Issue Briefs | April 2021

COVID-19 Information and Resources

Overview

This site serves to share the research and information we are using to inform health service delivery for COVID-19, HIV, pregnancy, and general health programs. If you have any questions, or wish to suggest additional research, contact publications@pedaids.org.

EGPAF Resources on COVID-19

Article: Prioritizing Communities We Serve in the Midst of COVID-19
EGPAF Webinar: COVID-19 and Its Impact on Pregnancy and Potential Mother-to-child SARS-CoV-2 Viral
Video: EGPAF’s COVID-19 Response with Chip Lyons and Craig Evans
Interview with Chip Lyons, CEO in The Business of Giving, “Leading Through a Crisis”
Interview with Catherine Connor, VP, Public Policy & Advocacy in Devex: “After the pandemic: How will COVID-19 transform global health and development?
UNICEF Webinar featuring EGPAF Senior Research Advisor Dr. Lynne Mofenson: COVID 19: What Paediatric HIV Programmes Need to Know
Global Health Council Webinar featuring EGPAF CEO Chip Lyons: COVID Conversations: Deep Dive on Low- and Middle-Income Countries
EGPAF Issue Brief: EGPAF Committee of African Youth Advisors (CAYA) Rapid Response Recommendations for Adolescent and Youth Programming Amidst COVID-19
Stories: Stepping Up Against COVID-19
Medscape article featuring EPGAF Technical Advisor Dr. Lynne Mofenson: COVID-19 Severity in Pregnancy Appears Lower Than H1N1
EGPAF CEO Chip Lyons on LinkedIn: Stepping Up Against COVID-19
Webinar: Evidence to Action – Children and COVID-19
Webinar: Dual Pandemics – Global Youth Perspectives on Fighting HIV and COVID-19
Interview: We Must Not Forget Our Mission to End AIDS in Children, Mothers, and Families – The Director of EGPAF-Kenya Talks About Maintaining HIV Programs During COVID-19
Interview: We Are Living in a Volatile, Uncertain, Complex, and Ambiguous World – The Director of EGPAF-Kenya Talks About Maintaining HIV Programs During COVID-19 Part 2
Journal article: The evolving picture of SARS-CoV- 2 and COVID-19 in children – Critical knowledge gaps.
Journal Article: Clinical Characteristics and Outcomes of Patients Hospitalized for COVID-19 in Africa
Interview: The Broader Impact of COVID-19, A Conversation with John Ditekemena, Country Director of EGPAF-Cameroon
Story: A Clinician Works to Make Sure that His Health Center Is Not Overwhelmed
Article: The Critical Need for Pooled Data on COVID-19 in African Children: An AFREhealth Call for Action through Multi-Country Research Collaboration

Frequently Asked Questions

What is COVID-19/SARS-CoV-2 and How is it Transmitted?
How is SARS-COV-2 Diagnosed?
What is the Current State of the Pandemic?
New SARS-CoV-2 Variants
Approved COVID-19 Vaccines
How Can We Prevent Infection and Spread?
What Are The Implications of COVID-19 On HIV-Positive Populations?
Vaccines for People Living with HIV
What Precautions should HIV-Positive Persons Take?
What Do We Know About COVID-19’s Effect On Children And Youth Populations?
What about SARS-CoV-2 In Pregnancy and Breastfeeding? Can SARS-CoV-2 Be Transmitted From Mother to Child?
Where Are We On SARS-CoV-2 Treatment Development?
What Is Antibody Testing And Can Reinfection Occur?
What Do We Need to Know About the New Vaccines to Protect Against SARS-CoV-2?
What Happens After Vaccination?
What Can Health Programs And Facilities In Resource-Limited Settings Do Now To Ensure The Health Of All Their Clients?
What Will Pandemic Recovery Look Like?

What is COVID-19/SARS-CoV-2 and How is it Transmitted?

Common symptoms of SARS-CoV-2 include fever, dry cough, and fatigue. Early symptoms can include alterations to taste and smell. Serious illness, including shortness of breath, lower blood oxygen levels, and prolonged high fever, can occur in almost anyone. However, serious illness and greater risk of fatality does appear to be more pronounced in those suffering from preexisting conditions including: cardiovascular disease, diabetes, and obesity. Individuals with malignancy and solid organ transplant recipients may be at increased risk of severe COVID-19 infection, as well. Pre-existing conditions are not rare, and exist in close to 22% of the global population – or 1·7 billion individuals (read more).

Although COVID-19 is primarily known for causing substantial respiratory pathology, it can also result in several extrapulmonary manifestations. These conditions include thrombotic complications, myocardial dysfunction and arrhythmia, acute coronary syndromes, acute kidney injury, gastrointestinal symptoms, hepatocellular injury, hyperglycemia and ketosis, neurologic illnesses, ocular symptoms, and dermatologic complications (read more).

The virus predominantly spreads from person to person in the following ways: (a) a non-infected person inhales the virus, which is contained in small droplets released into the air by an infected person’s cough or sneeze, and (b) through contact with surfaces that have become contaminated with the virus. Because this virus can appear asymptomatic, many people feel healthy and continue interacting with others, which may result in increased transmission risk.

Some contact tracing investigations indicate that approximately one-fifth of infected individuals are asymptomatic (read more). Those who have become infected usually experience symptoms within two weeks from the time of infection (on average, symptoms appear within a five- to six-day incubation period). Persons carrying the virus are generally most contagious during the five days leading up to, and five days after, the appearance of symptoms. The high transmissibility of COVID-19 before and immediately after symptom onset suggests that isolating only symptomatic patients may not suffice to contain the epidemic. Asymptomatic patients may be contagious and thus a potential source of transmission of COVID-19.

Studies found that COVID-19-related deaths were associated with being male, older age, social deprivation, diabetes, and various other medical conditions. Additionally, an array of research has found that racial minorities, including Black and South Asian people were at higher risk of death – even after adjustment for other factors. Emerging research concerning Multisystem Inflammatory Syndrome in Children (MIS-C), a more severe form of COVID-19, has been observed to occur more frequently among Black, Afro-Caribbean and Latino/Hispanic children, a further testament to the ways in which socioeconomic disparity creates disproportionate impacts for vulnerable populations.

Population age has also been shown to be a determining factor in the spread of infection. Accordingly, one stratified deterministic mathematical model indicated that countries with sizable adult, elderly, or small child populations may experience large and rapid epidemics in absence of interventions. Meanwhile, countries with predominantly younger age cohorts may experience smaller and slower epidemics (read more).

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How is SARS-COV-2 Diagnosed?

The symptoms COVID-19 are broad. Moreover, they are sometimes non-existent – despite the presence of the SARS-CoV-2 virus. Thus, diagnosis cannot depend on symptoms alone. A real-time nucleic acid amplification polymerase chain reaction test (rt PCR) is used to detect viral infection. The test amplifies the viral nucleic acid to enable direct detection of viral RNA, and can be performed on nasopharyngeal or oropharyngeal swabs, as well as other body fluids and tissues. A positive test indicates current infection with SARS-CoV-2, similar to the viral detection tests used to detect HIV (DNA or RNA PCR). Professionals seeking further guidance regarding SARS-CoV-2 may wish to review the Infectious Diseases Society of America’s (IDSA) 15 diagnostic recommendations, available here.

Of course, expansive testing contributes to the ultimate goal of viral control. Notably, new research suggests that self-testing may be a viable option in the future. This study found that self-administered tests had high specificity and relatively high sensitivity (75%-80%) to identify individuals with a significant probability of contagiousness.
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What is the Current State of the Pandemic?

As of August 22, 2021, there have been 209,876,613 confirmed global COVID-19 cases reported to the World Health Organization (WHO), inclusive of 4,400,284 deaths. There have also been over 4.5 billion vaccine doses administered – approximately 165 million of which took place in the United States. The latest WHO data specific to the U.S. reported 37,085,214 confirmed cases, 620,355 deaths, and over 350 million doses administered at the time of this report. Notably, however, research suggests that underestimation is probable: given the likelihood of missed cases early in the pandemic, and underlying causes or comorbidities attributed to deaths that may have actually been caused by COVID-19. Of course, this data is constantly evolving, and the latest global statistics are available here.

The emergency use authorizations granted by the U.S. Food and Drug Administration (FDA) helped bring ongoing lockdowns to an end, as states to lifted stay-at-home orders in anticipation of widespread vaccination. Data current to the drafting of this report indicates that approximately 50% of the U.S. population (around 168 million people) has completed a vaccination series. Moreover, progress is underway for demographics that were not accounted for during the 2020 vaccine development processes. Indeed, 2021 saw Pfizer-BioNTech conduct the first trial for pregnant women, and its vaccine became the first to be widely approved for children (aged 12–15). Trial outcomes demonstrate that the Pfizer-BioNTech vaccine is both safe and highly effective in this demographic, and a trial for children aged 6 months to 11 years has begun. There is also evidence that Moderna has an acceptable safety profile in adolescents and a trial for preadolescents is already underway, while Sinovac’s mRNA vaccine (CoronaVac) has been approved for use in children aged 3 years and older in China. There has also been some progress made in low- and middle-income countries, though access and rollout have been significantly problematized by lack of vaccine equity. Recent data indicates that just 10 countries have administered 75% of all COVID-19 vaccines and COVAX – the global initiative aimed at providing equitable access to vaccines – has been responsible for less than 4%. Read more about the current vaccination landscape and the emergent challenges here. The WHO and SAGE have produced and updated a roadmap for prioritizing COVID vaccine use in the context of limited supply, available here.

Beyond inequity, new SARS-CoV-2 variants and a phenomenon known as ‘long covid’ / post-acute SARS-CoV-2 infection have emerged as issues of concern. The latter involves physiological symptoms of COVID-19 that persist post-recovery. Notably, there is no global consensus on the what defines the beginning of the post-acute period, though some researchers propose that it begins 3 weeks after symptom onset. The medical literature includes reports of subjective symptoms in patients who recovered from a wide spectrum of acute COVID-19, including mild infection through critical illness. The literature also describes various findings of objective organ pathology (such as acute kidney injury), viral encephalitis, and increased risk for venus thromboembolism.

Emerging research observes cases of long COVID among children, too. As in adult cases, children present with persisting symptoms, including fatigue, muscle and joint pain, headache, insomnia, respiratory problems, and palpitations. This study found that nearly half of children experienced at least one of the aforementioned symptoms as late as 120 days post-recovery. A research review regarding persistent symptoms following severe COVID-19 is available here.

While 2020 saw SARS-CoV-2 vaccines developed at an unprecedented pace, 2021 has been the year of vaccine rollout. Still, the ongoing global outbreaks demonstrate the pandemic is far from over. Achieving global vaccine coverage remains a major hurdle, not just due to the need for equity but as a viable means to achieve viral control. SARS-CoV-2 continues to evolve under immune selective pressure, and as long as transmission remains high there is an increased likelihood of vaccine escape variants evolving.

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New SARS-CoV-2 Variants

Early in the COVID-19 pandemic, the number of ‘mutant’ variant viruses was low as the small number of people infected left few opportunities for escape mutants to emerge. They are referred to as such because the mutations they contain make them more adept at evading the body’s immune responses. As the pandemic progressed, the significant increase in infections (including prolonged infection in immunocompromised individuals) enabled multiple SARS-CoV-2 variants to evolve in this manner.

The most detailed information currently available relates to four variants of concern (VOCs). The WHO classifies a viral mutation as a VOC when the changes either increase transmission / virulence or decrease the impact of vaccines and therapeutic measures. When compared to the original or reference strain (Wuhan), the Alpha (B.1.1.7), Beta (B.1.351), Gamma (P.1), and Delta (B.1.617.2) variants predominantly exhibit changes in their S genes. S protein mutations are concerning because they can change the COVID infection rate and modify the impact of neutralizing antibodies – resulting in compromised vaccine efficacy.

With these variants, scientists have observed a reduction of in vitro serum neutralization activity, along with cases of vaccinated persons experiencing ‘breakthrough infections’. However, disease severity is still reduced in vaccinated persons – indicating that the shots are still highly effective for preventing acute illness. This is not a small benefit, as severe COVID increases the risk for hospitalization and death. Unfortunately, researchers state that even more VOCs will emerge and their impact on vaccine effectiveness is hard to predict. However, as global vaccine coverage is still low, some assert that increased transmission may be a greater concern than vaccine escape due to mutant variants. Still, global public health organizations are monitoring developments and updating available data and resources accordingly; a live global map for countries reporting viral variant cases is available here.

Alpha (B.1.1.7)

In early October 2020, a new lineage of the SARS-CoV-2 virus (named B.1.1.7) was identified in southeast England. By December, local public health authorities had identified the virus as a variant of concern (VOC-202012/1). Simultaneously, a rapid spread was underway, first to London and then rest of the United Kingdom. There, three quarters of infections were attributable to the new variant by the year’s end. Some studies found that the Alpha strain posed a significantly higher risk of mortality than previously circulating variants. Still, the risk of death remained low overall, and clinical studies indicate that vaccine efficacy is similar or only slightly lower against Alpha.

Beta (B.1.351)
The Beta variant was discovered in South Africa, and piqued the interest of epidemiologists when early studies showed it to be markedly more resistant to neutralization by convalescent plasma (at 9.4 fold) and vaccine sera (at 10.3 to 12.4 fold) than Alpha (B.1.1.7). More recent studies in the U.S., Latin America, and South Africa confirm that B.1.351 is more resistant to antibody-mediated protection. Notably these trials involved the Janssen, Novavax, and AstraZeneca vaccines. Of these, Janssen demonstrated the highest efficacy in all regions (66-72%) apart from South Africa (57%). Novavax demonstrated a slightly higher efficacy in South Africa (60%) – an outcome that may be due to the greater presence of the Beta variant in this region. Similarly, this study notes that, of all the lineages, Beta has been associated with the biggest drops in vaccine efficacy – but only in cases of mild to moderate disease. Notably, the AstraZeneca trial in South Africa did not demonstrate protection against mild to moderate Beta-induced COVID-19. It is currently unclear whether this vaccine offers protection against severe disease and death.

Gamma (P.1)
First observed in Brazil, the Gamma variant has accumulated a high number of S protein mutations, enhancing its capacity to escape neutralizing antibodies in vitro. This study suggests that it is potentially less resistant to antibody-mediated protection than the Beta variant, but other researchers anticipate that it will be just as resistant – if not more. Reliable data about vaccine efficacy for this variant are scarce at this stage, though the latest statistics from reporting countries can be found here.

Delta (B.1.617.2)
This variant was originally detected in India, which subsequently saw a massive spike in cases before the strain quickly spread around the globe. Like other VOCs, Delta demonstrates viral mutations thought to reduce antibody efficacy and neutralizing antibodies. As of August 2021, this highly transmissible variant has become the predominant strain circulating in the U.S.

BOOSTER SHOTS
One option to counteract the impact of viral variants is to develop new vaccines that more closely reflect the viruses in circulation. For instance, Moderna has developed a novel vaccine targeting the B.1.1.7 VOC, and clinical trials are underway. Still, it is unclear how beneficial vaccines designed to target new variants will be. The main consideration will be how much the viruses circulating in late 2021 (the suggested period for booster vaccination in some countries) antigenically differ from the original sequence of the SARS-CoV-2 S protein referenced in the creation of the first-generation vaccines that we currently have.

Currently, the conversation surrounding booster shots may be most relevant to immunocompromised people, since they are at greater risk for poor COVID-19 outcomes (including severe illness, prolonged infection, and greater transmission to household contacts) and more vulnerable to breakthrough COVID. Moreover, emerging research shows that this demographic has a reduced antibody response to vaccines compared to healthy individuals. In terms of solutions, there is evidence that a third vaccine dose can enhance antibody response within this group. Moreover, a few small studies found that a third dose did not result in more severe side effects than prior doses, nor were any acute rejection episodes observed. More information concerning vaccine efficacy in immunocompromised persons is available here.

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Approved COVID-19 Vaccines

On November 20, 2020 Pfizer and BioNTech submitted an emergency use authorization (EUA) request to the FDA for an investigational COVID vaccine known as Comirnaty (also known as Tozinameran (INN), and codenamed BNT162b2). Interim data from the clinical trial showed the Pfizer-BioNTech vaccine to be 95.0% effective in preventing symptomatic laboratory-confirmed COVID-19 in persons without evidence of previous SARS-CoV-2 infection. Shortly thereafter, the United Kingdom gave emergency authorization to Pfizer and BioNTech’s vaccine, becoming the first Western country to give such an approval to a coronavirus vaccine. The U.S. followed suit when the FDA granted an emergency use authorization on December 11, 2020. The vaccination has emergency approval in several countries, and full approval in Bahrain, Canada, and Saudi Arabia, among others.

On November 20, 2020, ModernaTX submitted an emergency use authorization request to the FDA for an investigational COVID vaccine named mRNA-1273. Interim findings from the clinical trial indicate that Moderna’s vaccine efficacy is 94.1% after two does.

On December 18, 2020, the FDA issued an EUA for the Moderna COVID-19 vaccine. This allowed for the shipping of 5.9 million doses across the U.S. to commence. After reviewing the available data, the Advisory Committee on Immunization Practices (ACIP) issued an interim recommendation for use of the Moderna COVID-19 vaccine among persons over 18 years old. On December 23, 2020, the vaccine was approved for use in Canada; Moderna has also made supply agreements with the European Commission, Japan, and Qatar.

On February 27, 2021, the FDA issued an EUA for Johnson & Johnson’s Janssen vaccine for persons aged 18 and above. This is the first single-dose vaccination available to the American public.

As of 14 June 2021, Pfizer–BioNTech, Moderna, AstraZeneca, Janssen, Gamaleya, Sinovac Biotech, Sinopharm, and Bharat Biotech were approved for rollout to adults (and, in some cases, adolescents), being subject to a range of approval processes determined by the regions and regulatory agencies in question. Also as of mid-2021, there were 322 candidate vaccines, 99 of which were in clinical testing and 25 of which had entered phase III efficacy studies. Nearly 20 of these have received some form of approval for use. Ongoing vaccine trials are important because they test the efficacy of new vaccines in the face of an evolving virus. They also increase options for the global manufacture of sufficient vaccine doses and strengthen the data for novel vaccine efforts that could prove useful in the event of future pandemics.

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How Can We Prevent Infection and Spread?

Although we now have multiple vaccines, and more on the way, we must continue to strictly follow preventative measures. Mass and widespread vaccine uptake is the ultimate goal, and the success of risk mitigation efforts (social distancing, masks, etc.) has implications for vaccination benefits. Since vaccination impact is highly dependent on the context it is implemented in (the severity of the epidemic), the non-pharmaceutical protective measures noted below, which we have observed through much of 2020, must continue for now.

National- or state-level measures: The WHO has called on countries and major entities to cancel or postpone mass gatherings. Should these entities opt to proceed with such gatherings, risk mitigation measures must be taken. Additional interventions that provide significant efficacy (but minimal burden) include testing symptomatic individuals and closing high-risk businesses. Existing research suggests that closing most nonessential businesses and issuing stay-at-home orders imposes a high burden while having limited additional effects.

While social distancing is considered the safest option for communities, quarantine has been accompanied by an increase in domestic violence – both in the U.S. and abroad. Scholars suggest that women living with HIV may be particularly vulnerable during this time, due to multiple intersecting inequities. Indeed, the high levels of intimate partner violence, food insecurity, and unstable housing experienced by this demographic can make it unsafe or impossible to follow stay-at-home regulations. For this vulnerable population, and others, national programs must emphasize comprehensive approaches that provide support and assistance from a nuanced, intersectional perspective.

To limit transmission, most countries are employing mass testing, contact tracing, and mask use. Moreover, many encourage individuals to maintain a 6-foot distance from others, and those knowingly exposed to a sick person (or feeling unwell themselves), to stay home. Contact investigation is an important strategy to detect and isolate infection sources and reduce continuing transmission. Notably, this technique has been used to control transmission of other infectious respiratory diseases such as Tuberculosis (TB), Middle East respiratory syndrome-related coronavirus (MERS), and SARS; localities can adapt a TB contact investigation strategy for COVID-19 (read more here). New app technology allowing for greater volume of contract tracing has resulted in reduced rates of transmission and should be considered for wider use / further scale-up.

Researchers anticipate that continued restrictions will be required to decrease transmission in the short term to enhance response systems that are found to be ineffective. These restrictions serve to suppress SARS-CoV-2 infections to an extent that allows for rapid detection of localized outbreaks and the rapid deployment of find, test, trace, isolate, and support systems. Robust public health responses have been shown to support transmission control in Japan, Vietnam, and New Zealand, for instance, thereby allowing life to return to some semblance of normalcy. Ultimately, the evidence suggests that controlling community spread of COVID-19 is the best way to protect our societies and economies until widespread vaccination uptake has been achieved.

Individual measures: Safety measures for individuals include avoiding social interactions (especially mass gatherings), maintaining a physical distance from others, and wearing face masks to cover one’s nose and mouth in public. In addition to confirming the previous findings that physical distance of 1m (approximately 3 feet) is effective (while 2m, approximately 6 feet, may be even more so), contemporary research suggests that wearing protective eye gear can provide additional protection.

The U.S. Centers for Disease Control (CDC) recommends mask use for children aged 3 and older. Notably, however, a recent study among Italian children >24 months found that those who wore face masks for 30 minutes did not experience respiratory distress. Mask use among children this young has been an issue of concern due to their inability to remove them if uncomfortable, or to let adults know if they have trouble breathing. This particular study ended with a proposition that mask use among children below 24 months may be reserved for situations that present a high risk for transmission, and not embraced as a regular practice. Most importantly – children this young must be supervised by an adult the entire time their masks are on, so that any discomfort is immediately noticed and addressed.
Beyond this, individuals of all ages should engage in frequent and thorough hand washing with soap and water and/or use hand sanitizers containing at least 60% alcohol. It is also important to avoid touching one’s face, to cover coughs and sneezes, clean and disinfect frequently touched surfaces daily, stay home (isolate) if ill, and consult a health provider if one experiences a cough, fever, and shortness of breath.

If someone in your household becomes infected, there are several precautions individuals should implement to keep other household members safe. These include limiting contact with the infected individual and ensuring the home remains well ventilated throughout (read more). A recent study of environmental surfaces recorded greater SARS-CoV-2 contamination on household lavatories, suggesting that persons with COVID-19 should avoid sharing bathroom with other household members, if possible.

Sharing indoor spaces remains a significant condition for transmission, even beyond the home. Contemporary findings attest to the possibility of high viral emission from oral breathing during heavy exercise. Indoor sporting events that involve intense physical exertion, for instance, have the potential to act as “superspreader” events: in which one infectious person transmits the virus to many others. This can, of course, lead to explosive growth at the beginning of an outbreak and facilitate sustained transmission later on (read more). In terms of potential protective measures in close quarters, a recent study found that the use of air purifiers with HEPA filters substantially reduced the risks of airborne transmission in high school classrooms. These findings suggest that such measures may limit the inhaled dose of SARS-CoV-2 in other confined spaces that are shared with persons carrying the virus. Importantly, however, this is emerging research which needs to be further explored and validated.

Both the science and anecdotal evidence, however, support the continued use of masks, with recent studies suggesting that they lower the chances of both transmitting and catching COVID-19. Moreover, some studies suggest that masks might reduce the severity of infection if people do contract the disease. A Kansas study following the Governor’s July 3rd executive mask order found that the trend of COVID-19 incidence was reversed in the 24 counties that complied. Conversely, the spread continued to increase in the 81 counties that opted out of the mandate. More on the latest findings concerning mask efficacy is available here.

Ultimately, all individuals should follow reliable sources of information to engage in best practices for prevention, i.e., the WHO and the CDC, and regularly assess their exposure risks.

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What Are The Implications of COVID-19 On HIV-Positive Populations?

There is a lack of consensus regarding the risk faced by people living with HIV during this pandemic. While some evidence suggests that the risk is greatest among those with advanced HIV, a low CD4 cell count, and persons who are not on treatment (read more). NNotably, estimates place the number people living with HIV and out of treatment at over 9 million, making the question of treatment adherence and risk for severe COVID extremely compelling.

Recent cohort studies observed that people living with HIV who were hospitalized for COVID-19 had similar clinical characteristics and outcomes to other hospitalized cohorts of HIV-negative patients. This was reported to be the case even when the former did not have an undetectable viral load. Similarly,another study found that the risk factors for severe disease among people living with HIV were similar to those without HIV, and neither CD4 count nor type of antiretroviral therapy (ART) was associated with outcomes. A small Nigerian study found mild clinical outcomes among persons with SARS-CoV-2 and HIV / SARS-CoV-2 co-infection. However, researchers suggested that the antiretroviral regimen may present some protective benefits to people living with HIV.

In this study from a national COVID treatment unit in Uganda, 10% of the sampled patients were also living with HIV, and results showed that HIV / SARS-CoV-2 co-infection was not associated with illness severity. Similarly, this research from South Africa found that the underlying conditions of hypertension and diabetes were far greater risk factors for in-hospital COVID deaths than HIV and past or present TB. Notably, however, people living with HIV who were not ART-adherent and those with a viral load exceeding 1,000 copies per mL or CD4 counts of less than 200 cells per μL in the past year were found to be at greater risk for severe COVID outcomes. Still, researchers concluded that underlying HIV is not necessarily a risk factor for COVID-19 hospitalization or severe disease, noting that this is corroborated by a few population-based observational studies in the U.K. and elsewhere. This contradicts the findings of small South African study from early 2020, which indicated a higher mortality rate in all HIV-populations, though researchers noted the presence of limitations that called for further investigation at the time.

n this study from a national COVID treatment unit in Uganda, 10% of the sampled patients were also living with HIV, and results showed that HIV / SARS-CoV-2 co-infection was not associated with illness severity. Similarly, this research from South Africa found that the underlying conditions of hypertension and diabetes were far greater risk factors for in-hospital COVID deaths than HIV and past or present TB. Notably, however, people living with HIV who were not ART-adherent and those with a viral load exceeding 1,000 copies per mL or CD4 counts of less than 200 cells per μL in the past year were found to be at greater risk for severe COVID outcomes. Still, researchers concluded that underlying HIV is not necessarily a risk factor for COVID-19 hospitalization or severe disease, noting that this is corroborated by a few population-based observational studies in the U.K. and elsewhere. This contradicts the findings of small South African study from early 2020, which indicated a higher mortality rate in all HIV-populations, though researchers noted the presence of limitations that called for further investigation at the time.

Ultimately, there remains limited evidence about clinical course and outcomes for COVID-19 among people living with HIV, though we have seen some improvement as the pandemic progresses and more researchers turn their much-needed attention to this demographic.

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Vaccines for People Living with HIV

Guidelines from the Advisory Committee on Immunization Practices’ (ACIP) state that people may accept any COVID-19 vaccine authorized for emergency use and are encouraged to receive whichever is available to them at the earliest date. Moreover, the WHO released updated information in early 2021 stating:

“available information suggests COVID-19 vaccines are safe for people living with HIV. The vaccines often include genetic material from SARS-CoV-2, but do not contain the whole virus, so the virus cannot replicate. As they are not live vaccines, they are not expected to be less safe in people who are immunocompromised. There is no known or observed interactions between COVID-19 vaccines and antiretroviral drugs; people living with HIV should continue to take antiretroviral therapy after vaccination, which maintains health and prevents onward HIV transmission. At this time, no antiretroviral drug has been shown to be effective against SARS-CoV-2 infection. People living with HIV should not switch or add antiretroviral drugs to their regimens for the purpose of preventing or treating COVID-19”.

Notably, the WHO does not discount the possibility that people who have low CD4 cell counts might have a weaker immune response to a vaccine. However, it notes that this has not been the case for several other vaccines, suggesting that there is no cause to anticipate that persons with a low CD4 cell count would have a less robust immune response to COVID-19 vaccines. In terms of prioritization, people living with HIV who have certain co-morbidities (such as asthma, COPD, diabetes, heart disease, kidney disease, liver disease, Parkinson’s disease, multiple sclerosis, motor neurone disease, and severe obesity), will be afforded early vaccination in most settings.

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What Precautions should HIV-Positive Persons Take?
- Stay safe: cover coughs, wear masks, avoid social interactions (especially mass gatherings), stay home (isolate) if ill, and consult a health provider if experiencing cough, fever, and shortness of breath.
- Stay informed: follow a reliable source, such as the WHO or the CDC, for all information and guidelines.
- Be prepared: avoid ART interruption, and ensure you have all necessary medical supplies on hand—ideally enough for 30 days or more. The WHO HIV treatment guidelines now recommend multi-month (three months or more) dispensation of HIV medicines for most people during routine visits. Still, this has not been implemented widely across countries, thus people living with HIV should be in touch with their health care providers to ensure these measures are in place.
  - A study that considered the effects of various HIV program disruptions found that ART interruption would have devastating consequences for the 17 million people on treatment. Indeed, a six-month interruption of ART supply would be expected to double HIV-related deaths over the course of a single year.
  - Researchers exploring the impact of the COVID‑19 lockdown on attendance to ART collection clinic appointments in Kigali, Rwanda found an association between place of residence and attendance status. There was a higher percentage of those adhering to scheduled appointments living within the city compared to those outside it. Researchers noted the need for strengthened patient tracking and the development of programs that can function during crises that limit individual mobility.
- Provide mutual protection and support: Hold virtual adherence support group meetings using platforms like WhatsApp and Zoom. Do what you can to reduce stigma and fear, and support the safety and well-being of people living with HIV.
More Resources:
1. International AIDS Society. (2020). ART Services in the time of COVID-19: Adaptions to differentiated service delivery (DSD) models with a focus on those struggling with ART.
2. Joint United Nations Program on HIV and AIDS. (2020). What People Living with HIV Need to Know about HIV and COVID-19.
3. L. Jewell B, Mudimu E, Stover J, Kelly SL, Phillips A. Potential effects of disruption to HIV programmes in sub-Saharan Africa caused by COVID-19: results from multiple mathematical models. May 15 2020. doi:10.6084/m9.figshare.12279914.v1
4. The Lancet HIV. (2020). When pandemics collide. The Lancet. 7(5), e301. April 24, 2020
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What Do We Know About COVID-19’s Effect On Children And Youth Populations?

Early and contemporary studies support the observation that children may experience milder clinical symptoms than adults, although some propose that those under twelve months old may experience more severe symptoms compared to older children. A prospective cohort study of febrile infants (≤60 days old) found that symptomatology was typically benign for those with and without acute SARS-CoV-2 infection during the course of the observational period. Still, among febrile infants with SARS-CoV-2 who also had respiratory symptoms, cough and nasal congestion were somewhat prolonged. However, the symptom duration did not drastically exceed that observed in prior studies of infants with acute upper respiratory infections. This study suggests that clinicians and parents can expect the duration of SARS-CoV-2 illness in febrile (but otherwise well) infants to be similar to the ‘normal’ duration of other viral illnesses in this demographic.

Early research found that children and adolescents had lower susceptibility to SARS-CoV-2 than adults, with an infection ratio of 0.56. However, youths demonstrate comparable viral loads to adults, and children under five can carry even higher viral levels than older children or adolescents. Moreover, a contemporary study found that children below age five accounted for a greater percentage of child patients with severe illness, along with children with that had a history of non-congenital heart disease, disease of the respiratory system, metabolic disease/endocrine disease, congenital malformation or chromosomal abnormalities, and disease of the nervous system. Clinicians are advised to closely monitor young children with COVID-19 who also have underlying conditions. As seen in adults, a history of comorbidity increases the likelihood of hospitalization and severity presentation of clinical symptoms among children, also.

A meta-analysis of 176 published cases of neonatal SARS-Cov-2 found that the most common symptoms were gastrointestinal, neurological, and respiratory, in addition to fever. Moreover, abnormal lung imaging was observed in 64% of neonates. Other research, however, has found that the most well recognized symptoms in adults – cough, fever, anosmia, and ageusia – are less frequent in children. Indeed, they may often present with mild and nonspecific symptoms, or with gastrointestinal symptoms alone (read more). Because many affected children may be asymptomatic, it has been suggested that they may be significant facilitators of SARS-CoV-2 transmission and amplification. Yet, the evidence does not suggest that children transmit the virus to a greater extent than adults (read more).

As of late December 2020, there are some emerging reports that convalescent plasma therapy may be a useful therapeutic resource for COVID-19 management among pediatric patients. However, case reports comprise the only scientific literature currently available. There is a need for more quality research to provide compelling evidence regarding the efficacy and safety of CPT in the treatment of pediatric COVID-19 infection, yet such studies remain in the protocol phase.

Multisystem Inflammatory Syndrome

A growing number of children have been identified as having a multisystem inflammatory syndrome that is associated with SARS-CoV-2 infection. MIS-C is believed to be a hyperinflammatory syndrome that develops approximately 2-6 weeks after SARS-CoV-2 infection. This condition is characterized by persistent fever, rash, conjunctival injection, and (most commonly) gastrointestinal symptoms – including vomiting and diarrhea. It may be associated with the immunologic response to the SARS-CoV-2 virus, as opposed to being directly caused by viral infection (read more).

Moreover, there is some risk that patients experiencing this inflammatory syndrome may be misclassified as having COVID-19 and miss out on optimal treatment as a result. This study compared cases of children and adolescents with MIS-C to those with severe COVID-19, and found that the former was distinguished by demographic features and clinical presentations, including: being aged 6 to 12 years, being of non-Hispanic Black race, having severe cardiovascular or mucocutaneous involvement, and having more extreme inflammation.

Moderate heart dysfunction was observed in some cases of MIS-C early on, but more recent studies suggest that this is actually the dominant symptom, along with gastrointestinal disturbances. Notably, presentations of MIS-C are also similar to those of Kawasaki’s disease (fever and dermatologic, mucocutaneous, and gastrointestinal manifestations). Unlike Kawasaki’s disease, however, reports found MIS-C to predominantly affect adolescents and children older than 5 years old, and to be more frequently associated with cardiovascular involvement.

Some research describes MIS-C as a more severe form of COVID-19 resembling Kawasaki disease – but with profound multiorgan dysfunction and shock. Various studies have found MIS-C to be significantly associated with lower socioeconomic status while disproportionately affecting minority children. There is, however, limited evidence concerning the nature of the relationship between race/ethnicity and this inflammatory syndrome. This study makes the distinction that the chief concern among persons with acute COVID-19 is respiratory tract symptoms, while that of MISC-C is fever with abdominal pain and/or rash. More on symptoms and demographic factors associated with severe MIS-C outcomes is available here.

Though the pathophysiology of MIS-C is not well established, prognosis is generally good, with most patients experiencing rapid recovery in clinical and myocardial function. The mortality rate of this already rare condition is reported to be around 2%. The syndrome appears to be heterogeneous, and there is currently no international consensus regarding disease classification. More information, including different classifications among entities and regions and emerging therapies, is available here. Local and global data concerning MIS-C, its relationship to COVID-19, as well as the best course of medical action determined thus far, is available here.

Socioeconomic Impacts
Overall, there remains a paucity of data about the manifestation and duration of symptoms of in pediatric populations. More devotion to the specific healthcare needs of children and adolescents is desperately needed in the response to SARS-CoV-2. One cannot discount the effect further economic hardship will have on children, especially the orphaned, vulnerable, and/or displaced children. For instance, many children who rely on school meals to sustain their nutrition are subjected to hunger as an unintended consequence of the lockdown. Moreover, in some settings, other child wellness services (such as the use of vaccines) are interrupted or declining in coverage. According to modeling studies, risks related to vaccine coverage decline far outweigh those of SARS-CoV-2 infection in neonate infants, children, and young adolescents (read more).

Indeed, children and youth living in poverty already face barriers to health, safety, nutrition, and education. These are further exacerbated in a global pandemic (read more) and global attention and support are needed. For instance, food insecurity will limit access to nutritional foods, which may lead to sub-optimal immune system function, thereby lowering the effectiveness of ART among people living with HIV. The allocation of cash transfers can help supplement lost income in lower-income households, thereby mitigating the burden of food insecurity. For example, South Africa implemented the COVID-19 Social Relief of Distress grant, which is paid to unemployed individuals who do not receive any other social grant. Because the extensive loss of life brought by the pandemic has unexpectedly orphaned numerous children around the world, researchers propose that we should draw on socioeconomic interventions that have been proven to be helpful in HIV programs to support children orphaned by COVID-19 as well. For example, interventions that provide cash benefits have been shown to improve the health, educational, and psychological outcomes of orphaned and vulnerable children in Kenya and Tanzania.

Access to contraceptives may also be challenging under COVID-19 stay-at-home requirements. Limited mobility, reduced availability of public transportation, and the closures of non-essential retail outlets and youth centers make it harder for young people to access contraceptives. Moreover, shortages may also lead to an increase in risky sexual practices and unintended pregnancies, both of which were already long-standing issues in East and Southern Africa before the response to COVID-19. For young people living with HIV, condom shortages may increase the likelihood of onward HIV transmission. More information on the socioeconomic impact of COVID-19 on youth populations in East and Southern Africa is available here, and potential interventions to mitigate this impact are noted.

The pandemic also has implications for children’s mental health: they may be unable to play outside, and children living with HIV may be unable to visit clinics for support and treatment. Moreover, young people living with HIV are more vulnerable to mental illness, particularly depression, and navigating a public health emergency of this magnitude can easily compound existing psychological distress. It is important that essential counseling and social support services remain accessible during this time.

This pandemic has a plethora of consequences that highlight the need for both material and psychosocial support. The creation of opportunities to enhance digital support or counsel caregivers on how to mentally support young people will go a long way toward the latter. As of late December 2020, children continue to be left out of clinical trials. This presents a missed opportunity to mitigate the social impact of COVID-19 on this vulnerable population.

When societies begin to reopen and children return to school, a ‘new normal’ is needed, to protect youth and educational staff from infection. The US National Academy of Sciences and Engineering authored a report on considerations cities, states, districts, and national governments should take into consideration when opening schools to protect all involved. Their considerations include lesser ‘cohort’ class sizes, intensified deep cleaning, reduced sharing of materials, masks worn by all with teachers recommended use of N-95 masks, increased hand washing, and temperature gauging at entry, among other precautions (available for download here).

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  What about SARS-CoV-2 In Pregnancy and Breastfeeding? Can SARS-CoV-2 Be Transmitted From Mother to Child?
  
  Based on currently available (albeit limited) information, pregnant women seem to have the same risk of SARS-CoV-2 infection as adults who are not pregnant. According to an article by the CDC, pregnancy is associated with increased risk for ICU admission and receipt of mechanical ventilation among women with COVID-19 between the ages of 15 and 44. However, it is not associated with increased risk for mortality; this finding has been echoed by contemporary evidence, which indicates that pregnancy is associated with greater risk for hospitalization and severe disease.
  Risk factors for severe COVID-19 in pregnancy include increasing maternal age, high body mass index, non-white ethnicity, pre-existing comorbidities, and pregnancy-specific disorders (such as gestational diabetes and pre-eclampsia). Pregnant women with COVID-19 are more likely to experience preterm birth and their neonates are more likely to be admitted to a neonatal unit.
  Still, the exclusion of pregnant and lactating women from vaccination trials throughout 2020 has significantly stalled progress toward establishing a safety profile for these populations. In the first quarter of 2021, however, Pfizer-BioNTech commenced a trial for pregnant women.
  This study notes that women who reported pregnancy post-vaccination (during the initial Pfizer trials) have reported no adverse impacts thus far. Moreover, there is some evidence that vaccination during pregnancy generates a more substantial immune response for pregnant women than natural infection does. Pregnant women can then transfer neutralizing antibodies to babies through the placenta, as seen in other studies of gestational vaccine recipients. This study reports a pregnant woman who received the Pfizer-BioNTech inoculation at 32 weeks of gestation, resulting in the documented presence of antibodies in the neonatal cord blood. This one also found vaccine-generated antibodies in all umbilical cord blood and breastmilk samples. Furthermore, no differences were noted in reactogenicity between pregnant and nonpregnant women.
  
  Mother-to-Child Transmission
  Pregnancy and Breastfeeding: Most of the limited research indicates that mother-to-child transmission is possible thought not common (read more). There is growing evidence that environmental exposure, and not vertical transmission, accounts for most infections among newborns. Comparatively, the possibility of in utero transmission is significantly smaller. Accordingly, samples from the placenta, the umbilical cord and blood from mothers and infants indicate that the virus rarely crosses from mother to fetus. A meta-analysis of 176 published cases of neonatal SARS-Cov-2 found that a lack of mother and neonate separation from birth was associated with late development of SARS-Cov-2, but that breastfeeding was not.
  
  Breastmilk is the best source of nutrition for infants, including infants whose mothers have confirmed or suspected coronavirus infection. As long as an infected mother takes appropriate precautions—outlined in WHO guidance—all women can and should breastfeed their babies. More breastfeeding guidance specific to the context of SARS-CoV-2, is available here.
  
  Careful monitoring of pregnancies with COVID-19 and putting in place measures to prevent neonatal infection after birth are warranted given the evidence we have now. Further, routine testing of women in the labor and delivery wards (regardless of maternal symptomatology) might be considered, as it would allow for appropriate triage, adequate obstetric and neonatal management, and safe patient transport within overcrowded hospitals.
  
  Birth: Emerging research suggests that SARS-CoV-2 infection during pregnancy is associated with increased risk of perinatal complications, including fetal distress, premature birth, perinatal death, increased rate of admission to intensive care units, and the need for mechanical ventilation. Other scholars observe high rates of cesarean delivery and preterm birth, with the majority of preterm delivery occurring in the setting of maternal respiratory failure. A high rate of cesarean delivery was associated with this indication.
  
  Clearly, complex medical decision-making is required in the management of critically ill pregnant women. Notably, however, there is some contemporary evidence that corroborates previous findings that SARS-CoV-2 infection during the first trimester of pregnancy does not appear to predispose women to early pregnancy loss. Indeed, a large, single-institution cohort study found that SARS-CoV-2 infection during pregnancy was not associated with adverse pregnancy outcomes. Notably, however, an overwhelming number of mothers (95%) were either asymptomatic or presented with mild symptoms.
  
  The impact of delivery mode on COVID-19 infection rates among newborns is currently unknown. However, a literature review of over 60 studies found that the rate of neonatal COVID-19 infection, neonatal deaths, and maternal deaths are no greater when mothers gave birth through vaginal delivery. Based on the evidence available, there is no sufficient evidence to suggest that a caesarean section is better than vaginal delivery when it comes to preventing possible vertical transmission from pregnant mothers with COVID-19 to neonates.
  
  Researchers recommend that delivery decision-making should balance the various risks and benefits, including fetal prematurity, the potential to improve or worsen maternal respiratory status, and the known maternal hemodynamic, and the inflammatory burden accompanying major surgery such as a cesarean section. Cesarean delivery is not required solely due to confirmed COVID-19.
  
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  What Is Antibody Testing And Can Reinfection Occur?
  
  There are two principal types of testing used for infectious diseases such as COVID-19: molecular and serological. Molecular tests detect the pathogen while it is circulating in the body and is used to diagnose / confirm cases. Serelogical tests, or “antibody tests” detect antibodies or immunoglobins (Ig) that are produced as human immune response to SARS-CoV-2 infection. They can determine past exposure to SARS-CoV-2 by detecting the specific immune response (antibody) to the virus, they can also be used to detect individuals who were previously infected (have a positive antibody test) and are theoretically immune and those who remain susceptible to infection (have a negative antibody test).
  
  Such antibody testing may be useful to identify the potentially immune, who can return to work and resume daily activities. There are ethical considerations around how this should be carried out, who should be prioritized for antibody testing, and how we create equitable access while reducing stigmatization of the non-immune. There are also logistical issues to address: how do we identify the immune from the non-immune as we move into wider adoption of serology? There are discussions around creating a “passport system”. For instance, China has employed QR codes loaded on to the phones of persons with immunity. Obviously, falsification of information, equitable access to testing, and the risk of individuals purposefully becoming infected (to achieve immune status) are significant considerations for policymakers who seek to re-integrate the immune into society, while protecting those at risk.
  
  Although antibody testing may facilitate improved public health surveillance and vaccine development, there are many issues to interrogate regarding current serology diagnostics and their interpretation. Indeed, some FDA-authorized COVID-19 antibody tests are estimated to have 96-98% specificity. In such cases, a positive test result is likely a false-positive if the prevalence or pretest probability is 5% or less. Further testing and policy considerations are certainly needed in this area of work; an area which is quickly developing. More information on antibody testing in low-prevalence areas is available here.
  
  Ensuring serology test validation is crucial. There are dozens of serology tests being marketed in the U.S. that are not providing accurate information and that are not comparable to each other. Ensuring that tests are comparable and accurate requires a validation process with access to many patient samples, overseen by the FDA, and while such a validation process is apparently under way, it is unclear when it will be completed.
  
  Re-infection of SARS-CoV-2 is possible. There is currently no evidence for lasting protective immunity to SARS-CoV-2 following natural infection. Instead, several lines of evidence support that the second episode of COVID-19 in patients previously infected with SARS-CoV-2 is related to re-infection instead of prolonged viral shedding (read more).
  
  Moreover, there is some evidence that reinfection can result in worse disease than the previous infection. This case-control study found that unvaccinated status was associated with 2.34 times the odds of reinfection compared to fully vaccinated status.
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  What Do We Need to Know About the New Vaccines to Protect Against SARS-CoV-2?
  
  Pfizer-BioNTech COVID-19 vaccine
  Evidence for this vaccine was largely drawn from a single, large, randomized, double-blind, and placebo-controlled Phase II/III clinical trial. There were just below 43,000 participants, ranging from 16 to 91 years old, and with a median age of 52 years. The average follow-up duration was two months, and interim data showed the Pfizer-BioNTech vaccine to be 95.0% effective in preventing symptomatic laboratory-confirmed COVID-19 in persons without evidence of previous SARS-CoV-2 infection.
  
  Significantly, vaccine efficacy was observed to be consistent (≥92%) across age, sex, race, and ethnicity categories, as well as with persons who have underlying medical conditions and participants with evidence of previous SARS-CoV-2 infection. Participant hospitalizations and deaths were low. Still, the available data were consistent with reduced risk for these severe outcomes among vaccinated persons (compared to those who received placebo recipients).
  
  An Israeli study sought to determine the efficacy of the vaccine beyond the clinical context, essentially assessing how well it would perform in real-life (non-controlled), mass vaccination settings. This massive study was part of a national vaccination campaign; thus it involved the data of over a million individuals. Researchers found that efficacy was high for serious outcomes (i.e., hospitalization, severe illness, and death). Results from Israel’s vaccination campaign provide early evidence of that vaccines can combat severe COVID-19 cases at the national level.
  
  Side effects: In clinical trials, reactogenicity refers to common adverse reactions or immunological responses to the vaccine. Adverse in this context reflects the discomfort these reactions may cause the vaccine recipient, e.g., painful injection site.
  In the 7 days following the Pfizer-BioNTech vaccination, reactogenicity symptoms were frequent and mostly mild to moderate. Reports of systemic adverse reactions were more common after the second dose than the first. Moreover, they were more frequently observed, and more severe, and among people aged 18–55 than those above age 55.
  Systemic adverse reactions had a median onset of 1–2 days after vaccine receipt and resolved in a median of 1 day. Severe local and systemic adverse reactions (grade ≥3, defined as interfering with daily activity) occurred more commonly in vaccine recipients than in placebo recipients.
  Indeed, 8.8% of vaccine recipients reported a grade ≥3 reaction; the most common symptoms were fatigue (4.2%), headache (2.4%), muscle pain (1.8%), chills (1.7%), and injection site pain (1.4%). Generally, grade ≥3 reactions were more commonly reported after the second dose than after the first dose and were less prevalent in older participants than younger ones. Serious adverse events were observed in a similar proportion of vaccine (0.6%) and placebo (0.5%) recipients, and included medical events occurring at a frequency similar to that within the general population. No specific safety concerns were identified in subgroup analyses by age, race, ethnicity, underlying medical conditions, or previous SARS-CoV-2 infection (read more). The full FDA briefing document on the Pfizer-BioNTech COVID vaccination can be found here. A nurse’s firsthand account of participation in the Pfizer-BioNTech clinical trial, and vaccination side effects is available here.
  
  MODERNA COVID-19 vaccine
  Evidence for the Moderna COVID-19 vaccine was primarily informed by a single, large, randomized, double-blind, and placebo-controlled Phase III clinical trial involving approximately 30,000 participants. Those enrolled were between ages 18 and 95, with a median of 52 years old. Like the Pfizer-BioNTech trial, this one also had an average follow-up duration of two months. Interim findings from the latter indicate that the Moderna COVID-19 vaccine efficacy is 94.1% after two does. This efficacy rate reflects the vaccine’s success in preventing symptomatic, laboratory-confirmed COVID-19 among persons without evidence of previous SARS-CoV-2 infection.
  Beyond this, high efficacy (≥86%) was also observed across age, sex, race, and ethnicity categories, and among people with underlying medical conditions. Notably, early data suggest that the Moderna COVID-19 vaccine may also provide some protection against asymptomatic SARS-CoV-2 infection.
  Side Effects: Reactogenicity symptoms during the 7 days following vaccination were frequent but mostly mild to moderate. Systemic adverse reactions were more commonly reported after the second dose than after the first dose and were more frequent and severe in persons between 18 and 64 years old than in those above 65. The majority of local and systemic adverse reactions occurred within the first 1 to 2 days after the vaccine was received. They were resolved in 2 to 3 days, on average.
  Severe local or systemic adverse reactions (grade ≥3 reactions) occurred more commonly in vaccine recipients than in placebo recipients (21.6% versus 4.4%). Specifically, 9.1% of vaccine recipients reported a grade ≥3 local injection site reaction, and 16.5% reported a grade ≥3 systemic adverse reaction. Overall, the frequency of serious adverse events was low in both the vaccine (1.0%) and placebo (1.0%) groups. The full FDA briefing document on the Moderna vaccine is available here.
  
  Moderna COVID-19 vaccine
  Evidence for the Moderna COVID-19 vaccine was primarily informed by a single, large, randomized, double-blind, and placebo-controlled Phase III clinical trial involving approximately 30,000 participants. Those enrolled were between ages 18 and 95, with a median of 52 years old. Like the Pfizer-BioNTech trial, this one also had an average follow-up duration of two months. Interim findings from the latter indicate that the Moderna COVID-19 vaccine efficacy is 94.1% after two does. This efficacy rate reflects the vaccine’s success in preventing symptomatic, laboratory-confirmed COVID-19 among persons without evidence of previous SARS-CoV-2 infection.
  Beyond this, high efficacy (≥86%) was also observed across age, sex, race, and ethnicity categories, and among people with underlying medical conditions. Notably, early data suggest that the Moderna COVID-19 vaccine may also provide some protection against asymptomatic SARS-CoV-2 infection.
  
  Side Effects: Reactogenicity symptoms during the 7 days following vaccination were frequent but mostly mild to moderate. Systemic adverse reactions were more commonly reported after the second dose than after the first dose and were more frequent and severe in persons between 18 and 64 years old than in those above 65. The majority of local and systemic adverse reactions occurred within the first 1 to 2 days after the vaccine was received. They were resolved in 2 to 3 days, on average.
  
  Severe local or systemic adverse reactions (grade ≥3 reactions) occurred more commonly in vaccine recipients than in placebo recipients (21.6% versus 4.4%). Specifically, 9.1% of vaccine recipients reported a grade ≥3 local injection site reaction, and 16.5% reported a grade ≥3 systemic adverse reaction. Overall, the frequency of serious adverse events was low in both the vaccine (1.0%) and placebo (1.0%) groups. The full FDA briefing document on the Moderna vaccine is available here.
  
  Moderna vs. Pfizer-BioNTech
  This study observed more frequent side effects among Moderna vaccine recipients (2.20%) than Pfizer-BioNTech (1.95%) recipients. However, Moderna recipients notably accounted for most of the study population in this case (60% of participants). Overall, this study of approximately 64,000 employees observed 16 cases of anaphylaxis, with 7 from the Pfizer-BioNTech vaccine and 9 cases from Moderna. Ultimately, the risk of anaphylaxis was found to be low for both options, and acute allergic reactions were low, as well (2.10%).
  Another study comparing vaccine outcomes notes that both Pfizer-BioNTech and Moderna provide immunogenicity (produce an immune response) for at least 119 days after the first vaccination. These researchers also observed more frequent adverse experiences among Moderna recipients and reported that severe allergic reactions (including anaphylaxis) were rare.
  
  Rare serious adverse events have been reported after COVID-19 vaccination, including Guillain-Barré syndrome (GBS) (a rare autoimmune neurologic disorder characterized by ascending weakness and paralysis) and thrombosis with thrombocytopenia syndrome (TTS) (a rare syndrome characterized by venous or arterial thrombosis and thrombocytopenia) after Janssen COVID-19 vaccination and myocarditis (cardiac inflammation) after mRNA (Pfizer-BioNTech and Moderna) COVID-19 vaccination.
  
  On July 22, 2021, the Advisory Committee on Immunization Practices reviewed updated benefit-risk analyses after Janssen and mRNA COVID-19 vaccination and concluded that the benefits in preventing COVID-19 morbidity and mortality outweigh the risks for rare serious adverse events after COVID-19 vaccination. The CDC and FDA continue to closely monitor reports of serious adverse events and will present any additional data to ACIP for consideration. Information regarding risks and how they vary by age and sex and type of vaccine should be disseminated to providers, vaccine recipients, and the public.
  
  Janssen Vaccine
  Evidence regarding the efficacy and safety of the Janssen vaccine is informed by an ongoing phase III randomized, double-blind and placebo-controlled trial. Notably, the trial is global, and involves nearly 40,000 participants with clinically confirmed, moderate to severe (critical) COVID-19. Like those of the other approved vaccines, this trial has a median follow-up time of two months post-vaccination. Unlike the others, however, Janssen is a single dose inoculation. Moreover, it has a significantly lower efficacy, at approximately 66.9%. It is worth noting, however, that efficacy figures vary among different study populations, reaching as high as 85% thus far.
  Predominant strains among those sequenced were the Wuhan-H1 variant, D614G in the U.S. (96.4% of sequenced cases), the 20H/501Y.V2 variant (B.1.351) in South Africa (94.5% of sequenced cases), and a variant of the P.2 lineage in Brazil. There were no cases identified as B.1.1.7 or P1 lineages as of February 12, 2021. In terms of distribution, Janssen’s storage and transportation requirements are compatible within existing vaccine distribution channels. A more detailed explanation of how the vaccine protects against SARS-CoV-2 infection, and how that process differs from that of mRNA vaccines (i.e., Pfizer and Moderna), is available here.
  Side effects: The most common side effects reported include injection site pain (experienced by nearly half of participants), headache, fatigue, muscle aches, and nausea. Most of these occurred within 1-2 days after vaccination, were of mild to moderate severity, and lasted 1-2 days. A small portion of vaccine recipients experienced fatigue (1.6%), myalgia (1.1%), headache (0.7%), and nausea (0.3%) for a period exceeding seven days. Just 0.3% of vaccine recipients reported grade 3 pain, while 5.3% reported swelling, and 7.3% reported Erythema (skin redness or rash due to inflammation). Data shows that some adverse reactions were more common among younger recipients (aged 18-59), a phenomenon also seen with the Pfizer-BioNTech vaccination. The full AICP brief on the Janssen vaccine is available here, and the entire FDA report is available here.
  Side effects: The most common side effects reported include injection site pain (experienced by nearly half of participants), headache, fatigue, muscle aches, and nausea. Most of these occurred within 1-2 days after vaccination, were of mild to moderate severity, and lasted 1-2 days. A small portion of vaccine recipients experienced fatigue (1.6%), myalgia (1.1%), headache (0.7%), and nausea (0.3%) for a period exceeding seven days. Just 0.3% of vaccine recipients reported grade 3 pain, while 5.3% reported swelling, and 7.3% reported Erythema (skin redness or rash due to inflammation). Data shows that some adverse reactions were more common among younger recipients (aged 18-59), a phenomenon also seen with the Pfizer-BioNTech vaccination. The full AICP brief on the Janssen vaccine is available here, and the entire FDA report is available here. Extremely rare events of a newly identified syndrome called thrombosis with thrombocytopenia syndrome (TTS) have been reported in association with the Janssen vaccine, with one study placing the number of deaths in the U.S. at 6 out of 6.8 million vaccinated individuals. This immune-mediated disorder involves blood clotting (thrombosis) in varying locations, accompanied by thrombocytopenia (low blood platelet levels). It has also been observed in persons who have received the AstraZeneca vaccine (detailed further below), though it has also been rare in that demographic. More information is available here.
  
  Astrazeneca Vaccine
  In March 2021, the European Medicines agency concluded that in an extremely small number of vaccinated individuals there is a causal link between AstraZeneca administration and TTS (see definition in the section above). It has led to 30 deaths in vaccinated individuals, though it is worth emphasizing that the number of persons who have received the vaccine numbers well into the millions, making the overall risk statistically small. Still, vaccine agencies in European Union countries and the U.K. issued age-based restrictions on the use of the vaccines. AstraZeneca continues to be used in multiple countries, though it is not one of the three approved vaccinations in the U.S.
  To date TTS has not been reported in association with any other vaccine besides Janssen and AstraZeneca. Notably, TTS appears to be more common in younger adults, leading several countries to restrict its use to older age groups with varying age cut-offs, and in some cases leading to the use of heterologous schedules to complete vaccination courses following a first dose AstraZeneca. Read more here.
  
  How Do we maximize the benefits of the available vaccines?
  The challenges of vaccine development do not end once an effective vaccine is identified. Researchers state that the benefit of any COVID-19 vaccine – even when highly effective during trials – is determined by how quickly and broadly it is implemented, the epidemiological context it finds, and the physiological properties the vaccine has shown during clinical trials. While the characteristics of the vaccine are fixed, healthcare and governmental entities must implement the necessary interventions to facilitate a social environment that can make the most of the vaccine benefits.
  One study found that COVID-19 vaccines will be highly dependent on the effective reproductive number of the virus (Rt) at the time a vaccine is deployed. The Rt reflects the success of efforts to maintain risk mitigation strategies (masking, physical distancing, etc.). When the Rt is low (meaning, viral circulation is being controlled) vaccines with lower efficacy (e.g., 25%) are able to achieve greater reductions in the fraction of infections and deaths than vaccines with much higher efficacy (75%) that are introduced when Rt is much higher (2.1). Even the effects of a vaccine with 90% efficacy and above, like those from Pfizer and Moderna, rely heavily on the background Rt at the time they are introduced. The same study concluded that vaccine impact invariably decreases as the severity of the epidemic increases. Read more about vaccine efficacy and Rt / contextual factors here.
  
  Vaccine Acceptance
  Researchers concur that achieving majority vaccination is both challenging and crucial. Obtaining the buy-in, or vaccine confidence, from diverse groups is particularly important. Accordingly, national promotion strategies that emphasizes urgency, speed, innovative behavioral science, and effective social marketing approaches have been suggested. Still, nationally representative polls in the U.S. (taken between August 2020 and February 2021) suggest that much of the American public is undecided about whether to accept a COVID-19 vaccine. This point is often overlooked, since interpreters of several recent polls have predicted that a majority will get vaccinated. Moreover, much of the literature has overlooked nuance in respondents’ perceptions of the vaccine, for instance, conflating “definitely” and “probably” as if they were synonymous.
  
  Beyond this, the polls indicate some disjuncture between individual wants or expectations and expert opinions. Beyond efficacy, many people deem vaccines valuable because they presumably allow them to return to their normal lives. From this perspective, expert recommendations to continue observing various preventative measures may discourage vaccine uptake. Moreover, the impact of sociohistorical and political factors translates to differing levels of vaccination trust among Black and White Americans, as well as Democrats and Republicans.
  
  Similar concerns have been noted abroad. For instance, this study regarding vaccine-related beliefs and attitudes in Africa reports that willingness to participate is as high of 94% in Ethiopia, and as low as 59% in the Democratic Republic of Congo. Vaccine safety is the chief concern of the majority and is partially influenced by beliefs concerning the safety of immunizations in general. A quarter of all respondents had safety objections. As in the U.S., such perceptions may be best addressed through tailored messaging using a wide range of media and addressing dominant concerns. Indeed, this strategy is noted as a key factor in Uganda’s response to the pandemic, which is widely regarded as both timely and effective. Along with other factors, dominant attitudes and perceptions impact the speed at which that immunization targets may be met. Thus, they have implications for herd immunity.
  
  This article suggests a substantial decline in COVID-related deaths and hospitalizations in the spring and summer 2021 but notes that the likelihood of achieving herd immunity against SARS-CoV-2 is low precisely because not all US residents are currently eligible for vaccination. Moreover, an estimated quarter of those who are eligible may refuse them. This, in addition to the issue of lower vaccine efficacy in relation to variant B.1.351 (and possibly others) suggests that COVID-19 may continue as a recurrent seasonal disease.
  
  The ACIP made the following recommendations for vaccine administration and the period thereafter:
  - The EUA Vaccine Fact Sheet should be provided to recipients and caregivers prior to vaccination.
  - Providers should counsel vaccine recipients about expected local and systemic reactogenicity.
  - Neither COVID-19 vaccine is interchangeable with the other; the safety and efficacy of a mixed-product series have not been evaluated. Indeed, while the ACIP does not state a product preference – individuals should complete the series with the same COVID-19 product they received for the first dose.
  - Adverse events that occur following vaccine receipt should be reported to the Vaccine Adverse Events Reporting System (VAERS). Notably, the FDA requires that vaccination providers report vaccination administration errors, serious adverse events, cases of multisystem inflammatory syndrome, and cases of COVID-19 that result in hospitalization or death after administration of COVID-19 vaccine under the EUA.
  - Reporting by anyone who gives or receives a COVID-19 vaccine is encouraged for any clinically significant adverse event, whether or not it is clear that a vaccine caused the adverse event. Information on how to submit a report to VAERS is available at https://vaers.hhs.gov/index.html.
  - Additional clinical considerations, including details of administration and use in special populations (e.g., persons who are pregnant, immunocompromised or who have a history of severe allergic reactions) are available at https://www.cdc.gov/vaccines/covid-19/info-by-product/clinical-considerations.html.
  More information on potential marketing and rollout strategies in support of vaccine uptake can be found here.
  
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  What Happens After Vaccination?
  
  The CDC has released initial public health guidelines for fully vaccinated people. Fully vaccinated means at least two weeks have passed since you completed your entire vaccination series (i.e., received both your Pfizer-BioNTech doses / both your Moderna vaccine doses / your single Janssen dose). Of course, the risks of SARS-CoV-2 infection in fully vaccinated people cannot be eliminated while the virus continues to circulate through our communities. Vaccinated people can still contract COVID-19 and spread it to others, thus they must continue to exercise caution even as they ease back into their pre-pandemic lives. As of March 8, 2021, CDC guidelines state that fully vaccinated people can:
  - Visit with other fully vaccinated people indoors without wearing masks or physical distancing
  - Visit with unvaccinated people from a single household who are at low risk for severe COVID-19 disease indoors without wearing masks or physical distancing
  - Refrain from quarantine and testing following a known exposure if asymptomatic
  For now, fully vaccinated people should continue to:
  - Take precautions in public like wearing a well-fitted mask and physical distancing
  - Wear masks, practice physical distancing, and adhere to other prevention measures when visiting with unvaccinated people who are at increased risk for severe COVID-19 disease or who have an unvaccinated household member who is at increased risk for severe COVID-19 disease
  - Wear masks, maintain physical distance, and practice other prevention measures when visiting with unvaccinated people from multiple households
  - Avoid medium- and large-sized in-person gatherings
  - Get tested if experiencing COVID-19 symptoms
  - Follow guidance issued by individual employers
  - Follow CDC and health department travel requirements and recommendations
  Similarly, this article suggests that medical professionals and other authority figures may wish to take a calculated approach to post-vaccination guidance. Unfortunately, perception of decreased danger is often associated with an increased in risky behavior: a phenomenon known as The Peltzman Effect. Particularly in light of widespread feelings of COVID-fatigue, this means that strict post-vaccination behavior guidelines are likely to be met with some resistance. Accordingly, physicians may wish to emphasize risk reduction through a clear and practical list of best practices, e.g., continued mask use even after vaccination, and socializing only with other vaccinated persons.
  
  Gyms / Physical Activity: While many people anticipate a return to their pre-pandemic fitness / wellness routines, it is important to note that the evidence suggests it is not safe to remove your mask at the gym – even if you maintain the recommended 6-foot separation from others. While proper ventilation, sanitizing, and distancing can decrease the likelihood of transmission, outbreaks at fitness centers have shown that these are not a substitute for face coverings. Beyond this, it is important to consider that masks have an added potential benefit of reducing disease severity even in cases when one does get sick.
  
  For those who wish to engage in group fitness classes, the research suggests that outdoor sports are safer to engage in than indoor and contact sports (e.g., wrestling). Ultimately, it is best to tailor physical activity to accommodate mask requirements, limit interpersonal contact, and maintain the maximum amount of distance and ventilation. For instance, if you find that intense cardiovascular activity is challenging with a mask on, you may wish to substitute with weight training, walks, or other activities that are less demanding on your lungs.
  
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  What Can Health Programs And Facilities In Resource-Limited Settings Do Now To Ensure The Health Of All Their Clients?
  
  COVID-19 is spreading at an increasing rate in many resource-limited settings, including sub-Saharan Africa. Many of the current measures to control the pandemic neglect important, complex, and context-specific realities in Africa, especially the reduction of patient outcomes due to increasing morbi-mortality stemming from HIV and AIDS, TB, and malaria. COVID-19 responses at the country level should be holistic and tailored to the local social, epidemiological, and economic profiles. This includes measures to protect under-served and vulnerable populations, and people living with HIV, communities living in malaria-endemic settings, and people on TB treatment in particular. Ensuring early and thoughtful resource allocation can reduce the overall cost to nations (read this modeling study, which considers resource allocation options and practices for the best possible outcomes). Best practices (listed below) can help inform strategies and preparedness plans for resource-limited countries. Moreover, The Lancet has published a checklist of considerations that nations may employ to fortify their pandemic responses (read more).
  
  Develop a Detection and Response to Respiratory Events (DaRRE) Strategy, Should None Currently Exist
  
  In 2016, Kenya began implementing a DARRE strategy which equipped the country achieve: 1) expanded severe acute respiratory illness (SARI) surveillance sites, 2) community event-based surveillance piloting, 3)expanded laboratory diagnostic capacity, 4) the training of public health practitioners in detection, investigation, and response to respiratory threats, and 5) an improved national emergency operations center (EOC) response capacity. This strategy is now providing substantial support to the country as it faces COVID-19.
  
  Adopt triage strategies
  
  Clinics in Uganda developed an algorithm to triage patients, initially determined by fever (subjective or measured) and/or cough. If these symptoms are combined with epidemiological risk, patients are sent to an isolated area of the health facility before gaining access to the space where SARS-CoV-2 diagnostics are. A chest X-ray is not required to move a patient to this area, given its limited availability in most health facilities in Uganda. TB and community-acquired pneumonia are particularly common in Uganda and other settings of sub-Saharan Africa, and their presentation could easily mimic SARS-CoV-2. Clinicians will have to consider these and other disease processes as part of a comprehensive clinical evaluation.
  
  Using Lessons From AIDS, TB, and Ebola Outbreaks – Preparation and Stockpile Support Needed from The Global Community:
  
  Although health system weakness remains acute in many places, there have been investments from national governments, the African Union, and international initiatives to tackle AIDS, TB, malaria, polio, and post-Ebola global health security. This support has established important public health capacities and practices. Researchers have found, for instance, that many practices in the TB response, such as: triaging in the health center setting, cough etiquette, contact tracing in the community, and infection control in health centers and the community (including isolation) would benefit the COVID-19 response (read more). Using our capacities, we must also counter market forces, ensuring that lives on the African continent count equally. Doing so will take both moral clarity and political courage.
  
  Adressing TB and SARS-CoV-2, Simultaneously
  
  Reduction in timely diagnosis and treatment of new cases (a possible outcome of prolonged period of COVID-19 suppression interventions) may have a significant impact on TB services (read more). To support TB patients during the COVID-19 pandemic, and reduce unnecessary strain on the healthcare system, it is essential that unnecessary visits to health facilities be minimized. Some experts champion focus on the primary care level: reducing the risk of SARS-COV-2 exposure during clinic attendance while prioritizing uninterrupted TB treatment provision. Associated adaptions include screening all TB patients at the facility for COVID-19, providing them with a surgical mask, triaging COVID-19-negative patients directly to TB services, and keeping those screening positive in a separate space within the COVID-19 investigative area. Following clinical assessment, visit frequency / treatment refill length should be determined by the clinician, to avoid unnecessary visits during the pandemic. Additionally, specific adaptions should be made for drug-susceptible TB patients, drug-resistant TB patients, and TB patients who are unwell (read more).
  
  Test and treat patients in unique, well-structured clinical settings
  
  The WHO has developed a practical manual to set up and manage temporary severe acute respiratory infections treatment centers and SARS-CoV-2 screening facilities within existing health care facilities. The manual provides guidance for the development of specific national standards relevant to outbreak preparedness and readiness, in different contexts. It also considers how those standards may be applied, how to plan and implement the required improvements to handle an influx of patients, and how to construct quality test and treat centers: ensuring an appropriate design to facilitate client flow, water supply access, health care waste management, cleaning, ventilation, management, and hygiene.
  
  Prepare Urban Locations for a Greater Impact
  
  Urban settings tend to face the greatest challenges in spread of SARS-CoV-2. Indeed, Cities have unique dynamics which shape the capacity of authorities to mount an effective response. Learning from the experiences and best practices of others, the WHO has built a guidance tool to enable city health programs to implement appropriate measures before a public health emergency occurs and to adjust them as necessary (read more).
  
  Ensure service continuity
  
  We have a duty to ensure the health and wellness of all people, not only in relation to SARS-CoV-2. Indeed, the pandemic does not relieve the responsibility to other priority areas for service delivery: TB and HIV case finding, prevention and treatment, management of chronic illnesses, pediatric health, and Sexual and Reproductive Health. Countries with high malaria, TB, and HIV burdens, maternal mortality, malnutrition, sexual and gender-based violence still require service delivery in response to all of these challenges. When these services are halted to facilitate social distancing, these unmet needs will lead to ramifications that outweigh the risk posed by SARS-CoV-2 (read more). Thus, the WHO urges health programs to maintain HIV testing access by offering home-based testing (read more) and to encourage adherence through multi-month dispensation. Furthermore, UNICEF has developed guidance on how to maintain HIV services during the pandemic.
  
  In the past few years, some of the top ten high-burden African nations have seen an increase in Malaria cases, while others have undergone periods of stalled progress. Researchers aiming to quantify the indirect effects of the pandemic on the distribution of insecticide treated nets and access to quality anti-malarial drugs estimated additional morbidity and mortality due to COVID-19-related disruptions in malaria-endemic Africa (read more). In the midst of the worldwide focus on COVID-19 treatment and prevention, a 2020 report from the WHO reminds us that TB and malaria remain among the deadliest diseases on the globe. Moreover, progress is not unfolding at the pace necessary to meet 2030 Sustainable Development Goals regarding incidence and mortality reduction for either disease.
  
  Another predictive study modelled three scenarios in which the coverage of essential maternal and child health (MCH) interventions is reduced by 9.8 to 51.9% and the prevalence of malnutrition among infants and young children is increased by 10–50% over the course of 6 months. These three scenarios saw a range of 25,500-1,157,000 additional child deaths, and 12,200-56,700 additional maternal deaths; outcomes were determined by higher or lower service coverage scenarios. Already, the ramifications of reduced stock supplies are evident in Kenya, as are the consequences of the redirection of maternal and child health resources to COVID-related needs. Lost MCH resources have already led to loss of life, undermining safe child delivery and postpartum care (read more). The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) has provided comprehensive guidance on how to maintain services while addressing this pandemic (read more). A review of PEPFAR’s COVID-19 technical guidance, with country-specific examples of program adaptions in sub-Saharan Africa, can be found here.
  
  While the available data suggest that COVID-19-related deaths are higher for men, women and girls bear a disproportionate burden in that they endure the larger impacts of the pandemic and of state emergency responses. UNAIDS listed six concrete measures to support women and girls, in all their diversity, in the midst of the pandemic (read more).
  
  Ensure access in particular to childhood health services
  
  Routine childhood immunization programs should be safeguarded for continued service delivery, and prioritized for the prevention of infectious diseases, to the extent logistically possible. As is the case with most crises, some experts anticipate that COVID-19 will ultimately exact the greatest harm on children. There is also concern that, like most crises, this damage will be underreported, understudied, and underappreciated until it is too late. The Editorial Board of the Journal of Tropical Pediatrics created a list of considerations and recommendations for strengthening health systems and improving the capacity of pediatric care centers in resource-limited settings in response to COVID-19. Moreover, it offers some suggestions to help systems become better placed to manage future outbreaks, and is available here.
  
  Infection prevention and control compliance
  
  A recent study in Tanzania found that preventive measures for health care worker infection and control compliance (particularly for hand hygiene and disinfection) were inadequate in the observed outpatient settings. Moreover, health worker age was negatively associated with correct glove use and female health workers were more likely to comply with hand hygiene. Improved supply provision and health worker behavior are urgently needed in these resource-limited settings as the pandemic continues to surge in said areas (read more).
  
  Point-of-care diagnostic testing
  
  RT-PCR detection of unique sequences of the viral genome is currently the gold standard for COVID-19 testing. However, COVID-19 RT-PCR test kits are expensive, making the cost of large-scale testing prohibitive for most resource-limited settings. Additionally, the test requires expensive equipment, including PCR machines and adequately equipped BSL-2 labs, as well as trained personnel. Therefore, it is important to develop point-of-care (POC) tests that facilitate proper last mile epidemiology. These POC tests will leverage available molecular platforms such as CRISPR, or be based on anti-gen or antibody detection (read more).
  
  The recent surge in COVID-19 cases is an urgent public health concern and requires coordinated efforts to scale-up testing to meet existing national capacities. There is also need to substantially decentralize testing from the current provincial level to district level. Governments must increase their own financial investment in response to COVID-19 and not solely depend on international donors (read more).
  
  Collect data to forEcast demand on health system
  
  Data on cases and outcomes are crucial to outbreak management, as they forecast the demand on the health care system. Resource-limited countries should, therefore, anticipate data that their health facilities will need to monitoring COVID-19, and consider best practices for its collection. Some experts believe a register should be developed to note the key indicators of those admitted to health facility wards, i.e., admission date, suspected or confirmed disease during in-patient care, demographic and clinical details, and health facility interventions.
  
  Ensure food security
  The Global Report on Food Crises estimates that 135 million people were food insecure in 2019. However, more recent World Food Program projections indicate that, due to the economic impact and supply chain disruptions associated with COVID-19, this number could double to 265 million in 2020. As communities respond to the pandemic, ensuring food security and limited supply chain disruption is crucial. Additionally, restrictions on transport and trade should be considered in the wider context of their potentially devastating effects on food supply (read more).
  
  Mental health focus
  
  COVID-19 and its economic consequences will profoundly affect the mental health of the community, essential workers, people with preexisting mental disorders, as well as people with the disease. Mitigating the mental health consequences of the unemployment, poverty, food insecurity, and social disruption caused by economic lockdowns should be made salient in the LMIC context. The treatment gap for mental disorders in LMICs allows only 2 in 100 people to receive minimally adequate care for severe depression, and is expected to increase (read more).
  
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  What Will Pandemic Recovery Look Like?
  
  A study from Johns Hopkins University explored metrics which could be used to define a path toward recovery, including: alleviating lingering financial and medical burdens from those still suffering, creating a greater definition of recovery which includes psychosocial health and trust in social interactions, extra time and financial support needed to revitalize local commerce, and an overall understanding of what “recovered” means (in that it could mean a “new normal”). We do know that recovery will occur, that we will be certainly changed by this pandemic, and that our recovery may be long and uneven at times, but it will occur. Terms and frameworks to define and ensure our recovery, and further research in this area, are needed. However, managing trauma, remaining ﬂexible in dynamic situations, and embracing discomfort to think bigger about context-speciﬁc solutions to collectively build back our systems is critical.
  
  Coming out of this crisis will require societal, governmental, and global approaches driven by compassion and solidarity. Responses to the pandemic should avoid locking in, or even worsening, already unsustainable inequalities, reversing hard-won development gains and poverty reduction. Public funds must be properly used, avoiding corruption that diverts resources and undermines public trust in institutions. The recovery must respect the rights of future generations, enhancing climate action aiming at carbon neutrality by 2050 and protecting biodiversity. Spending to revitalize economies should accelerate the decarbonization of our economy and privilege the creation of green jobs. The United Nations is urging governments to put women and girls at the center of their recovery efforts as COVID-19 could reverse the limited progress that has been made on gender equality and women’s rights.
  
  As we look upon the implementation of a worldwide vaccination program for SARS-CoV-2, researchers have noted the importance of a global coordinating body to provide technical advice and expertise, moral leadership, and vigorous advocacy. The WHO has played such a role in the past, leading the global campaign for chickenpox, by creating a special targeted program with clear objectives that included not just eradication, but accurate and complete reporting. Similarly, the global effort to control SARS-CoV-2 will need a global agency to coordinate the operational response to COVID-19.
  
  In terms of the response to other pandemics in the perhaps distant future, researchers note the importance of more aggressive, systematic approaches to early detection. Noting the threat posed by the increasing frequency of zoonotic disease outbreaks, one study proposes a combination of procuring and screening diagnostic samples from undiagnosed patients, the analysis of samples from suspicious fatalities of unknown cause, serosurveys of high-risk or sentinel groups, and analysis of archived samples. These sometimes-overlapping methods are capable of independently finding evidence of past or current unknown infections. Moreover, researchers propose that this model of related evidence types may be particularly helpful for LMICs which grapple with resource limitations, particularly those on the African continent.
  
  In the earlier stages of the pandemic, achieving herd immunity was a goal for many countries and localities looking to reopen their economies. However, researchers looking at SARS-CoV-2 seroprevalence in COVID-19 hotspots urge that any proposed approach to achieve herd immunity through natural infection is not only highly unethical but also unachievable. So far, there is no example of a large-scale successful intentional infection-based herd immunity strategy. There are only rare instances of seemingly sustained herd immunity being achieved through infection. Moreover, the population of the United States is about 330 million. Based on WHO estimates of an infection fatality rate of 0.5%, about 198 million individuals in the United States are needed to be immune to reach a herd immunity threshold of approximately 60%, which would lead to several hundred thousand additional deaths.
  
  As expected, virus circulation quickly returned to early pandemic dimensions in a second wave once quarantine measures were lifted (read more). Additionally, the confirmation of re-infection means it is unlikely that herd immunity can eliminate SARS-CoV-2, although it is possible that subsequent infections may be milder than the first infection. COVID-19 will likely continue to circulate in humans as in the case of other human coronaviruses, and even with modest infection fatality ratios, a new pathogen will result in substantial mortality because most, if not all, of the population would not have immunity to the pathogen. In some instances, re-infection occurs despite a static level of specific antibodies therefore vaccines may not be able to provide lifelong protection against COVID-19 (read more).
  
  Recovery is also an opportunity to address inequality, exclusion, gaps in social protection systems, the climate crisis, and the many other fragilities and injustices that have received greater exposure during this pandemic. There has never been a greater need discard unsustainable systems and approaches, in favor of transition to renewable energy, sustainable food systems, gender equality, stronger social safety nets, universal health coverage, and a sustainable international system. Recovery can help to steer the world onto a safer, healthier, more equitable and inclusive path.
  
  School reopening during the COVID-19 era is undoubtedly complex, and further problematized by socioeconomic disparity. Globally, only half of schools have access to soap and water for hand washing, and the availability is even slighter in low- and middle-income countries (LMICs). Moreover, public schools are often overcrowded, which may enhance transmission. Even when nearly all safety precautions are put in place, risk and explosive transmission rates have been observed, as in the Georgia camp case. Safely reopening requires investment to improve basic sanitation facilities, universal use of masks, environmental controls, operational changes (such as smaller classroom sizes, social distancing in classes), symptom screening of staff and students, and exclusion of high-risk staff from the workplace. The measures may be especially challenging in LMIC settings, where many schools are already under-resourced and overcrowded (read more).
  
  A group of Massachusetts physicians, including pediatricians, infectious disease physicians, and school district physicians, compiled a resource of published data regarding best practices to prevent and manage COVID-19 infection during re-opening efforts. This resource is available here. Furthermore, experiences from Taiwan can inform the safe re-opening of colleges and universities, as well. Indeed, these guidelines delineated the establishment of a task force at each university, general hygiene measures, ventilation and sanitization principles, a suspected case reporting process, quarantine measures, and policies regarding school closure and make-up classes (read more).
  
  It is important for schools and communities to monitor multiple indicators of COVID-19 among school-aged children and layer prevention strategies to reduce COVID-19 disease risk for students, teachers, school staff, and families. Since a large proportion of children are asymptomatic, symptom screening or temperature checks are inadequate for identifying potentially infectious children. In September 2020, the CDC issued guidelines describing a variety of indicators that could inform decisions about school reopening, including community incidence, test positivity, hospital capacity, and ability of the school to implement mitigation measures. Since then, various other such resources have emerged, and provide research-informed guidance to facilitate the safe reopening of schools. This Johns Hopkins report is a helpful resource that may aid SARS-CoV-2 risk assessment and screening program development for K-12 institutions. As of early March 2021, there is a growing body of literature suggesting that schools and other youth institutions may reopen safely in the presence of stringent preventative measures.
  
  Read More:
  1. Angulo, F.J., Finelli, L., &S werdlow, D.L. (2020) Reopening Society and the Need for Real-Time Assessment of COVID-19 at the Community Level. JAMA. 323(22), 2247-2248.
  2. Boehmer, T.K., DeVies, J., Caruso, E., et al. (2020). Changing Age Distribution of the COVID-19 Pandemic — United States, May–August 2020. MMWR, 69, 1404–1409.
  3. Gras-Le Guen, C., Cohen, R., Rozenberg, J., et al. (2021). Reopening schools in the context of increasing COVID-19 community transmission: The French experience. Archives de pediatrie : organe officiel de la Societe francaise de pediatrie, S0929-693X(21), 00017-8.
  4. Hoehl, S., Kreutzer, E., Schenk, B., et al. (2021). Longitudinal testing for respiratory and gastrointestinal shedding of SARS-CoV-2 in day care centres in Hesse, Germany. Clinical infectious diseases: an official publication of the Infectious Diseases Society of America, ciaa1912. Advance online publication. DOI: 10.1093/cid/ciaa1912
  5. Ismail, S. A., Saliba, V., Lopez Bernal, J., et al. (2020). SARS-CoV-2 infection and transmission in educational settings: a prospective, cross-sectional analysis of infection clusters and outbreaks in England. The Lancet. Infectious diseases, S1473-3099(20)30882-3. Advance online publication. DOI: 10.1016/S1473-3099(20)30882-3
  6. Klein, D., Kerr, C., Mistry, D., et al. (2021). Stepping Back to School: A Step-by-Step Look at COVID Introduction, Spread, and Exportation.
  7. Kozer, E., Rinott, E., Kozer, G., et al. (2021). Presence of SARS-CoV-2 RNA on Playground Surfaces and Water Fountains. Epidemiology & Infection. DOI: 10.1017/S0950268821000546
  8. Krishnaratne, S., Pfadenhauer, L. M., Coenen, M., et al. (2020). Measures implemented in the school setting to contain the COVID-19 pandemic: a scoping review. The Cochrane database of systematic reviews, 12: CD013812.
  9. Flasche, S., & Edmunds, J.W. (2020). The role of schools and school-aged children in SARS-CoV-2 transmission. The Lancet. DOI: 10.1016/S1473-3099(20)30927-0
  10. Leeb, R.T., Price, S., Sliwa, S., et al. (2020). COVID-19 Trends Among School-Aged Children — United States, March 1–September 19, 2020. MMWR,69, 1410–1415.
  11. Lessler, J. M., Grabowski, K., & Grantz, K.H. (2021). Household COVID-19 risk and in-person schooling. BMJ Yale. DOI: 10.1101/2021.02.27.21252597
  12. Logie, C.H. (2020). Lessons learned from HIV can inform our approach to COVID-19 stigma. Journal of the International AIDS Society. 23(5), e25504.
  13. Lo Moro, G., Sinigaglia, T., Bert, F., et al. (2020). Reopening Schools during the COVID-19 Pandemic: Overview and Rapid Systematic Review of Guidelines and Recommendations on Preventive Measures and the Management of Cases. International Journal of Environmental Research and Public Health, 17: 8839.
  14. Mensah, A.A., Sinnathamby, M., Zaidi, A., et al. (2021). SARS-CoV-2 infections in children following the full re-opening of schools and the impact of national lockdown: prospective, national observational cohort surveillance, July-December 2020, Journal of Infection. doi: 10.1016/j.jinf.202
  15. Ratner, L., Martin-Blais, R., Warrell, C., et al. (2020) Reflections on Resilience during the COVID-19 Pandemic: Six Lessons from Working in Resource-Denied Settings. The American Journal of Tropical Medicine and Hygiene. 102(6), 1178-1180.
  16. Schoch-Spana, M. (2020). An Epidemic Recovery Framework to Jumpstart Analysis, Planning, and Action on a Neglected Aspect of Global Health Security. Clinical Infectious Diseases. DOI: 10.1093/cid/ciaa486
  17. Sharfstein, J.M., & Morphew, C.C. (2020). The Urgency and Challenge of Opening K-12 Schools in the Fall of 2020. JAMA. 324(2), 133-134.
  18. Stage, H., Shingleton, J., Ghosh, S., et al. (2020). Shut and re-open: the role of schools in the spread of COVID-19 in Europe. medRxiv, DOI: 10.1101/2020.06.24.20139634.
  19. The PLoS Medicine Editors (2020) Pandemic responses: Planning to neutralizeSARSCoV-2 and prepare for future outbreaks. PLoS Med 17(4): e1003123.
  20. UN Sustainable Development Group. (2020). United Nations Comprehensive Response to COVID-19: Saving Lives, Protecting Societies, Recovering Better (Updated).
  21. Vermund, S.H., & Pitzer, V.E. (2020). Asymptomatic transmission and the infection fatality risk for COVID-19: Implications for school reopening. Clinical Infectious Diseases, ciaa855, DOI:https://doi.org/10.1093/cid/ciaa855
  22. Wrighton, M., & Lawrence, S.J. (2020). Reopening Colleges and Universities During the COVID-19 Pandemic. Annals of Internal Medicine. DOI: 10.7326/M20-4752
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  Text last updated 20 August 2021
  
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