries, and there is a low level of evidence.
  • This study provided references for HCWs to prevent PPE-related skin injuries by integrating evidence to form recommendations.

Journal of clinical nursing 5 March 2023

Wide QRS complex transient pattern in a patient with severe COVID-19
This case report describes a patient in their 60s with shortness of breath who tested positive for COVID-19. JAMA 4 March 2023

Immunity of heterologous and homologous boosted or convalescent individuals against Omicron BA.1, BA.2 and BA.4/5 variants
The authors here showed that twice vaccinated and convalescent individuals demonstrated the strongest immunity against Omicron BA.2 and BA.4/5 variant followed by heterologous and homologous booster vaccine regimens. Journal of infectious diseases 4 March 2023

The defenders of the Alveolus succumb in COVID-19 pneumonia to SARS-CoV-2 and necroptosis, pyroptosis and panoptosis
Alveolar type II (ATII) pneumocytes as defenders of the alveolus are critical to repairing lung injury. We investigated the ATII reparative response in COVID-19 pneumonia, because the initial proliferation of ATII cells in this reparative process should provide large numbers of target cells to amplify SARS-CoV-2 virus production and cytopathological effects to compromise lung repair. The authors show that both infected and uninfected ATII cells succumb to tumor necrosis factor-α (TNF)-induced necroptosis, Bruton’s tyrosine kinase (BTK)-induced pyroptosis and a new PANoptotic hybrid form of inflammatory cell death mediated by a PANoptosomal latticework that generates distinctive COVID-19 pathologies in contiguous ATII cells. Identifying TNF and BTK as the initiators of programmed cell death and SARS-CoV-2 cytopathic effects provides a rationale for early antiviral treatment combined with inhibitors of TNF and BTK to preserve ATII cell populations, reduce programmed cell death and associated hyperinflammation, and restore functioning alveoli in COVID-19 pneumonia. Journal of infectious diseases 3 March 2023

Aberrant olfactory network functional connectivity in people with olfactory dysfunction following COVID-19 infection: an exploratory, observational study
This work describes, for the first time to the author’s knowledge, functional differences within olfactory areas and regions involved in sensory processing and cognitive functioning. This work identifies key areas for further research and potential target sites for therapeutic strategies. eClinicalMedicine 2 March 2023

Public health emergency preparedness for infectious disease emergencies: a scoping review of recent evidence
The themes from this review contribute to the evolving understanding of critical public health emergency preparedness actions. The themes expand on the 11 elements outlined in the Resilience Framework for PHEP, specifically relevant to pandemics and infectious disease emergencies. Further research will be important to validate these findings, and expand understanding of how refinements to PHEP frameworks and indicators can support public health practice. BMC public health 2 March 2023

Audio interview: The path forward for Covid-19 therapeutics
In this audio interview conducted on February 21, 2023, the editors discuss interferon lambda, a potential new treatment for Covid-19, and the path forward for such agents. NEJM 2 March 2023

Association of preoperative COVID-19 and postoperative respiratory morbidity during the Omicron epidemic wave: the DROMIS-22 multicentre prospective observational cohort study
In this Omicron-predominant, highly immunised population undergoing general surgery, a preoperative COVID-19 was not associated with increased postoperative respiratory morbidity. eClinicalMedicine 2 March 2023

Neutralization of BQ.1, BQ.1.1, and XBB with RBD-Dimer Vaccines
The currently circulating omicron subvariants, especially BQ.1, BQ.1.1, and XBB, showed immune escape to the humoral immunity elicited by prototype strain sequence-based vaccines, such as inactivated vaccine and ZF2001. The author’s study showed that next-generation and updated Covid-19 vaccines are needed for better protection and pandemic control. Their newly updated delta–omicron BA.1 and BA.2 RBD heterodimers had high neutralizing activities against the emerging omicron subvariants. An analysis of clinical data regarding the delta–omicron BA.1 RBD-dimer vaccine ZF2202 is currently under way. NEJM 1 March 2023

Antibody responses to the SARS-CoV-2 ancestral strain and Omicron variants in Moderna mRNA-1273 vaccinated active-duty U.S. Navy Sailors and Marines
Omicron and its subvariants have steadily gained greater capability of immune escape compared to other variants of concern, resulting in an increased incidence of reinfections even among vaccinated individuals. We evaluated the antibody response to Omicron BA.1, BA.2, and BA.4/5 in U.S. military members vaccinated with the primary 2-dose series of Moderna mRNA-1273 in a cross-sectional study. While nearly all vaccinated participants had sustained Spike (S) IgG and neutralizing antibodies (ND50) to the ancestral strain, only 7.7% participants had detectable ND50 to Omicron BA.1 at eight months post-vaccination. The neutralizing antibody response to BA.2 and BA.5 was similarly reduced. The reduced antibody neutralization of Omicron correlated with the decreased antibody binding to the Receptor-Binding Domain. The participants’ seropositivity to the nuclear protein positively correlated with ND50. Our data emphasizes the need for continuous vigilance in monitoring for emerging variants and the need to identify potential alternative targets for vaccine design. Journal of infectious diseases 1 March 2023

US public investment in development of mRNA covid-19 vaccines: retrospective cohort study
The US government invested at least $31.9bn to develop, produce, and purchase mRNA covid-19 vaccines, including sizeable investments in the three decades before the pandemic through March 2022. These public investments translated into millions of lives saved and were crucial in developing the mRNA vaccine technology that also has the potential to tackle future pandemics and to treat diseases beyond covid-19. To maximize overall health impact, policy makers should ensure equitable global access to publicly funded health technologies. BMJ 1 March 2023

Monkeypox information
Updated 28 March  2023

Department of Health and Aged Care – health alert – Monkeypox (MPX) resources 

SA Health – health alert – Monkeypox

UpToDate – Monkeypox  if accessing outside of SA Health computer network use your library login

Monkeypox Resources for Health Professionals (Wolters Kluwer)

Monkeypox Resource Centre (JAMA)

World Health Organization Health alert

Journal articles

Erythema and Induration after Mpox (JYNNEOS) vaccination revisited
In a trial of Mpox vaccine, intradermal administration led to more erythema and induration than the subcutaneous route but resulted in a similar level of immune response with 20 % of the dose NEJM 22 March 2023

Monkeypox (Mpox) and occupational exposure
The highest work-related risk for mpox transmission has been noted among healthcare professionals, people working with animals, and sex workers. There is general agreement that a paramount issue to avoid transmission of infection in occupational settings is an appropriate decontamination of often-touched surfaces and usage of appropriate personal protective equipment by the workers at high risk of infection. The group that should especially protect themselves and be educated in the field of early symptoms of the disease and prevention are dentists, who are often the first to detect the symptoms of the disease on the oral mucosa. International journal of environmental research and public health 14 March 2023

Therapeutics for treating mpox in humans
This review found no evidence from randomized trials from which to draw certain conclusions concerning the efficacy of therapeutics in humans with mpox. Cochrane Database of Systematic Reviews – Intervention 14 March 2023

Potential anti-mpox virus activity of atovaquone, mefloquine, and molnupiravir, and their potential use as treatments
These data suggest that atovaquone would be potential candidates for treating mpox. Journal of infectious diseases 9 March 2023

Severe corneal involvement associated with Mpox infection
Mpox keratitis is rare but potentially severe. Infection of the eyelids should be monitored because it can spread to the cornea afterwards. Corneal infection is very painful and evolves from the limbus centripetally with a pathognomonic arcuate serpiginous epithelial pattern. The role of antivirals remains to be determined. JAMA 9 March 2023

An Mpox-related death in the United States
In hospitalized patients with severe mpox, it is important to consider treatment with intravenous tecovirimat. Second-line therapies including cidofovir, brincidofovir, and vaccinia immune globulin may also be considered. If progressive or persistent lesions are present after 14 days of treatment with tecovirimat, pharmacokinetic testing of tecovirimat and testing of lesion specimens for antiviral resistance are warranted. Patients with low CD4+ T-cell counts who become infected with MPXV should be monitored closely, given the potential risk of more severe illness. NEJM 8 March 2023

Brief report: Monkeypox virus cross-neutralizing antibodies in clinical trial subjects vaccinated with Modified Vaccinia Virus Ankara Encoding MERS-Coronavirus Spike Protein
Modified vaccinia virus Ankara (MVA) is used as a vaccine against monkeypox virus (MPXV) and as a viral vaccine vector. MVA-MERS-S is a vaccine candidate against Middle East respiratory syndrome- associated coronavirus (MERS-CoV). Here, we report that cross-reactive MPXV nAbs were detectable in only a single subject after the first dose, 3 out of 10 after the 2nd dose, and in 10 out of 10 after the 3rd dose of MVA-MERS-S vaccine. Journal of infectious diseases 1 March 2023

Possibility of mpox viral transmission and control from high-risk to the general population: a modeling study
Mpox has high transmissibility in men who have sex with men (MSM), which required minimize the risk of infection and exposure to high-risk populations. Community prevention and control is the top priority of interventions to contain the spread of mpox. BMC infectious diseases 24 February 2023

Mpox in people with advanced HIV infection: a global case series
A severe necrotising form of mpox in the context of advanced immunosuppression appears to behave like an AIDS-defining condition, with a high prevalence of fulminant dermatological and systemic manifestations and death. The Lancet 21 February 2023

Mpox—A rapidly evolving disease
This Special Communication provides an overview of the evolution of mpox skin findings from its initial description in humans in 1970 to the present-day multinational outbreak. JAMA 9 February 2023

Human monkeypox: diagnosis and management
What you need to know

  • Consider coinfections with monkeypox and other sexually transmitted infections among patients presenting with an acute rash or skin lesions and systemic symptoms
  • While it is safe to manage monkeypox patients virtually, they may need advice to maintain infection control measures and interventions to manage complications
  • A specialist infectious disease unit with access to novel antivirals such as tecovirimat and cidofovir should manage high risk patients
  • Healthcare workers should be aware of the stigma surrounding monkeypox, which may result in reduced health-seeking behaviours; healthcare staff should screen patients sensitively, using inclusive language to avoid alienating patients

BMJ 6 February 2023

Mpox vaccination encouraged ahead of World Pride
With upcoming World Pride events in Sydney, now is the perfect time to raise awareness and encourage vaccination against mpox. MJA InSight 30 January 2023

Use of wastewater for Mpox outbreak surveillance in California
Real-time results informed the state and local public health response, allowing for escalation of the state response level when detection in multiple watersheds suggested that MPXV was widespread or unexpected, alerting clinicians, and guiding the allocation of resources (e.g., testing, vaccines, and therapeutics) and personnel in affected areas. This experience in adapting routine wastewater-surveillance infrastructure to monitor for a nonenteric, nonrespiratory virus such as MPXV shows promise for the future use of this method as an adjunct public health tool. NEJM 18 January 2023

Real-time forecasting the trajectory of monkeypox outbreaks at the national and global levels, July–October 2022
The top-ranked model consistently predicted a decreasing trend in monkeypox cases on the global and country-specific scale during the last ten sequential forecasting periods. The findings reflect the potential impact of increased immunity, and behavioral modification among high-risk populations. BMC medicine 16 January 2023

MPXV transmission at a tattoo parlor
The authors describe cases of MPXV transmission that were likely to have occurred by means of direct inoculation from piercing and tattooing; such transmission has been observed with other poxviruses, such as Molluscum contagiosum. To date, sexual transmission of MPXV has been the most common mode of transmission, with men who have sex with men being disproportionately affected. In contrast, the cases in this report mostly involved female patients. MPXV may develop new networks of transmission, with epidemiologic changes of the disease. NEJM 5 January 2022

Tecovirimat treatment for Monkeypox Virus Keratouveitis
Currently, there is no specific medication to treat human monkeypox, and antiviral agents approved to treat smallpox have been used for its management. Compassionate use of tecovirimat has been reported in this setting, with minimal adverse effects. A case of MPXV keratouveitis confirmed by PCR and treated with tecovirimat was presented. Patients should be advised not to rub the eyes, since self-inoculation of the ocular surface from contaminated hands may occur. Although possible, we do not know whether MPXV is transmissible through tears. Resources are more than needed to put in place new action plans and strategies. JAMA 22 December 2022

Audio interview: Applying new studies of Mpox and Ebola to Covid-19
In this audio interview conducted on December 9, 2022, the editors discuss new data on mpox and Ebola and how what we’ve learned can be applied to the Covid-19 pandemic. NEJM 15 December 2022

Breakthrough infections after postexposure vaccination against Mpox
During the current outbreak of monkeypox (recently renamed mpox), smallpox vaccination has been recommended to prevent mpox infection in persons who have had mpox exposure, but evidence to support this practice is limited.1,2 We conducted a study to evaluate potential breakthrough infections in participants who had received smallpox vaccine after high-risk exposure to mpox. In this study population, 4% of the participants who had received postexposure vaccination with a third-generation smallpox vaccine had a subsequent mpox infection during the first month after receipt of the first vaccination. NEJM 7 December 2022

Monkeypox – review article
The gradual decline in immunity to smallpox may partly explain an increase in the incidence of monkeypox in some regions where the disease is endemic. However, the current epidemic reminds us that viral emergence is a permanent phenomenon without boundaries and is often unpredictable in its nature, target, and magnitude. This outbreak illustrates how a disease affecting one region of the world can have a strong effect on areas where it is not endemic, with different target populations and new clinical presentations. NEJM 10 November 2022

Contact tracing and exposure investigation in response to the first case of Monkeypox Virus infection in the United States during the 2022 Global Monkeypox Outbreak
In a contact tracing investigation involving 166 community and health care contacts of a patient with monkeypox, no secondary cases were identified. Annals of infectious diseases 8 November 2022

Immunological signature in human cases of monkeypox infection in 2022 outbreak: an observational study
Our data showed the immunological signature of monkeypox virus infection, characterised by an early expansion of activated effector CD4+ and CD8+ T cells that persisted over time. Almost all patients, even regardless of HIV infection, developed a poxvirus-specific Th1 cell response. These results might have implications on the expected immunogenicity of monkeypox vaccination, suggesting that it might not be necessary to vaccinate people who have already been infected. The Lancet infectious diseases 7 November 2022

Monkeypox virus and ophthalmology—A primer on the 2022 Monkeypox outbreak and Monkeypox-related ophthalmic disease
The ophthalmologist may play an important role in the diagnosis and management of monkeypox. MPXROD may be associated with severe ocular and visual morbidity. As the current outbreak evolves, up-to-date guidance from public health organizations and professional societies are critical. JAMA 3 November 2022

Ocular pox lesions in a male patient with Monkeypox treated with Tecovirimat
Monkeypox can be transmitted via bodily fluids, blood, infected lesions, or respiratory droplets. The infection is usually self-limited, lasting 2 to 4 weeks. Along with cutaneous and systemic findings, ocular manifestations include conjunctivitis, eyelid edema, keratitis, corneal scarring, and conjunctival lesions. Herein, the authors describe a case of ocular pox lesions in a male individual successfully treated with tecovirimat, an expanded-access investigational therapy, and conservative ocular management. JAMA 3 November 2022

Transmission dynamics of monkeypox in the United Kingdom: contact tracing study
Analysis of the instantaneous growth rate of monkeypox incidence indicates that the epidemic peaked in the UK as of 9 July and then started to decline. Short serial intervals were more common than short incubation periods suggesting considerable pre-symptomatic transmission, which was validated through linked patient level records. For patients who could be linked through personally identifiable data, four days was the maximum time that transmission was detected before symptoms manifested. An isolation period of 16 to 23 days would be required to detect 95% of people with a potential infection. The 95th centile of the serial interval was between 23 and 41 days, suggesting long infectious periods. BMJ 2 November 2022

Monkeypox : review article
The gradual decline in immunity to smallpox may partly explain an increase in the incidence of monkeypox in some regions where the disease is endemic. However, the current epidemic reminds us that viral emergence is a permanent phenomenon without boundaries and is often unpredictable in its nature, target, and magnitude. This outbreak illustrates how a disease affecting one region of the world can have a strong effect on areas where it is not endemic, with different target populations and new clinical presentations. NEJM 26 October 2022

Monkeypox: Challenging clinical questions
This article summarizes the ACP/Annals virtual forum held on 11 October 2022. Annals of internal medicine 14 October 2022

Neonatal Monkeypox virus infection
Reports of neonatal monkeypox virus infection are rare. This was a case of neonatal monkeypox virus infection after peripartum transmission within a family cluster; transplacental transmission could not be ruled out. Because this was a single case, it is not possible to attribute the clinical illness to either pathogen (monkeypox virus or adenovirus) directly, nor is it possible to attribute the improvement in the infant’s clinical condition to the use of tecovirimat or cidofovir. Monkeypox virus infection should be considered in the differential diagnosis of a neonatal vesicular rash. NEJM 12 October 2022

Development of an accessible and scalable qPCR assay for Monkeypox virus detection
During the 2022 monkeypox (MPX) outbreak, testing has been limited and results delayed, allowing ongoing transmission. Gold-standard qPCR diagnostics are difficult to obtain. This research adapted the June 2022 CDC MPX qPCR assay for broad implementation. Validated using MPX stocks in a matrix with multiple sample types, MPX was detected with Cq values of 17.46 to 35.59 and titer equivalents 8.01 × 106 to 2.45 × 100 PFU/mL. The detection limit was 3.59 PFU/mL. Sensitivity and specificity were both 100%. This qPCR assay can be quickly and broadly implemented in research and public health labs to increase diagnostic capacity amid the growing MPX outbreak. Journal of infectious diseases 12 October 2022

Air and surface sampling for monkeypox virus in a UK hospital: an observational study
These data show contamination in isolation facilities and potential for suspension of monkeypox virus into the air during specific activities. PPE contamination was observed after clinical contact and changing of bedding. Contamination of hard surfaces in doffing areas supports the importance of cleaning protocols, PPE use, and doffing procedures. The Lancet microbe 7 October 2022

Epidemiological and clinical characteristics of patients with monkeypox in the GeoSentinel Network: a cross-sectional study
Clinical manifestations of monkeypox infection differed by HIV status. Recommendations should be expanded to include pre-exposure monkeypox vaccination of groups at high risk of infection who plan to engage in sexual or close intimate contact. The Lancet infectious diseases 7 October 2022

Asymptomatic monkeypox infection: a call for greater control of infection and transmission
National surveillance programmes should be conducted, particularly among populations at high risk of infection, to detect asymptomatic cases. Such surveillance will require rapid diagnostic or home-based tests that could identify undiagnosed infections. Surveillance at a country's entry points (eg, airports) might be effective, particularly in non-endemic countries with little evidence of local transmission, similar to approaches previously suggested for asymptomatic COVID-19 transmission.9,  10 Health-care providers should also establish a proper differential diagnosis before excluding monkeypox, especially considering the increasing non-specific presentations of the disease. Finally, cases could be decreased and the processes of case identification and contact tracing could be facilitated by individuals limiting their numbers of sexual partners and by limitations on areas and gatherings where people commonly engage in anonymous sexual activities. The Lancet microbe 6 October 2022

Recognizing minimal cutaneous involvement or systemic symptoms in Monkeypox
In patients with umbilicated or ulcerated lesions, particularly localized to the anogenital region, clinicians should perform a thorough social history and maintain a high index of suspicion for monkeypox, even in those with mild constitutional symptoms, who report a new sexual partner in the preceding 2 weeks. Increased public awareness of risk factors, the ability to recognize subtle skin findings, as well the increased availability/dissemination of vaccines will be important in containing and preventing further outbreaks. JAMA 6 October 2022

Human Monkeypox virus infection in the immediate period after receiving modified Vaccinia Ankara vaccine
In this small study, the majority of postvaccination monkeypox infections occurred within 2 weeks of receiving the first dose of MVA-BN, before full effectiveness was likely to have been achieved, in line with published immunogenicity data. Because the incubation period for monkeypox is 3 to 17 days, some of the cases occurring between 1 and 14 days after vaccination may not represent true vaccine failure because patients may have sought vaccination after realizing they were exposed. Of concern is that at least 2 breakthrough infections were observed in individuals at least 3 weeks after a second dose. JAMA 30 September 2022

Intradermal vaccination for Monkeypox — Benefits for individual and public health
Despite limited clinical evidence, all available data suggest that intradermal administration of JYNNEOS will be as immunogenic as subcutaneous dosing for preventing monkeypox infection and illness, which leads the authors to favor intradermal use from both the individual and public health perspectives. The Centers for Disease Control and Prevention and the FDA are committed to performing the studies needed to assure that these expectations are borne out. In the meantime, they urge people who are at the highest risk for infection to receive both doses of the two-dose vaccine, and we encourage manufacturers to consider routinely testing intradermal dose administration in future clinical vaccine trials, in order to expand our understanding of this operationally attractive option. The currently available evidence suggests that shifting to intradermal dosing that requires less vaccine is not a lesser option. Rather, it is a rational, evidence-informed means of advancing access, equity, and our chances of controlling the monkeypox outbreak. NEJM 29 September 2022

Neurologic complications of Smallpox and Monkeypox: A review
Monkeypox should be considered in high-risk populations who present with neurologic syndromes. Diagnosis may require serology and polymerase chain reaction testing of blood and spinal fluid. Antiviral therapy should be initiated early in the course of the illness. JAMA 20 September 2022

Monkeypox prevention and treatment while nursing
Although no specific guidelines have appeared for monkeypox, individuals with smallpox are recommended not to breastfeed their infant because of the risk of passing variola virus to the infant through direct contact. Presumably, the same precautions apply with monkeypox. Providing pumped milk to the infant may be possible if no lesions are near the breast and adequate precautions are taken with respect to cleaning hands, breasts, breast pumps, and any other apparatuses used to provide milk to the infant. As the current monkeypox situation evolves, recommendations may change, so refer to the CDC website for the most up-to-date information Breastfeeding medicine 15 September 2022

Annals on call - Diagnosis and treatment of Monkeypox Proctitis
In this episode of Annals On Call, Dr. Centor discusses the diagnosis and treatment of monkeypox proctitis with Drs. Jose Lucar and Tara Palmore. Annals of internal medicine 13 September 2022

Vaccinia-virus-based vaccines are expected to elicit highly cross-reactive immunity to the 2022 Monkeypox Virus
Beginning in May 2022, a novel cluster of monkeypox virus infections was detected in humans. This virus has spread rapidly to non-endemic countries, sparking global concern. Specific vaccines based on the vaccinia virus (VACV) have demonstrated high efficacy against monkeypox viruses in the past and are considered an important outbreak control measure. Viruses observed in the current outbreak carry distinct genetic variations that have the potential to affect vaccine-induced immune recognition. Here, by investigating genetic variation with respect to orthologous immunogenic vaccinia-virus proteins, we report data that anticipates immune responses induced by VACV-based vaccines, including the currently available MVA-BN and ACAM2000 vaccines, to remain highly cross-reactive against the newly observed monkeypox viruses. Viruses 3 September 2022

Reports of asymptomatic Monkeypox suggest that, at the very least, some infections go unnoticed
Two recent case reports from Europe have raised the possibility that some monkeypox virus infections may be asymptomatic. Whether or not these infections were truly symptom free, the studies suggest that clinicians and individuals at high risk should be aware that monkeypox can go unnoticed—possibly even when it’s transmissible. JAMA 31 August 2022

Monkeypox Virus infection in humans across 16 Countries — April–June 2022
In this case series, monkeypox manifested with a variety of dermatologic and systemic clinical findings. The simultaneous identification of cases outside areas where monkeypox has traditionally been endemic highlights the need for rapid identification and diagnosis of cases to contain further community spread. NEJM 25 August 2022

Compassionate use of Tecovirimat for the treatment of Monkeypox infection
The authors assessed adverse events and clinical resolution of systemic symptoms and lesions in an uncontrolled cohort study of patients with monkeypox who were treated with tecovirimat on a compassionate use basis. In this preliminary study, oral tecovirimat was well tolerated by all patients with monkeypox infection, with minimal adverse effects. However, adverse effects could not always be differentiated from symptoms related to the infection. No control group was included, limiting conclusions of antiviral efficacy pertaining to duration of symptoms or severity. Time from symptom onset to presentation was variable among patients, and conclusions related to antiviral use vs natural evolution of disease should be made with caution. Limited clinical data exist on the use of tecovirimat for monkeypox infection. In one case report, no new lesions followed 24 hours of therapy and no adverse effects occurred by treatment completion at 14 days. JAMA 22 August 2022

How does monkeypox spread? An epidemiologist explains why it isn’t an STI and what counts as close contact
The monkeypox virus typically spreads through direct contact with respiratory secretions, such as mucus or saliva, or skin lesions. Skin lesions traditionally appear soon after infection as a rash – small pimples or round papules on the face, hands or genitalia. These lesions may also appear inside the mouth, eyes and other parts of the body that produce mucus. They can last for several weeks and be a source of virus before they are fully healed. Other symptoms usually include fever, swollen lymph nodes, fatigue and headache. MJA Insight 22 August 2022

Audio interview: Responding to Monkeypox
In this audio interview conducted on August 16, 2022, the editors are joined by White House National Monkeypox Response Deputy Coordinator Demetre Daskalakis to discuss the new public health emergency and what HIV and Covid-19 have taught us. NEJM 18 August 2022

Update on the Monkeypox Outbreak
The current monkeypox outbreak illustrates why global health cannot be ignored. Despite monkeypox being endemic in Africa for decades, clinical trials on treatments and vaccines were not done. Now more than 3 months into the global monkeypox outbreak, there is much to learn. While test capacity has been increased, more is needed. Contact tracing is not happening, and data systems are not informing the response in rapid fashion. Many individuals at risk for monkeypox may not be engaged with the health care system, making diagnosis, containment, and prevention challenging. The demand for vaccines far exceeds availability. Although the supply of tecovirimat has increased, this drug must still be used under an IND protocol, which limits access. In addition, a decentralized and wholly underresourced public health infrastructure is even more strained as officials must now respond to both COVID-19 and monkeypox. JAMA 11 August 2022

The changing face of monkeypox
What should patients and clinicians look out for? BMJ 10 August 2022

Clinical presentation and virological assessment of confirmed human monkeypox virus cases in Spain: a prospective observational cohort study
In this cohort, monkeypox caused genital, perianal, and oral lesions and complications including proctitis and tonsillitis. Because of the variability of presentations, clinicians should have a low threshold for suspicion of monkeypox. Lesion swabs showed the highest viral loads, which, combined with the history of sexual exposure and the distribution of lesions, suggests close contact is probably the dominant transmission route in the current outbreak. The Lancet 8 August 2022

Ophthalmic manifestation of monkeypox infection
Despite mucosal localisation of vesicles being not uncommon in monkeypox, the diagnosis might be overlooked. During the ongoing monkeypox outbreak, monkeypox should be included in the differential diagnosis of patients with vesicular and pustular eye lesions, especially in the presence of epidemiological links or risk factors. The Lancet infectious diseases 29 July 2022

Clinical features and novel presentations of human monkeypox in a central London centre during the 2022 outbreak: descriptive case series
These findings confirm the ongoing unprecedented community transmission of monkeypox virus among gay, bisexual, and other men who have sex with men seen in the UK and many other non-endemic countries. A variable temporal association was observed between mucocutaneous and systemic features, suggesting a new clinical course to the disease. New clinical presentations of monkeypox infection were identified, including rectal pain and penile oedema. These presentations should be included in public health messaging to aid early diagnosis and reduce onward transmission. BMJ 28 July 2022

Monkeypox virus infection in humans across 16 countries — April–June 2022
In this case series, monkeypox manifested with a variety of dermatologic and systemic clinical findings. The simultaneous identification of cases outside areas where monkeypox has traditionally been endemic highlights the need for rapid identification and diagnosis of cases to contain further community spread. NEJM 21 July 2022

Is Australia ready for monkeypox?
Disease control efforts can draw on lessons from the past and prevent the epidemic from becoming established in Australia MJA 18 July 2022

Monkeypox emerges on a global scale: a historical review and dermatological primer
The current monkeypox outbreak reawakens the concern that poxviridae have high potential of zoonotic spillover and for causing pandemic.1 Much fieldwork and research has been done by healthcare and public health workers in Africa during previous human outbreaks, and their knowledge should inform our global response to the current outbreak. However, unusual clinical presentations now have potential implications in recognizing disease. Infections from poxviridae such as monkeypox have common cutaneous signs that occur early, may be related to periods of transmissibility, and can leave scarring. Therefore, dermatologists will play a key role in recognizing and diagnosing infections, and in educating and preparing front-line healthcare workers for early detection of new cases and clusters of monkeypox. Journal of the American Academy of Dermatology 8 July 2022

Efficacy of biocidal agents and disinfectants against the monkeypox virus and other orthopoxviruses
As orthopoxviruses may stay infectious on inanimate surfaces under laboratory conditions for up to 42 days, disinfection may be relevant in the surroundings of confirmed cases. The aim of this review was to evaluate published data on the antiviral efficacy of biocidal agents and disinfectants against the monkeypox virus and other orthopoxviruses. Journal of hospital infection 28 June 2022

The outbreak of monkeypox 2022: An overview
On May 6, 2022 an outbreak of monkeypox (MPX) was confirmed in the United Kingdom, originating from a British resident who had travelled to Nigeria. As of May 21, 2022, 92 cases have been confirmed worldwide, from 13 countries where monkeypox virus (MPXV) is not endemic. Reported cases thus far have mainly but not exclusively been identified among gay and bisexual men aged 20–50. MPXV is a viral zoonosis transmitted to humans via contacting or eating an infected animal, and direct connect with natural host’s blood and body fluids. In addition to contacting with a patient’s respiratory droplets, lesions, body fluids and polluted personal objects. Symptoms including shivers, headaches, fainting, backaches, and myodynia do not have any specific characteristics making it difficult to establish a proper diagnosis. Nevertheless, lymphatic hyperplasia, one of the most common symptoms of monkeypox, can be useful for diagnosing the disease. Clinical symptoms help establish the suspicion of monkeypox. However, in the absence of confirmed diagnostic tests it is very difficult to verify the disease and determine its cause based on clinical symptoms alone. There are numerous methods for detecting MPX, involving genetic, phenotypic, immunological methods, and electron microscopy. These tests require modern equipment and expert hands, which may not be available in developing countries where this disease is prevalent. Currently, there is no definite treatment for MPX. CDC recommends administering the smallpox vaccine within 4 days of exposure which may prevent the disease from happening, and within 2 weeks to reduce symptoms severity. To promptly identify patients and prevent further spreading, physicians should be aware of the travel or contact history of the patient with compatible symptoms. Annals of medicine and surgery 24 June 2022

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SA Health Library Service 12/8/2022