tag:theconversation.com,2011:/id/topics/pneumonia-14404/articlesPneumonia – The Conversation2023-12-04T15:39:27Ztag:theconversation.com,2011:article/2189672023-12-04T15:39:27Z2023-12-04T15:39:27ZChildhood pneumonia is surging in many countries – while the germs causing it are known, the effects of co-infections aren’t<figure><img src="https://images.theconversation.com/files/563296/original/file-20231204-23-ogevti.jpg?ixlib=rb-1.1.0&rect=8%2C0%2C5331%2C3554&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/cough-elbow-prevention-barrier-gestures-curb-1693522387">castiglioni veronica/Shutterstock</a></span></figcaption></figure><p>You may have heard reports about outbreaks of pneumonia affecting children in <a href="https://www.foxnews.com/health/childhood-pneumonia-surge-reported-netherlands-outbreak-china">the Netherlands</a>, <a href="https://www.dailymail.co.uk/health/article-12808991/Denmark-battles-surge-pneumonia-sparking-fears-China.html">Denmark</a> and parts of <a href="https://www.independent.co.uk/news/health/white-lung-pneumonia-outbreak-ohio-b2457652.html">the US</a> and <a href="https://news.sky.com/story/china-suffers-walking-pneumonia-outbreak-as-many-other-countries-see-spike-in-infections-13020285">China</a>, which are higher than usual for this time of year. Parents are keeping a watchful eye on the news, while public health officials monitor the global incidence of severe respiratory infections and record cases and causes. However, there is no new virus or other type of new pathogen to worry about in these outbreaks. </p>
<p>Here’s what we know.</p>
<p>Pneumonia is inflammation of the lungs, usually caused by bacterial or viral infections. It may affect deeper lung tissues than bronchitis, which is airway tube inflammation, and can have symptoms such as fever, breathing problems and chest pain, showing up as a white shade in lung chest X-rays. There is no special designation of “<a href="https://www.independent.co.uk/news/health/white-lung-pneumonia-outbreak-ohio-b2457652.html">white lung pneumonia</a>”, <a href="https://www.mirror.co.uk/news/health/what-white-lung-syndrome-mystery-31571473">scary as it may sound</a>. </p>
<p>This season, known respiratory germs, including respiratory syncytial virus (RSV) and <em>Mycoplasma pneumoniae</em> bacteria, have been recorded and are quite expected for this time of year. Mycoplasma outbreaks flare up <a href="https://www.cdc.gov/pneumonia/atypical/mycoplasma/surv-reporting.html">every few years</a> and can be <a href="https://bestpractice.bmj.com/topics/en-gb/605">resistant</a> to common antibiotics. </p>
<p>Most infected children and adults will develop flu-like symptoms that will clear up on their own after a few days, but some may develop into more serious inflammation of the lungs requiring treatment and, in some cases, hospitalisation. </p>
<p>But why do some people get more severe diseases? And are there any differences this season?</p>
<figure class="align-center ">
<img alt="Chest X-ray showing a white shadow on the lung" src="https://images.theconversation.com/files/563341/original/file-20231204-15-59vaa6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/563341/original/file-20231204-15-59vaa6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/563341/original/file-20231204-15-59vaa6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/563341/original/file-20231204-15-59vaa6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/563341/original/file-20231204-15-59vaa6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/563341/original/file-20231204-15-59vaa6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/563341/original/file-20231204-15-59vaa6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Pneumonia can show up as a white shadow on a chest X-ray.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/chest-xray-film-patient-left-lung-1819284152">Tomatheart/Shutterstock</a></span>
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<p>Healthy children make the most of passing harmless respiratory viruses to each other at an early age, helping to educate their immune systems and build immunity to similar germs in the future. </p>
<p>Over 200 viruses can cause respiratory infection, including RSV, adenoviruses, enteroviruses, rhinoviruses and coronaviruses. Symptoms can be more serious in the young when similar infections have not been previously encountered. It takes about <a href="https://en.wikipedia.org/wiki/Adaptive_immune_system">a week</a> for specific immunity to develop its arsenal to a new pathogen. </p>
<p>After the infection is cleared, memory cells remain to protect against future infections. We appreciate that antibodies to common cold viruses such as coronaviruses <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8319587/">wane</a> after around two years and RSV-specific antibodies in infants may wane <a href="https://academic.oup.com/jid/article/226/12/2064/6582314">even faster</a>. However, memory cells persist, so to escape immunity, viruses mutate to avoid recognition. </p>
<p>There are no differences in expected viral infections this year, and the known culprits were reported in expected waves based on pre-pandemic levels, <a href="https://www.independent.co.uk/news/health/pneumonia-outbreak-china-cases-map-b2456410.html">according to the World Health Organization</a>. <em>Mycoplasma pneumoniae</em> flares are also as expected. However, waning mycoplasma-specific herd immunity has been <a href="https://www.thelancet.com/journals/lanmic/article/PIIS2666-5247(23)00182-9/fulltext">flagged up</a> with a warning to watch out for the resurgence of severe cases following the pandemic restrictions.</p>
<h2>Unknown effects of co-infection</h2>
<p>COVID restrictions are a thing of the past and people that mix in schools, nursing homes and other high-risk environments are likely to come across several infectious diseases at the same time.</p>
<p>Studies in children with acute severe hepatitis <a href="https://www.nature.com/articles/s41586-023-05948-2">in the UK</a> and <a href="https://www.nature.com/articles/s41586-023-05949-1">the US</a> showed that multiple viral infections were causing unexpected liver damage. Multiple infections can lead to more severe disease, where even viruses that can be <a href="https://www.nature.com/articles/d41586-023-00570-8">considered harmless</a> can add to tissue injury. </p>
<p>In science labs, it has been shown that being infected with more than one respiratory virus (known as “co-infection”) can lead to <a href="https://www.nature.com/articles/s41564-022-01242-5">hybrid viruses</a>. These hybrid viruses may behave differently from the individual viruses – causing different symptoms and perhaps even evading the immune system.</p>
<p>So what do we need to know to determine if a new dangerous outbreak occurs? The incidence of known infections and symptoms are recorded and reported so that any new, potentially more dangerous variants can be detected. Hospitals can become overwhelmed during <a href="https://www.cdc.gov/flu/about/season/index.html">flu season</a>, but flu does not circulate in isolation and symptoms can worsen when people are simultaneously infected with more than one respiratory virus.</p>
<p>Respiratory infections can cause lung injury, which takes time to heal. Having one respiratory infection followed by another can prolong this healing time, leading to more severe symptoms and longer illness. This is particularly felt by <a href="https://www.cdc.gov/asthma/respinf.html">asthma sufferers</a>, who are advised to take their annual flu jab and avoid catching seasonal infections. </p>
<p>Pneumonia-causing infections are contagious. The COVID pandemic has highlighted tips to avoid catching a respiratory infection, which include avoiding contact with infected people, effective ventilation, masking and hand hygiene. Given what we now know about the impact of “harmless” infections, particularly simultaneous infections with more than one pathogen, it is critical to take action to stop the spread.</p><img src="https://counter.theconversation.com/content/218967/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Zania Stamataki does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Hybrid viruses can emerge from co-infections. And we don’t know their effects.Zania Stamataki, Associate Professor in Viral Immunology, University of BirminghamLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2185142023-11-27T04:36:11Z2023-11-27T04:36:11ZHow worried should we be about the pneumonia outbreak in China?<p>Reports of a surge in <a href="https://www.nytimes.com/2023/11/23/world/asia/who-china-children-respiratory-illness.html">pneumonia-like illness</a> primarily affecting children in northern China have captured our attention. The last time we heard about a mysterious respiratory outbreak leading to overcrowding in hospitals was the beginning of the COVID pandemic, so it’s not entirely surprising this has caused some alarm.</p>
<p>On November 22 the <a href="https://www.who.int/emergencies/disease-outbreak-news/item/2023-DON494">World Health Organization</a> requested information from China about this surge. Chinese health authorities have since said the outbreak is due to a number of respiratory pathogens.</p>
<p>So what are the pathogens possibly causing this uptick in respiratory illness? And do we need to be concerned that any have pandemic potential? Let’s take a look.</p>
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<h2><em>Mycoplasma</em></h2>
<p>One is a bacteria, <em><a href="https://www.cdc.gov/pneumonia/atypical/mycoplasma/about/signs-symptoms.html">Mycoplasma</a></em>, which has been causing outbreaks of respiratory illness in China <a href="https://flutrackers.com/forum/forum/china-other-health-threats/china-pneumonia-respiratory-and-influenza-like-illnesses-ili/978160-china-hospital-pediatric-mycoplasma-pneumonia-infections-up-from-june-in-children-over-4-years-old-guangzhou-guangdong-province-august-17-2023">since June this year</a>. </p>
<p><em>Mycoplasma</em> is usually treated in the community <a href="https://www.webmd.com/a-to-z-guides/mycoplasma-infections">with antibiotics</a> and hospitalisation is not common. It can lead to a phenomenon called “walking pneumonia”, which is when the chest x-ray looks much worse than the patient appears. </p>
<p>In Taiwan, however, reports have suggested there’s a high level of <a href="https://www.taipeitimes.com/News/taiwan/archives/2023/11/24/2003809643">antibiotic resistance</a> to <em>Mycoplasma</em>, which may explain why it’s causing more hospital admissions.</p>
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Read more:
<a href="https://theconversation.com/how-do-bacteria-actually-become-resistant-to-antibiotics-213451">How do bacteria actually become resistant to antibiotics?</a>
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<h2>Influenza</h2>
<p>Influenza fell to <a href="https://onlinelibrary.wiley.com/doi/10.1002/jmv.26964">very low levels</a> during the first two years of the COVID pandemic due to masks, physical distancing and other measures. But once things began to return to “normal”, flu infections have tended to <a href="https://app.powerbi.com/view?r=eyJrIjoiZTkyODcyOTEtZjA5YS00ZmI0LWFkZGUtODIxNGI5OTE3YjM0IiwidCI6ImY2MTBjMGI3LWJkMjQtNGIzOS04MTBiLTNkYzI4MGFmYjU5MCIsImMiOjh9">bounce back</a>.</p>
<p>Influenza is <a href="https://www.cdc.gov/flu/professionals/acip/background-epidemiology.htm">most severe</a> in children under age five and the elderly, so may be <a href="https://www.ajmc.com/view/severe-influenza-incidence-strikes-us-children-and-adolescents-in-2022-23-season">contributing to hospitalisations</a> among children. </p>
<h2>RSV and adenovirus</h2>
<p>Respiratory syncytial virus (RSV) can also be severe in children, and like influenza, all but disappeared during the first two years of the pandemic. But it’s now <a href="https://theconversation.com/rsv-is-everywhere-right-now-what-parents-need-to-know-about-respiratory-syncytial-virus-208855">circulating widely</a>. </p>
<p>Adenovirus, which can cause a range of syndromes including <a href="https://www.cdc.gov/adenovirus/symptoms.html">gastroenteritis and a flu-like illness</a>, has also been reported as contributing to the current outbreak in China. There are reports of children <a href="https://china.huanqiu.com/article/4FLM9f1p2JC">vomiting</a> and pictures of children <a href="https://twitter.com/shanghaidaily/status/1727596965473747020">receiving IV fluids</a>, presumably for dehydration as a result of gastroenteritis.</p>
<h2>The role of COVID</h2>
<p>SARS-CoV-2, the virus that causes COVID, can also cause pneumonia, but <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/apa.15270">less so in children</a>. Early in the pandemic, we knew SARS-CoV-2 could show pneumonia on a chest scan in asymptomatic children, so COVID too can cause “<a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30154-9/fulltext">walking pneumonia</a>” in kids. </p>
<p>SARS-CoV-2 causes <a href="https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2800816">more deaths in children</a> than influenza, so likely is contributing to the overcrowding seen in hospitals. </p>
<p>Some research suggests SARS-CoV-2 may also result in <a href="https://www.nature.com/articles/s41586-023-06651-y">immune dysfunction</a> after the infection, which may explain the unexpected rise of other infections, including <a href="https://www.thelancet.com/journals/lanchi/article/PIIS2352-4642(22)00374-1/fulltext">streptococcal infections</a> and <em>Mycoplasma</em>, since the pandemic. </p>
<h2>Co-infections</h2>
<p>People can become infected with SARS-CoV-2 and other <a href="https://www.thelancet.com/journals/landig/article/PIIS2589-7500(21)00077-7/fulltext#%20">bacteria or viruses</a> at the same time, which may also explain the severity of the current epidemic. One study showed co-infection with SARS-CoV-2 and <em>Mycoplasma</em> is <a href="https://www.cureus.com/articles/93180-the-severity-of-the-co-infection-of-mycoplasma-pneumoniae-in-covid-19-patients#!/">very common</a> and results in more serious complications.</p>
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Read more:
<a href="https://theconversation.com/rsv-is-a-common-winter-illness-in-children-why-did-it-see-a-summer-surge-in-australia-this-year-156492">RSV is a common winter illness in children. Why did it see a summer surge in Australia this year?</a>
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<h2>Could it be a new pandemic?</h2>
<p>The below figure shows reports of outbreaks of unspecified influenza-like illness and pneumonia, together with known causes influenza A and B, SARS-CoV-2, RSV, pertussis (whooping cough), adenovirus and <em>Mycoplasma</em>. It confirms an increase in respiratory illnesses this year in China compared to the same time last year. </p>
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<p>In contrast, the same comparison for the world shows a decrease this year compared to last year, which tells us China is indeed experiencing more respiratory illness than expected.</p>
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<p>If no known cause for this surge had been identified, that would give us greater cause for concern. But several have been identified, which gives us confidence we are not dealing with a novel virus.</p>
<p>The virus we are most worried about with pandemic potential is avian influenza, which may mutate to become easily transmissible in humans. China has been an epicentre of avian flu <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0174980">in the past</a>, but the spread of H5N1 <a href="https://www.nature.com/articles/s41586-023-06631-2">has shifted</a> to the Americas, Europe and Africa. </p>
<p>Still, this year, China has reported multiple human cases of various avian flu strains, including <a href="https://www.who.int/emergencies/disease-outbreak-news/item/2023-DON456#:%7E:text=On%2027%20March%202023%2C%20the,have%20been%20reported%20from%20China.">H3N8</a>, <a href="https://bnonews.com/index.php/2023/07/chinese-woman-suffered-from-h5n1-bird-flu-and-covid-19-at-the-same-time/">H5N1</a>, <a href="https://www.info.gov.hk/gia/general/202308/23/P2023082300439.htm">H5N6</a> and <a href="https://www.chp.gov.hk/files/pdf/2023_avian_influenza_report_vol19_wk46.pdf">H9N2</a>. With large and continual outbreaks <a href="https://www.who.int/news/item/12-07-2023-ongoing-avian-influenza-outbreaks-in-animals-pose-risk-to-humans">in birds and mammals</a>, there is a greater likelihood of mutations and mixing of bird and human influenza genetic material, which could lead to a new pandemic influenza virus. </p>
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Read more:
<a href="https://theconversation.com/alert-but-not-alarmed-what-to-make-of-new-h1n1-swine-flu-with-pandemic-potential-found-in-china-141872">Alert but not alarmed: what to make of new H1N1 swine flu with 'pandemic potential' found in China</a>
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<p>The threat of new viruses <a href="https://www.nature.com/articles/s41579-021-00639-z">is increasing</a>, and pandemic potential is greatest for viruses spread by the respiratory route and which are severe enough to cause pneumonia. There is no indication that the current situation in China is a new pandemic, but we should always identify and pay attention to undiagnosed pneumonia clusters. <a href="https://www.epiwatch.org/">Early warning systems</a> give us the best chance of preventing <a href="https://www.sciencedirect.com/science/article/pii/S0264410X23006308?via%3Dihub">the next pandemic</a>.</p><img src="https://counter.theconversation.com/content/218514/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>C Raina MacIntyre receives funding from NHMRC and MRFF. She is currently receiving funding from Sanofi for research on influenza and pertussis. She is on the WHO COVID-19 Vaccine Composition Technical Advisory Group and the WHO SAGE Monkeypox and Smallpox ad hoc working group. She leads EPIWATCH early warning system.</span></em></p><p class="fine-print"><em><span>Ashley Quigley works as the Epidemiological Team Lead on EPIWATCH® at The Kirby Institute, UNSW.</span></em></p><p class="fine-print"><em><span>Haley Stone works as a Research Officer on EPIWATCH® at The Kirby Institute, UNSW.
</span></em></p><p class="fine-print"><em><span>Rebecca Dawson is a Research Associate with EPIWATCH® at the Kirby Institute, UNSW. </span></em></p>There are a number of pathogens which are reported to be causing the outbreak of respiratory illness in China.C Raina MacIntyre, Professor of Global Biosecurity, NHMRC Principal Research Fellow, Head, Biosecurity Program, Kirby Institute, UNSW SydneyAshley Quigley, Senior Research Associate, Global Biosecurity, UNSW SydneyHaley Stone, PhD Candidate, Biosecurity Program, Kirby Institute, UNSW SydneyRebecca Dawson, Research Associate, The Kirby Institute, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2164502023-11-15T14:30:06Z2023-11-15T14:30:06ZHealth risks at home: a study in six African countries shows how healthy housing saves children’s lives<p>Housing is a critical social determinant of health. The World Health Organization (WHO) <a href="https://iris.who.int/bitstream/handle/10665/276001/9789241550376-eng.pdf?sequence=22">defines healthy housing</a> as a shelter that supports physical, mental and social wellbeing. </p>
<p>The WHO has developed <a href="https://iris.who.int/bitstream/handle/10665/276001/9789241550376-eng.pdf?sequence=1">guidelines</a> outlining the attributes of healthy housing. These include structural soundness, as well as access to a local community that enables social interactions. Healthy housing protects inhabitants from the effects of disasters, pollution, waste and extreme heat or cold. It provides a feeling of home, including a sense of belonging, security and privacy. </p>
<p>Health risks in the home environment are important to think about because of the amount of time people spend there. In countries where unemployment levels are high or where most work is home based, people spend <a href="https://iris.who.int/bitstream/handle/10665/276001/9789241550376-eng.pdf?sequence=23">more than 70% of their time indoors</a>. Children especially spend a large amount of time at home, which exposes them to any health risks in the home environment.</p>
<p>We are researchers from the African Population and Health Research Center with an interest in urbanisation and population dynamics. We recently set out to <a href="https://bmcpediatr.biomedcentral.com/articles/10.1186/s12887-023-03992-5">study the link between housing and children’s health</a>. We found that healthy housing generally lowered the chances of children falling ill with three diseases that we tracked: diarrhoea, acute respiratory illnesses and fever. </p>
<p>The impacts of housing quality extend beyond health and can have significant implications for education and subsequent economic outcomes, particularly for children. </p>
<h2>The research</h2>
<p><a href="https://www.brookings.edu/articles/can-rapid-urbanization-in-africa-reduce-poverty-causes-opportunities-and-policy-recommendations/">Rapid urbanisation and population growth</a> in Africa have pushed many people into informal settlements. Sub-Saharan Africa has <a href="https://blogs.afdb.org/fr/inclusive-growth/urbanization-africa-191">65%</a> of the world’s slum dwellers. This population generally lives in poor housing that lacks access to clean water, sanitation and hygiene services. The structures are overcrowded. They tend to have leaking roofs and damp walls, floors and foundations. They may also have indoor pollution, compromising the health of millions of people.</p>
<p>We set out to <a href="https://bmcpediatr.biomedcentral.com/articles/10.1186/s12887-023-03992-5">evaluate</a> the relationship between healthy housing and the likelihood of children falling sick across six African countries: Burkina Faso, Cameroon, Ghana, Kenya, Nigeria and South Africa.</p>
<p>We studied the incidence of diarrhoea, acute respiratory illness and fever among children under the age of five. These three conditions can have severe consequences for child health and wellbeing. </p>
<p>Diarrhoea and acute respiratory infections are <a href="https://academic.oup.com/inthealth/advance-article/doi/10.1093/inthealth/ihad046/7210800">leading causes</a> of disease and deaths in children aged below five worldwide. Diarrhoea accounted for <a href="https://data.unicef.org/topic/child-health/diarrhoeal-disease/">9%</a> of all deaths among children under five in 2019. Acute respiratory illnesses caused about <a href="https://www.who.int/data/gho/indicator-metadata-registry/imr-details/3147">20%</a> of deaths among children in this age group. The burden of under-five deaths linked to diarrhoea and respiratory illnesses like pneumonia is <a href="https://childmortality.org/wp-content/uploads/2023/01/UN-IGME-Child-Mortality-Report-2022.pdf#page=4">higher</a> for children in developing countries than those in developed regions. </p>
<p>We selected the six countries in our study because they provided data on the three diseases we tracked. They also allow for a comparative analysis across African countries. Our study used the latest available demographic and health survey data at the time of our research: Burkina Faso (2010), Cameroon (2011), Ghana (2014), Kenya (2014), Nigeria (2018) and South Africa (2016). We sampled data on 91,096 children aged under five.</p>
<h2>The findings</h2>
<p>Our study found that healthy housing was <a href="https://bmcpediatr.biomedcentral.com/articles/10.1186/s12887-023-03992-5/tables/2">generally associated with reduced odds</a> of contracting the three illnesses we considered: diarrhoea, acute respiratory illness and fever. Our definition of healthy housing considered several attributes, including sanitation, drinking water sources and housing characteristics. </p>
<p>Homes that protect occupants from the elements, ensure access to adequate space and reduce overcrowding help keep children healthy. Homes that use cleaner cooking and lighting fuels reduce household air pollution, which leads to lower chances of respiratory infections.</p>
<p>Children living in healthy housing had fewer incidences of fever in all countries apart from South Africa. Here, children living in the healthiest homes are twice as likely to have fever than those living in unhealthy homes.</p>
<p>Fever is an indication of an underlying infection that could be viral or bacterial. Such infections are common in South Africa. In addition, the main causes of fevers among children under five are <a href="https://www.hindawi.com/journals/grp/2023/1906782/">diarrhoea and acute respiratory illnesses</a>. Among the countries included in the analysis, South Africa had the highest proportion of young mothers (aged below 25) and never-married mothers. This increases the chances that these mothers are engaged in work outside the home, leading to the early introduction of complementary feeding. This has been shown to increase the incidence of diarrhoea. These results call for addressing the causes of diarrhoea and respiratory illnesses by, for instance, ensuring South African homes have access to clean drinking water, adequate sanitation and clean energy for cooking.</p>
<p>While healthy housing is crucial, it’s not the sole determinant of a child’s health. Other factors, such as a sense of community, environmental exposure, parental education, income levels, healthcare access, and maternal and child-level factors <a href="https://bmcpediatr.biomedcentral.com/articles/10.1186/s12887-023-03992-5/tables/3">also contribute to the overall health status of children</a>. For instance, we found that children in Burkina Faso who were not breastfed had higher chances of getting diarrhoea than those who were breastfed despite the condition of their housing. This tracks with studies that have documented that breastfeeding has a <a href="https://doi.org/10.3389/fped.2023.1086999">protective role</a> over gastrointestinal and respiratory tract infections among children. </p>
<h2>What next</h2>
<p>From our findings, parents can improve the wellbeing of their children by implementing simple strategies. This includes ensuring they use clean energy for cooking to reduce indoor air pollution and consequently reduce the incidence of acute respiratory illnesses. Similarly, using clean drinking water, hand washing and improving sanitation can help reduce cases of diarrhoea. </p>
<p>Bold but nuanced policy and programme government-level interventions can also help address the incidence of diseases affecting children under five in Africa. This requires efforts that go beyond just addressing the issue of housing to working with complementary sectors, like health, urban planning, environment and education.</p><img src="https://counter.theconversation.com/content/216450/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Hellen Gitau received funding from Wellcome Trust for this Complex Urban System for Sustainability and Health study. </span></em></p><p class="fine-print"><em><span>Blessing Mberu received funding from Wellcome Trust for this Complex Urban System for Sustainability and Health study. </span></em></p><p class="fine-print"><em><span>Kanyiva Muindi received funding from Wellcome Trust for this Complex Urban System for Sustainability and Health study. </span></em></p><p class="fine-print"><em><span>Samuel Iddi received funding from Wellcome Trust for this Complex Urban System for Sustainability and Health study.</span></em></p>The impact of housing quality extends beyond health to education and subsequent economic outcomes, particularly for children.Hellen Gitau, Research officer, African Population and Health Research CenterBlessing Mberu, Head of Urbanisation and Wellbeing, African Population and Health Research Center, African Population and Health Research CenterKanyiva Muindi, Associate Research Scientist, African Population and Health Research CenterSamuel Iddi, Research Scientist, African Population and Health Research CenterLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2088552023-07-26T00:32:56Z2023-07-26T00:32:56ZRSV is everywhere right now. What parents need to know about respiratory syncytial virus<figure><img src="https://images.theconversation.com/files/538668/original/file-20230721-21-8jb0lp.jpg?ixlib=rb-1.1.0&rect=1%2C4%2C997%2C661&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/newborn-baby-weakened-bronchitis-getting-oxygen-1022883532">Shutterstock</a></span></figcaption></figure><p>This winter, we’re having to get our heads around another respiratory virus – RSV.</p>
<p>It’s less well known than COVID or flu, but it’s also responsible for unplanned visits to the GP or emergency department, and days off school, childcare and work.</p>
<p>It’s the <a href="https://pubmed.ncbi.nlm.nih.gov/31383776/">most common</a> cause of hospitalisation in infants. Most children have at least one RSV infection by the age of three years and yet, many Australians have not heard of RSV or know little about this potentially serious winter virus.</p>
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Read more:
<a href="https://theconversation.com/mondays-medical-myth-you-can-catch-a-cold-by-getting-cold-2488">Monday's medical myth: you can catch a cold by getting cold</a>
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<h2>What is RSV?</h2>
<p>RSV stands for respiratory syncytial (pronounced sin-CITY-al) virus. This common respiratory virus usually causes a mild cold with symptoms such as a fever, runny nose, coughing, decreased appetite and a wheeze. </p>
<p>Adults can be infected with RSV but usually recover in a few days.</p>
<p>But in young babies RSV can cause more severe respiratory illnesses such as <a href="https://www.rch.org.au/kidsinfo/fact_sheets/pneumonia/">pneumonia</a> or <a href="https://www.rch.org.au/kidsinfo/fact_sheets/bronchiolitis/">bronchiolitis</a>. These cause babies to breathe rapidly, stop breathing for a few seconds (apnoeas) and/or feed poorly. RSV in infancy can also potentially affect a child’s long-term health, increasing their risk of asthma, wheezing and allergies. </p>
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<p>In Australia, a wave of RSV infections typically begins in late autumn (April-May) and peaks in June-July. Cases are <a href="https://nindss.health.gov.au/pbi-dashboard/">starting to decline</a> in Australia now.</p>
<p>Because health staff have to report cases of RSV, we can keep track of <a href="https://nindss.health.gov.au/pbi-dashboard/">known cases</a>. But we suspect most go unreported as they are mild and/or doctors don’t always test for the virus.</p>
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Read more:
<a href="https://theconversation.com/heard-of-kindy-flu-theres-no-such-thing-but-kids-are-at-risk-this-flu-season-for-one-simple-reason-207825">Heard of 'kindy flu'? There's no such thing. But kids are at risk this flu season for one simple reason</a>
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<h2>Who’s most at risk?</h2>
<p>Both young and old people are most at risk of severe disease. </p>
<p>For children, those <a href="https://adc.bmj.com/content/107/4/359.long">most at risk</a> of severe disease include babies under two months old, premature infants, those with other medical conditions, or ones infected with another virus at the same time. First Nations children are <a href="https://pubmed.ncbi.nlm.nih.gov/31066061/">three to six times</a> more likely to be hospitalised with bronchiolitis caused by RSV than non-First Nations children.</p>
<p>Otherwise healthy children under 12 months old (usually under six months old) are the ones most often admitted to hospital. Of children admitted to hospital, <a href="https://pubmed.ncbi.nlm.nih.gov/35168504/">about a quarter</a> (26%) will be admitted to intensive care.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/538662/original/file-20230721-28237-d8ek9e.jpg?ixlib=rb-1.1.0&rect=4%2C0%2C994%2C667&q=45&auto=format&w=1000&fit=clip"><img alt="Male toddler with oxygen mask over face in hospital bed" src="https://images.theconversation.com/files/538662/original/file-20230721-28237-d8ek9e.jpg?ixlib=rb-1.1.0&rect=4%2C0%2C994%2C667&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/538662/original/file-20230721-28237-d8ek9e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/538662/original/file-20230721-28237-d8ek9e.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/538662/original/file-20230721-28237-d8ek9e.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/538662/original/file-20230721-28237-d8ek9e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/538662/original/file-20230721-28237-d8ek9e.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/538662/original/file-20230721-28237-d8ek9e.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Young children and the elderly are most at risk.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/2-years-old-asian-toddler-boy-1163046754">Shutterstock</a></span>
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<h2>Why are we seeing so many cases now?</h2>
<p>RSV is spread via coughing and sneezing so it’s easy to see how the virus can spread among children inside during winter months.</p>
<p>But measures earlier in the COVID pandemic limited the spread of RSV.</p>
<p>There was very little RSV circulating in 2020 during the harshest lockdowns. However, in New South Wales and Western Australia (in late 2020) and in Victoria (early 2021) there was an <a href="https://www.nature.com/articles/s41467-022-30485-3">out-of-season re-emergence</a> of RSV, overwhelming hospitals and health-care facilities.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1531461682307821570"}"></div></p>
<p>In 2022, RSV settled back into the usual winter peak. However, many states are experiencing a winter surge in cases and hospitalisations attributed to it this year – bigger than before the pandemic.</p>
<p>This may relate to <a href="https://www.health.gov.au/diseases/respiratory-syncytial-virus-rsv-infection">new reporting requirements</a> for RSV and more testing for it.</p>
<p>However, reduced immunity in young infants due to lower maternal and infant exposure may have contributed to the record number of cases.</p>
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<strong>
Read more:
<a href="https://theconversation.com/ive-had-covid-and-am-constantly-getting-colds-did-covid-harm-my-immune-system-am-i-now-at-risk-of-other-infectious-diseases-188899">I've had COVID and am constantly getting colds. Did COVID harm my immune system? Am I now at risk of other infectious diseases?</a>
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<h2>Is there a vaccine?</h2>
<p>There are no vaccines to protect against RSV in Australia.</p>
<p>Australia’s only currently available preventative medicine is <a href="https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Palivizumab_for_at-risk_patients/">palivizumab</a>, which is a long-acting monoclonal antibody given monthly during the RSV season. Due to its cost, it is reserved for infants at highest risk for severe RSV infection and is usually given in hospital. </p>
<p>However, several new preventative agents are in the pipeline. </p>
<p><a href="https://www.fda.gov/news-events/press-announcements/fda-approves-first-respiratory-syncytial-virus-rsv-vaccine">In May this year</a>, the US Food and Drug Administration approved the RSV vaccine Arexvy for people aged 60 and over. It is being <a href="https://www.tga.gov.au/resources/prescription-medicines-under-evaluation/arexvy-glaxosmithkline-australia-pty-ltd">considered for use</a> in Australia.</p>
<p>Results from clinical trials for RSV vaccines given to pregnant women to protect their baby for the first six months are promising. The maternal Pfizer vaccine <a href="https://www.nejm.org/doi/full/10.1056/NEJMoa2216480">has demonstrated</a> greater than 80% effectiveness against severe lower respiratory tract illness in their infants for the 90 days after birth.</p>
<p>However, safety data is being closely examined, including a <a href="https://www.bmj.com/content/381/bmj.p1021">potential risk</a> of premature birth. </p>
<p>The long-acting monoclonal antibody nirsevimab, (given as a single injection at the beginning of the RSV season) has regulatory approval in Europe and the US. It is currently <a href="https://www.tga.gov.au/resources/prescription-medicines-under-evaluation/beyfortus-astrazeneca-pty-ltd">being considered</a> for Australian children.</p>
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Read more:
<a href="https://theconversation.com/fdas-approval-of-the-worlds-first-vaccine-against-rsv-will-offer-a-new-tool-in-an-old-fight-4-questions-answered-205111">FDA's approval of the world's first vaccine against RSV will offer a new tool in an old fight – 4 questions answered</a>
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<h2>How can I protect my children in the meantime?</h2>
<p>Parents can minimise the risk of RSV by using many of the measures we’ve been using during the COVID pandemic. Encourage children to cover their mouths and noses when coughing or sneezing, and regularly wash their hands.</p>
<p>Ensuring kids stay away from school, childcare or other children when sick helps prevent the spread of many viruses, including RSV.</p>
<p><a href="https://www.rch.org.au/kidsinfo/fact_sheets/Respiratory_syncytial_virus_RSV/">Viral symptoms</a> to watch out for include difficulty feeding, cough, irritability and/or rapid breathing. If parents notice these signs or are worried about their child they should seek urgent medical assessment and not delay.</p><img src="https://counter.theconversation.com/content/208855/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jane Tuckerman is an investigator on a project grant sponsored by Industry. Her institution has received funding from Industry (GSK) for investigator led research. She does not receive any personal payments from Industry. </span></em></p><p class="fine-print"><em><span>Ashleigh Rak receives funding from NHMRC and the Victorian Government.</span></em></p><p class="fine-print"><em><span>Danielle Wurzel receives funding from NHMRC, MRFF and has received honoraria and/or consultancy fees from MSD, Sanofi, GSK which have been paid into her research fund.</span></em></p><p class="fine-print"><em><span>Margie Danchin receives funding from NHMRC, MRFF, WHO, DFAT and the Victorian Government. She is chair, Australian Regional Immunisation Alliance. </span></em></p>Even otherwise healthy children can end up in hospital with this winter respiratory virus.Jane Tuckerman, Senior Research Officer, Murdoch Children's Research InstituteAshleigh Rak, Research Nurse Coordinator, Murdoch Children's Research InstituteDanielle Wurzel, Paediatric Respiratory Physician, and Honorary Fellow Manager, Murdoch Children's Research InstituteMargie Danchin, Paediatrician at the Royal Childrens Hospital and Associate Professor and Clinician Scientist, University of Melbourne and MCRI, Murdoch Children's Research InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2078362023-07-13T11:46:33Z2023-07-13T11:46:33ZFungal infections in the brain aren’t just the stuff of movies – Africa grapples with a deadly epidemic<figure><img src="https://images.theconversation.com/files/532417/original/file-20230616-19-tunqcw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The fungus Aspergillus fumigatus. This fungus can cause a number of disorders in people with compromised immune function or other lung diseases.</span> <span class="attribution"><span class="source">Kateryna Kon/Science Photo Library/GettyImages</span></span></figcaption></figure><p>In the 2023 American post-apocalyptic drama television series <a href="https://www.hbo.com/the-last-of-us">The Last of Us</a>, humans are plunged towards extinction as a fungal infection of the brain zombie-fies most of the species. This may seem far-fetched but fungi can, and do, infect human brains.</p>
<p>Fungi are present everywhere in our environment: in the air, in the soil, in decaying plant material, on our skin, and even in the gut as part of our natural flora.</p>
<p>Microscopic, disease-causing fungi can invade various parts of the body, leading to a range of symptoms and health problems. In fact, fungal infections contribute to <a href="https://doi.org/10.3390%2Fjof7050367">about 1.5 million deaths</a> every year. </p>
<p>I am a neurobiologist who has been studying fungal infections of the brain for 10 years. I was part of a team that recently <a href="https://doi.org/10.1111/pim.12953">published a review</a> discussing the emergence, and re-emergence, of fungal infections in Africa, especially in sub-Saharan Africa. We conclude that Africa is suffering from a silent, but costly, epidemic of fungal infections. We found that the emergence of deadly fungal infections in the region is primarily driven by a high burden of HIV infections, lack of access to quality healthcare, and unavailability of effective antifungal drugs.</p>
<h2>What are fungal infections?</h2>
<p>For the greater part of the history of humankind, fungal infections were never a threat to human health. This is mainly because most fungi cannot survive the warm human body temperature of 37°C. However, climate change and other environmental pressures <a href="https://doi.org/10.1016/j.joclim.2022.100156">have led</a> to the emergence of species of fungi that are capable of surviving at human body temperatures. </p>
<p>Even then, our immune systems are quite capable of fighting against fungal infections. For instance, our bodies can create localised acidic environments, limit micronutrient availability and release antimicrobial agents. </p>
<p>However, when the immune system is weakened, fungi are able to evade the body’s defences and avoid detection. They can generate bioactive agents which help them evade or adjust to the host immune response. Some adapt to survive in hostile, low-nutrient and low-oxygen environments. </p>
<p>Immunocompromised people are at risk of developing serious or life-threatening fungal diseases. Africa accounts for <a href="https://www.unaids.org/sites/default/files/media_asset/UNAIDS_FactSheet_en.pdf">67%</a> of the global burden of HIV, and opportunistic fungal diseases <a href="https://doi.org/10.1111/pim.12953">are on the rise</a>.</p>
<h2>Some examples</h2>
<p>One example of opportunistic fungal diseases is <a href="https://www.ncbi.nlm.nih.gov/books/NBK525986/">cryptococcal meningitis</a>, which emerged with the HIV pandemic in the late 1980s. Today, sub-Saharan Africa contributes about <a href="https://doi.org/10.1016/s1473-3099(17)30243-8">73%</a> of all global cases and deaths resulting from the disease. Cryptococcal meningitis is caused by the fungus <em>Cryptococcus neoformans</em>, which is found in soil and bird droppings. Infection by the fungus occurs when someone inhales fungal spores. It first leads to the development of a lung infection and later a fatal brain infection. Cryptococcal meningitis is a leading cause of adult meningitis in sub-Saharan Africa and it’s associated with <a href="https://doi.org/10.1016/S1473-3099(22)00499-6">almost 20%</a> of all AIDS-related deaths. </p>
<p>Effective treatments for cryptococcal meningitis are unaffordable and inaccessible for most affected people. Costs <a href="https://doi.org/10.1093/cid/ciy971">range between</a> US$1,400 and US$2,500 per patient for a full two-week antifungal treatment course. </p>
<p>The development of cheaper drugs has been hindered by a limited understanding of how the fungus causes such extreme damage in the brain. </p>
<p>Another example of an HIV-related opportunistic fungal disease is pneumocystis jirovecii pneumonia. It’s caused by a ubiquitous, airborne fungus <em>Pneumocystis jirovecii</em>, which is passed on from person to person. Pneumocystis hardly causes trouble in people with healthy immune systems, but they act as reservoirs and pass the infection to those with poor immune systems, who may develop serious symptoms including fever, a dry cough and trouble with breathing. Pneumocystis jirovecii pneumonia occurs in <a href="https://doi.org/10.1186/s12879-016-1809-3">15%-20%</a> of HIV patients who present with respiratory problems. </p>
<p>The diagnosis of pneumocystis jiroveci pneumonia is expensive and requires a well-equipped laboratory. In Africa’s poor urban and rural healthcare facilities this will be a challenge. The fungus, <em>P. jirovecii</em>, is also extremely difficult to culture, which limits diagnosis and research. </p>
<h2>Growing burden</h2>
<p>In our review, <a href="https://doi.org/10.1111/pim.12953">we found</a> various factors driving the emergence and reemergence of fungal threats. They include climate change, the spread of immunosuppressive diseases, medical advances such as organ transplants (the immune system is suppressed to minimise rejection), the use of immunosuppressants to manage inflammatory diseases, and the use of antibiotics. </p>
<p>While these factors are not unique to Africa, the burden of fungal diseases and the number of people who succumb to them is much greater. </p>
<p>The COVID pandemic seems to have made the global fungal burden worse. For instance, <a href="https://doi.org/10.1016/j.gr.2021.12.016">recent studies</a> have <a href="https://doi.org/10.4103%2Fijd.ijd_17_22">shown</a> that people who were infected with COVID and have recovered are vulnerable to infection with a fungus called mucormycosis, also known as the black fungus. COVID-induced lung damage, high blood sugar, and the steroids often used to treat it are all predisposing factors to black fungus infection. With a reduced capacity to clear fungal spores and a reduced immune response, thanks to the steroids, the fungus can gain entry and infect the sinuses and facial bones, eventually moving to the brain. </p>
<h2>But don’t we have antifungal drugs?</h2>
<p>Most of the population affected by fungal infections live in rural or poor urban settlements. </p>
<p>With poorly funded and overburdened healthcare systems, many African countries are not well prepared to deal with fungal infections. Additionally, some of the WHO-recommended antifungal drugs – such as flucytosine – are <a href="https://gaffi.org/antifungal-drug-maps/">unavailable</a> in most African countries. Ineffective and even rather toxic drugs are sometimes used instead. </p>
<p>The emergence of drug-resistant fungal strains is also a growing threat. Of great concern is the rise in multi-drug resistant Candida species, <a href="https://doi.org/10.1007/s11908-019-0702-9">azole-resistant Aspergillus</a> species and clinically resistant <a href="https://doi.org/10.1007/978-1-60327-595-8_20">Cryptococcus</a>. </p>
<h2>Management strategies</h2>
<p>Fungal threats are adding pressure to overburdened health systems with a limited arsenal of treatment options. </p>
<p>Healthcare professionals, scientific researchers, policymakers and governments must address the gaps in the diagnosis and management of fungal infections. This will help to improve capacity to deal with them.</p><img src="https://counter.theconversation.com/content/207836/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rachael Dangarembizi is a scientific researcher in the field of neuroscience and medical mycology and her research is funded by several funding bodies including the Gabriel Foundation and the UK Medical Research Council. </span></em></p>Africa is suffering from a silent, but costly, epidemic of fungal infections.Rachael Dangarembizi, Neuroinfections Researcher, Neuroscience Institute, University of Cape TownLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2069322023-06-04T11:19:08Z2023-06-04T11:19:08ZRemoving antimicrobial resistance from the WHO’s ‘pandemic treaty’ will leave humanity extremely vulnerable to future pandemics<figure><img src="https://images.theconversation.com/files/529846/original/file-20230602-27-nnu80l.png?ixlib=rb-1.1.0&rect=17%2C80%2C1680%2C1219&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Antimicrobial resistance is now a leading cause of death worldwide due to drug-resistant infections, including drug-resistant strains of tuberculosis, pneumonia and Staph infections like the methicillin-resistant Staphylococcus aureus shown here.</span> <span class="attribution"><span class="source">(NIAID, cropped from original)</span>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><iframe style="width: 100%; height: 100px; border: none; position: relative; z-index: 1;" allowtransparency="" allow="clipboard-read; clipboard-write" src="https://narrations.ad-auris.com/widget/the-conversation-canada/removing-antimicrobial-resistance-from-the-who-s--pandemic-treaty--will-leave-humanity-extremely-vulnerable-to-future-pandemics" width="100%" height="400"></iframe>
<p>In late May, the latest version of the draft Pandemic Instrument, also referred to as the “pandemic treaty,” was shared with Member States at the <a href="https://www.who.int/about/governance/world-health-assembly">World Health Assembly</a>. The text was made available online via <a href="https://healthpolicy-watch.news/wp-content/uploads/2023/05/DRAFT_INB_Bureau-text_22-May.pdf">Health Policy Watch</a> and it quickly became apparent that all mentions of addressing antimicrobial resistance in the Pandemic Instrument were at risk of removal.</p>
<p>Work on the Pandemic Instrument began in December 2021 after the World Health Assembly agreed to a global process to draft and negotiate an international instrument — under the Constitution of the World Health Organization (WHO) — to protect nations and communities from future pandemic emergencies.</p>
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Read more:
<a href="https://theconversation.com/drug-resistant-superbugs-a-global-threat-intensified-by-the-fight-against-coronavirus-135790">Drug-resistant superbugs: A global threat intensified by the fight against coronavirus</a>
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<p>Since the beginning of negotiations on the Pandemic Instrument, there have been calls from civil society and leading experts, including the <a href="https://www.amrleaders.org/docs/librariesprovider20/default-document-library/amr-as-substantive-element-of-the-international-instument-of-pandemic-prevention-preparedness-and-response.pdf?sfvrsn=300292c8_5&download=true">Global Leaders Group on Antimicrobial Resistance</a>, to include the so-called “silent” pandemic of antimicrobial resistance in the instrument.</p>
<p>Just three years after the onset of a global pandemic, it is understandable why Member States negotiating the Pandemic Instrument have focused on preventing pandemics that resemble COVID-19. But not all pandemics in the past have been caused by viruses and not all pandemics in the future will be caused by viruses. Devastating past pandemics of bacterial diseases have included <a href="https://www.who.int/news-room/fact-sheets/detail/plague">plague</a> and <a href="https://www.who.int/news-room/fact-sheets/detail/cholera">cholera</a>. The next pandemic could be caused by bacteria or other microbes.</p>
<h2>Antimicrobial resistance</h2>
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<img alt="Yellow particles on purple spikes" src="https://images.theconversation.com/files/529862/original/file-20230602-19-rvxpbm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/529862/original/file-20230602-19-rvxpbm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/529862/original/file-20230602-19-rvxpbm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/529862/original/file-20230602-19-rvxpbm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/529862/original/file-20230602-19-rvxpbm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/529862/original/file-20230602-19-rvxpbm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/529862/original/file-20230602-19-rvxpbm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Microscopic view of Yersinia pestis, the bacteria that cause bubonic plague, on a flea. Plague is an example of previous devastating pandemics of bacterial disease.</span>
<span class="attribution"><span class="source">(NIAID)</span>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>Antimicrobial resistance (AMR) is the process by which infections caused by microbes become resistant to the medicines developed to treat them. Microbes include bacteria, fungi, viruses and parasites. Bacterial infections alone cause <a href="https://www.tropicalmedicine.ox.ac.uk/gram/news/bacterial-infections-linked-to-one-in-eight-global-deaths-according-to-gram-study">one in eight deaths</a> globally.</p>
<p>AMR is fueling the rise of drug-resistant infections, including <a href="https://www.cdc.gov/tb/publications/factsheets/drtb/xdrtb.htm">drug-resistant tuberculosis</a>, <a href="https://www.cdc.gov/drugresistance/pdf/threats-report/strep-pneumoniae-508.pdf">drug-resistant pneumonia</a> and drug-resistant Staph infections such as <a href="https://www.cdc.gov/mrsa/index.html">methicillin-resistant Staphylococcus aureus</a> (MRSA). These infections are killing and debilitating millions of people annually, and <a href="https://doi.org/10.1016/S0140-6736(21)02724-0">AMR is now a leading cause of death worldwide</a>. </p>
<p>Without knowing what the next pandemic will be, the “pandemic treaty” must plan, prepare and develop effective tools to respond to a wider range of pandemic threats, not solely viruses.</p>
<p>Even if the world faces another viral pandemic, <a href="https://theconversation.com/when-covid-19-or-flu-viruses-kill-they-often-have-an-accomplice-bacterial-infections-187056">secondary bacterial infections</a> will be a serious issue. During the COVID-19 pandemic for instance, large percentages of those hospitalized with COVID-19 required treatment for secondary bacterial infections. </p>
<p>New research from Northwestern University suggests that many of the deaths among hospitalized COVID-19 patients <a href="https://news.feinberg.northwestern.edu/2023/05/05/secondary-bacterial-pneumonia-drove-many-covid-19-deaths/">were associated with pneumonia — a secondary bacterial infection that must be treated with antibiotics</a>. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/529852/original/file-20230602-29-ejrjyi.gif?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="An illustrative diagram that shows the difference between a drug resistant bacteria and a non-resistant bacteria." src="https://images.theconversation.com/files/529852/original/file-20230602-29-ejrjyi.gif?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/529852/original/file-20230602-29-ejrjyi.gif?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=558&fit=crop&dpr=1 600w, https://images.theconversation.com/files/529852/original/file-20230602-29-ejrjyi.gif?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=558&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/529852/original/file-20230602-29-ejrjyi.gif?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=558&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/529852/original/file-20230602-29-ejrjyi.gif?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=701&fit=crop&dpr=1 754w, https://images.theconversation.com/files/529852/original/file-20230602-29-ejrjyi.gif?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=701&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/529852/original/file-20230602-29-ejrjyi.gif?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=701&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Antimicrobial resistance means infections that were once treatable are much more difficult to treat.</span>
<span class="attribution"><span class="source">(NIAID)</span>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>Treating these bacterial infections requires effective antibiotics, and with AMR increasing, <a href="https://www.who.int/news-room/fact-sheets/detail/antimicrobial-resistance">effective antibiotics are becoming a scarce resource</a>. Essentially, safeguarding the remaining effective antibiotics we have is critical to responding to any pandemic.</p>
<p>That’s why the potential removal of measures that would help mitigate AMR and better safeguard antimicrobial effectiveness is so concerning. Sections of the text which may be removed include measures to prevent infections (caused by bacteria, viruses and other microbes), such as:</p>
<ul>
<li> better access to safe water, sanitation and hygiene; </li>
<li> higher standards of infection prevention and control; </li>
<li> integrated surveillance of infectious disease threats from human, animals and the environment; and </li>
<li> strengthening <a href="https://www.cdc.gov/antibiotic-use/core-elements/index.html">antimicrobial stewardship</a> efforts to optimize how antimicrobial drugs are used and prevent the development of AMR.</li>
</ul>
<p>The exclusion of these measures would hinder efforts to protect people from future pandemics, and appears to be part of a <a href="https://www.nature.com/articles/d41586-023-01805-4">broader shift to water-down the language in the Pandemic Instrument</a>, making it easier for countries to opt-out of taking recommended actions to prevent future pandemics. </p>
<h2>Making the ‘pandemic treaty’ more robust</h2>
<p>Measures to address AMR could be easily included and addressed in the “pandemic treaty.”</p>
<p>In September 2022, I was part of a group of civil society and research organizations that specialize in mitigating AMR who were invited the WHO’s <a href="https://inb.who.int/">Intergovernmental Negotiating Body</a> (INB) to provide an <a href="https://amrpolicy.org/resources/recommendations-to-the-intergovernmental-negotiating-body-inb-concerning-amr-the-pandemic-instrument/">analysis on how AMR should be addressed</a>, within the then-draft text. </p>
<p>They outlined that including bacterial pathogens in the definition of “pandemics” was critical. They also identified specific provisions that should be tweaked to track and address both viral and bacterial threats. These included AMR and recommended harmonizing national AMR stewardship rules.</p>
<p>In March 2023, I joined other leading academic researchers and experts from various fields in publishing a special edition of the <a href="https://www.cambridge.org/core/journals/journal-of-law-medicine-and-ethics/issue/DC40B54126C7B273BD62EBEED9641D2A"><em>Journal of Medicine, Law and Ethics</em>,</a> outlining why the Pandemic Instrument must address AMR. </p>
<p>The researchers of this special issue argued that the Pandemic Instrument was overly focused on viral threats and ignored AMR and bacterial threats, including the need to manage antibiotics as a common-pool resource and revitalize research and development of novel antimicrobial drugs. </p>
<h2>Next steps</h2>
<p>While <a href="https://apps.who.int/gb/inb/pdf_files/inb4/A_INB4_3-en.pdf">earlier drafts of the Pandemic Instrument</a> drew on guidance from AMR policy researchers and civil society organizations, after the first round of closed-door negotiations by Member States, all of these insertions, are now at risk for removal.</p>
<p>The Pandemic Instrument is the best option to mitigate AMR and safeguard lifesaving antimicrobials to treat secondary infections in pandemics. AMR exceeds the capacity of any single country or sector to solve. Global political action is needed to ensure the international community works together to collectively mitigate AMR and support the conservation, development and equitable distribution of safe and effective antimicrobials.</p>
<p>By missing this opportunity to address AMR and safeguard antimicrobials in the Pandemic Instrument, we severely undermine the broader goals of the instrument: to protect nations and communities from future pandemic emergencies.</p>
<p>It is important going forward that Member States recognize the core infrastructural role that antimicrobials play in pandemic response and strengthen, rather than weaken, measures meant to safeguard antimicrobials. </p>
<p>Antimicrobials are an essential resource for responding to pandemic emergencies that must be protected. If governments are serious about pandemic preparedness, they must support bold measures to conserve the effectiveness of antimicrobials within the Pandemic Instrument.</p><img src="https://counter.theconversation.com/content/206932/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Susan Rogers Van Katwyk is a member of the WHO Collaborating Centre on Global Governance of Antimicrobial Resistance at York University. She receives funding from the Wellcome Trust and the Social Sciences and Humanities Research Council of Canada. </span></em></p>Drug-resistant microbes are a serious threat for future pandemics, but the new draft of the WHO’s international pandemic agreement may not include provisions for antimicrobial resistance.Susan Rogers Van Katwyk, Adjunct Professor, School of Global Health and Managing Director, AMR Policy Accelerator, York University, CanadaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2025942023-04-12T12:09:29Z2023-04-12T12:09:29ZHuman metapneumovirus, or HMPV, is filling ICUs this spring – a pediatric infectious disease specialist explains this little-known virus<figure><img src="https://images.theconversation.com/files/520067/original/file-20230410-5874-jymbdf.jpg?ixlib=rb-1.1.0&rect=34%2C22%2C7634%2C4207&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Human metapneumovirus, or HMPV, peaks in North America from February to May, just on the heels of flu season.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/doctor-visiting-young-mother-at-home-for-routine-royalty-free-image/1471832871?phrase=children%20lung%20infection&adppopup=true">martin-dm/E+ via Getty Images</a></span></figcaption></figure><p>In the year 2000, Dutch scientists went on a mission of exploration – not to discover lands or riches, but to identify unknown causes of acute respiratory infections. </p>
<p>These illnesses, from the common cold to pneumonia, have been a plague on mankind throughout history. Most are caused by viruses, so if you’ve ever been told “you probably have a virus” by a clinician, they were likely correct. However, respiratory illnesses can be much more severe than simple colds.</p>
<p>Respiratory infections are the <a href="https://doi.org/10.1016/S0140-6736(12)60560-1">leading cause of death in children under 5 globally</a> and a major reason for hospitalization of children in developed countries. They are also a major cause of disease and death among people at high risk for severe disease, such as premature infants, older adults and those with underlying conditions. </p>
<p>However, meticulous research studies by many groups over decades had failed to identify a virus or bacteria in every person with an acute respiratory illness. Did this failure to detect a microbe result from tests that weren’t good enough, or viruses that doctors and scientists didn’t know about? The answer was partly the first; modern molecular tests are much better, so doctors find more known viruses. </p>
<p>But the Dutch group discovered a new virus, <a href="https://doi.org/10.1038/89098">human metapneumovirus</a>, abbreviated HMPV or MPV, which turns out to be a leading cause of respiratory infections. HMPV often presents like other common respiratory viruses, with congestion, cough and fever.</p>
<p>As a <a href="https://www.pediatrics.pitt.edu/people/john-v-williams-md">pediatric infectious disease specialist and virologist</a>, I have led my team in <a href="https://scholar.google.com/citations?user=Bar0h_8AAAAJ&hl=en">HMPV research for over 20 years</a>, and I’ve personally cared for many children with this infection. I’ve received emails from colleagues, clinicians and parents all over the country and the world with questions about severe and tragically fatal cases. </p>
<p>The U.S. saw a <a href="https://www.cdc.gov/surveillance/nrevss/hmpv/natl-trend.html">spike in HMPV detections</a> during the first few months of 2023. This trend is similar to the <a href="https://theconversation.com/rsv-treatments-for-young-children-are-lacking-but-the-record-2022-cold-and-flu-season-highlights-the-urgency-for-vaccines-and-other-preventive-strategies-195700">higher-than-normal case rates</a> of <a href="https://www.cdc.gov/surveillance/nrevss/rsv/natl-trend.html">respiratory syncytial virus, or RSV</a>, and influenza in the fall of 2022 and winter of 2023, likely related to decreased population immunity after two years of wearing face masks and social distancing. </p>
<p>Still, I find that many people even in health care are unfamiliar with this virus.</p>
<p><iframe id="eIbPJ" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/eIbPJ/2/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<h2>Origins of human metapneumovirus</h2>
<p>The human metapneumovirus was isolated from people with acute respiratory infection and sequenced in 2001 using a combination of specialized culture and molecular techniques.</p>
<p>It is related to RSV, which is the <a href="https://doi.org/10.1136/thoraxjnl-2018-212212">leading cause of serious respiratory infection in children</a> and a major problem in adults. Both viruses are in the same large group with measles, mumps and parainfluenza viruses, all of which are <a href="https://doi.org/10.1128/CMR.00015-11">leading causes of childhood disease</a>. </p>
<p>However, abundant data shows that HMPV is distinct from its cousin RSV in many ways. First, the order of genes in its <a href="https://doi.org/10.1006/viro.2001.1355">genome is quite different</a>. In addition, HMPV is missing two genes that RSV uses to overcome the immune response that would normally target it; yet HMPV has its own ways to <a href="https://doi.org/10.3390/v10090505">block immunity</a>.</p>
<p>Third, genetic analysis by several different groups shows that the <a href="https://doi.org/10.1099/vir.0.2008/006957-0">closest recent ancestor of HMPV</a> is a bird virus, <a href="https://doi.org/10.1099/vir.0.19043-0">avian metapneumovirus</a>. This is an agricultural pathogen of chickens and turkeys. Evolutionary and genetic analysis suggests that the human virus diverged from the bird virus <a href="https://doi.org/10.1371/journal.pone.0152962">several hundred years ago</a>. This is an example of a zoonosis: an <a href="https://theconversation.com/what-is-spillover-bird-flu-outbreak-underscores-need-for-early-detection-to-prevent-the-next-big-pandemic-200494">animal virus that jumps to humans</a>. In this case, HMPV became established as a permanent pathogen of humans. </p>
<p>Understanding how HMPV successfully made the leap might help predict which other animal viruses could be capable of transforming into primary human pathogens. The <a href="https://theconversation.com/as-bird-flu-continues-to-spread-in-the-us-and-worldwide-whats-the-risk-that-it-could-start-a-human-pandemic-4-questions-answered-200204">recent H5N1 bird flu outbreak</a> – which has been transmitted to humans only to a limited extent – illustrates this risk.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/sbkeFJOQhO4?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">HMPV is a common respiratory illness during the spring months that can cause a narrowing of the airways, a barking cough and other nasty symptoms, particularly in children and older adults.</span></figcaption>
</figure>
<h2>HMPV in children</h2>
<p>Despite its being recognized only two decades ago, many studies have confirmed that HMPV is a major cause of respiratory infection in humans. Initial research groups focused on children and quickly discovered that HMPV caused respiratory infections in children worldwide, including <a href="https://doi.org/10.3201/eid0906.030017">Canada</a>, <a href="https://doi.org/10.3201/eid1708.051239">Australia</a>, <a href="https://doi.org/10.1128/JCM.42.1.126-132.2004">Japan</a>, <a href="https://doi.org/10.3201/eid0906.030009">Hong Kong</a>, <a href="https://doi.org/10.1097/INF.0b013e3180621192">South Africa</a> and <a href="https://doi.org/10.1086/383350">Argentina</a>. </p>
<p>Indeed, HMPV is a common cause of acute respiratory disease in children in <a href="https://doi.org/10.1016/S2214-109X(20)30393-4">every country</a> examined, and most children get the infection <a href="https://doi.org/10.1128/JCM.43.3.1213-1219.2005">for the first time by age 5</a>. One study using samples collected over 25 years in the U.S. found that HMPV was the <a href="https://doi.org/10.1056/NEJMoa025472">second most common</a> cause of lung infection in children after RSV. Other studies of multiple children’s hospitals in U.S. cities found that HMPV was the second most common cause of respiratory infections, leading to <a href="https://doi.org/10.1056/NEJMoa1204630">hospitalization</a> and <a href="https://doi.org/10.1056/NEJMoa1405870">pneumonia</a>.</p>
<p>Children with underlying risk factors, such as <a href="https://doi.org/10.2147/RRN.S76270">those born prematurely</a> and those with conditions like <a href="https://doi.org/10.1097/INF.0000000000002038">asthma</a>,
or those who have compromised immune systems, such as organ transplant recipients or children being treated for cancer, are at <a href="https://doi.org/10.1093/jpids/piu100">higher risk for severe HMPV</a>. Most children who become hospitalized with HMPV are otherwise healthy before they acquire it, yet <a href="https://doi.org/10.1093/jpids/piv027">many require intensive care</a> from the illness. </p>
<h2>Not just for kids</h2>
<p>HMPV is also a common cause of <a href="https://doi.org/10.1097/INF.0b013e3181684dac">serious lung infections among adults</a>. This is especially true in adults over 65 years old, or those with underlying conditions. A New York study over four winters found that HMPV was as common in hospitalized older adults as RSV or influenza, <a href="https://doi.org/10.1001/archinte.168.22.2489">with similar rates of ICU care and death</a>. </p>
<p>Studies over three winters in Nashville of adults over age 50 detected <a href="https://doi.org/10.1093/infdis/jis309">rates of HMPV hospitalization</a> and <a href="https://doi.org/10.1111/irv.12234">emergency department visits</a> that were similar to RSV and influenza. HMPV and RSV were more common than the flu in people 65 and older, presumably because many were vaccinated against the flu.</p>
<p>Another national study of adults hospitalized for pneumonia showed that <a href="https://doi.org/10.1056/NEJMoa1500245">HMPV was as common as RSV</a>, and nearly as common as influenza. As in children, HMPV is a particular problem for adults with chronic conditions such as <a href="https://doi.org/10.1086/444392">asthma</a>, <a href="https://doi.org/10.1002/cncr.30599">cancer</a> or <a href="https://doi.org/10.1016/j.jinf.2005.11.010">chronic obstructive pulmonary disease, also called COPD</a>.</p>
<p>Similar to the dire effects of flu and <a href="https://www.politico.com/news/2023/02/15/pandemic-nursing-home-covid-00082913">COVID-19 in nursing homes</a>, HMPV has also caused numerous outbreaks among vulnerable older adults in <a href="https://doi.org/10.3201/eid2502.181298">long-term care facilities</a>.</p>
<h2>Why HMPV is still so underrecognized</h2>
<p>Despite being a common cause of serious respiratory disease, HMPV remains underdiagnosed by clinicians and little recognized by the general population. Most people with an acute respiratory illness don’t get any testing, and if they do, only complex molecular testing can detect HMPV. But this testing is usually done only for hospitalized patients under select circumstances. </p>
<p>People tend to believe what they see, and therefore even health care professionals are most aware of diseases they test for frequently. But HMPV circulates predictably every year, and in North America the <a href="https://doi.org/10.1056/NEJMoa025472">peak is typically February through May</a>. So if you’ve had a cold recently this winter or spring, <a href="https://www.cdc.gov/surveillance/nrevss/hmpv/natl-trend.html">HMPV was a likely culprit</a>. Children’s hospitals around the country are seeing an <a href="https://time.com/6264539/respiratory-virus-not-covid-spring-2023/">increased number of cases</a>, including many in the ICU. Based on past research, this is almost certainly happening in adults too – it’s just that usually only those patients with severe illness are tested for HMPV. </p>
<h2>A dearth of treatments</h2>
<p>Right now, there are no specific antiviral drugs to treat HMPV as there are for flu and COVID-19. As with the many other respiratory viruses that cause colds, most infected people will do just fine with rest and fluids. </p>
<p>But some may develop trouble breathing and need to seek medical attention. Children or adults with serious underlying conditions should be especially careful, and just as with COVID-19, using hand sanitizer and washing hands can <a href="https://theconversation.com/yes-we-should-be-keeping-the-healthier-hand-washing-habits-we-developed-at-the-start-of-the-pandemic-169892">reduce transmission</a>.</p>
<p>Preventive vaccines and antibodies for HMPV are <a href="https://doi.org/10.1128/CVI.00230-15">in development</a> but are still a way off. So, for the moment, wear a mask if you’re sick and avoid others who are sick. You may dodge a repeat engagement with this virus that you’ve had but hadn’t heard of.</p><img src="https://counter.theconversation.com/content/202594/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>John V. Williams receives funding from the NIH and CDC. He previously served on a scientific advisory board for Quidel and an independent data monitoring committee for GlaxoSmithKline, neither related to the subject of the article. </span></em></p>Similar to the patterns seen with COVID-19, flu and RSV, HMPV is making a comeback after years of being repressed by people wearing masks and social distancing.John V. Williams, Professor of Pediatrics, Microbiology and Molecular Genetics, University of PittsburghLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1925972022-10-30T12:21:24Z2022-10-30T12:21:24ZHow COVID-19 damages lungs: The virus attacks mitochondria, continuing an ancient battle that began in the primordial soup<figure><img src="https://images.theconversation.com/files/492284/original/file-20221028-37683-z5drng.jpeg?ixlib=rb-1.1.0&rect=18%2C9%2C2011%2C1578&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Red mitochondria in airway cells become coated with green SARS-COV-2 proteins after viral infection: Researchers discovered that the virus that causes COVID-19 damages lungs by attacking mitochondria.</span> <span class="attribution"><span class="source">(Stephen Archer)</span>, <span class="license">Author provided</span></span></figcaption></figure><iframe style="width: 100%; height: 100px; border: none; position: relative; z-index: 1;" allowtransparency="" allow="clipboard-read; clipboard-write" src="https://narrations.ad-auris.com/widget/the-conversation-canada/how-covid-19-damages-lungs--the-virus-attacks-mitochondria--continuing-an-ancient-battle-that-began-in-the-primordial-soup" width="100%" height="400"></iframe>
<p>Viruses and bacteria have a very long history. Because viruses can’t reproduce without a host, they’ve been attacking bacteria for millions of years. Some of those <a href="https://doi.org/10.1016/0022-5193(67)90079-3">bacteria eventually became mitochondria</a>, synergistically adapting to life within eukaryotic cells (cells that have a nucleus containing chromosomes). </p>
<p>Ultimately, mitochondria became the powerhouses within all human cells. </p>
<p>Fast-forward to the rise of novel coronaviruses like SARS-CoV-2, and the <a href="https://coronavirus.jhu.edu/map.html">global spread of COVID-19</a>. <a href="http://doi.org/10.1056/NEJMoa2002032">Approximately five per cent of people infected with SARS-CoV-2 suffer respiratory failure (low blood oxygen)</a> requiring hospitalization. <a href="https://resources-covid19canada.hub.arcgis.com">In Canada about 1.1 per cent of infected patients (almost 46,000 people) have died</a>. </p>
<p>This is the story of how a team, assembled during the pandemic, recognized the mechanism by which these viruses were causing lung injury and lowering oxygen levels in patients: It is a throwback to the primitive war between viruses and bacteria — more specifically, between this novel virus and the evolutionary offspring of bacteria, our mitochondria.</p>
<p>SARS-CoV-2 is the third novel coronavirus to cause human outbreaks in the 21st century, following <a href="https://www.who.int/health-topics/severe-acute-respiratory-syndrome#tab=tab_1">SARS-CoV in 2003</a> and <a href="https://www.who.int/health-topics/middle-east-respiratory-syndrome-coronavirus-mers#tab=tab_1">MERS-CoV in 2012</a>. We need to better understand how coronaviruses cause lung injury to prepare for the next pandemic.</p>
<h2>How COVID-19 affects lungs</h2>
<p>People with severe COVID-19 pneumonia often arrive at the hospital with unusually low oxygen levels. They have two unusual features distinct from patients with other types of pneumonia:</p>
<ul>
<li>First, they suffer widespread injury to their lower airway (the alveoli, which is where oxygen is taken up). </li>
<li>Second, they shunt blood to unventilated areas of the lung, which is called ventilation-perfusion mismatch. This means blood is going to parts of the lung where it won’t get sufficiently oxygenated.</li>
</ul>
<p>Together, these abnormalities lower blood oxygen. However, the cause of these abnormalities was unknown. In 2020, our team of 20 researchers at three Canadian universities set about to unravel this mystery. <a href="https://doi.org/10.1161/circulationaha.120.047915">We proposed that SARS-CoV-2 worsened COVID-19 pneumonia by targeting mitochondria in airway epithelial cells (the cells that line the airways) and pulmonary artery smooth muscle cells</a>. </p>
<p>We already knew that mitochondria are not just the powerhouse of the cell, but also its main consumers and <a href="https://doi.org/10.1056/nejmra050002">sensors of oxygen</a>. Mitochondria control the process of programmed cell death (called apoptosis), and they regulate the distribution of blood flow in the lung by a mechanism called hypoxic pulmonary vasoconstriction. </p>
<p>This mechanism has an important function. It directs blood away from areas of pneumonia to better ventilated lobes of the lung, which optimizes oxygen-uptake. By damaging the mitochondria in the smooth muscle cells of the pulmonary artery, the virus allows blood flow to continue into areas of pneumonia, which also lowers oxygen levels. </p>
<p>It appeared plausible that SARS-CoV-2 was damaging mitochondria. The results of this damage — an increase in apoptosis in airway epithelial cells, and loss of hypoxic pulmonary vasoconstriction — were making lung injury and hypoxemia (low blood oxygen) worse. </p>
<p>Our discovery, <a href="https://doi.org/10.1016/j.redox.2022.102508">published in <em>Redox Biology</em></a>, explains how SARS-CoV-2, the coronavirus that causes COVID-19 pneumonia, reduces blood oxygen levels. </p>
<p>We show that SARS-CoV-2 kills airway epithelial cells by damaging their mitochondria. This results in fluid accumulation in the lower airways, interfering with oxygen uptake. We also show that SARS-CoV-2 damages mitochondria in the pulmonary artery smooth muscle cells, which inhibits hypoxic pulmonary vasoconstriction and lowers oxygen levels. </p>
<h2>Attacking mitochondria</h2>
<p>Coronaviruses damage mitochondria in two ways: by regulating mitochondria-related gene expression, and by direct protein-protein interactions. When SARS-CoV-2 infects a cell, it hijacks the host’s protein synthesis machinery to make new virus copies. However, these <a href="http://doi.org/10.1038/s41586-020-2286-9">viral proteins also target host proteins, causing them to malfunction</a>. We soon learned that many of the host cellular proteins targeted by SARS-CoV-2 were in the mitochondria. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/490891/original/file-20221020-25-rozyzy.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Cartoon with three panels: a coronavirus shooting arrows at mitochondria and spitting them in two; lungs and contrasting healthy and damaged lung cells; an oxygen meter with the needle in the red zone; and a human silhouette showing airways" src="https://images.theconversation.com/files/490891/original/file-20221020-25-rozyzy.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/490891/original/file-20221020-25-rozyzy.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=384&fit=crop&dpr=1 600w, https://images.theconversation.com/files/490891/original/file-20221020-25-rozyzy.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=384&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/490891/original/file-20221020-25-rozyzy.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=384&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/490891/original/file-20221020-25-rozyzy.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=483&fit=crop&dpr=1 754w, https://images.theconversation.com/files/490891/original/file-20221020-25-rozyzy.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=483&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/490891/original/file-20221020-25-rozyzy.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=483&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">How SARS-CoV-2 targets mitochondria to kill lung cells and prevent oxygen sensing.</span>
<span class="attribution"><span class="source">(drawn by Brooke Ring)</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>Viral proteins fragment the mitochondria, depriving cells of energy and interfering with their oxygen-sensing capability. The viral attack on mitochondria starts within hours of infection, turning on genes that break the mitochondria into pieces (called mitochondrial fission) and make their membranes leaky (an early step in apoptosis called mitochondrial depolarization). </p>
<p>In our experiments, we didn’t need to use a replicating virus to damage the mitochondria — simply introducing single SARS-CoV-2 proteins was enough to cause these adverse effects. This mitochondrial damage also occurred with other coronaviruses that we studied. </p>
<p>We are now developing drugs that may one day counteract COVID-19 by blocking mitochondrial fission and apoptosis, or by preserving hypoxic pulmonary vasoconstriction. Our drug discovery efforts have already enabled us to identify <a href="https://doi.org/10.1096/fj.201901467r">a promising mitochondrial fission inhibitor, called Drpitor1a</a>. </p>
<p>Our team’s infectious diseases expert, Gerald Evans, notes that this discovery also has the potential to help us understand Long COVID. “The predominant features of that condition — fatigue and neurologic dysfunction — could be due to the lingering effects of mitochondrial damage caused by SARS-CoV-2 infection,” he explains.</p>
<h2>The ongoing evolutionary battle</h2>
<p>This research also has an interesting evolutionary angle. Considering that <a href="https://doi.org/10.1016/0022-5193(67)90079-3">mitochondria were once bacteria, before being adopted by cells back in the primordial soup</a>, our findings reveal an Alien versus Predator scenario in which viruses are attacking “bacteria.”</p>
<p>Bacteria are regularly attacked by viruses, called bacteriophages, that need a host to replicate in. The bacteria in turn fight back, using an ancient form of immune system called the CRISPR-cas system, that chops up the viruses’ genetic material. Humans have recently exploited this CRISPR-cas system for <a href="https://www.synthego.com/blog/gene-editing-nobel-prize">a Nobel Prize-winning gene editing discovery</a>. </p>
<p>The ongoing competition between bacteria and viruses is a very old one; and recall that our mitochondria were once bacteria. So perhaps it’s not surprising at all that SARS-CoV-2 attacks our mitochondria as part of the COVID-19 syndrome.</p>
<h2>Pandemic pivot</h2>
<p>The original team members on this project are heart and lung researchers with expertise in mitochondrial biology. In early 2020 we pivoted to apply that in another field — virology — in an effort to make a small contribution to the COVID-19 puzzle. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/492257/original/file-20221028-27-7vme8l.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A grid of photographs of 25 scientists, and the three collaborating institutions (Queen's University, the Vaccine and Infectious Disease Organization (VIDO) and University of Toronto)" src="https://images.theconversation.com/files/492257/original/file-20221028-27-7vme8l.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/492257/original/file-20221028-27-7vme8l.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=342&fit=crop&dpr=1 600w, https://images.theconversation.com/files/492257/original/file-20221028-27-7vme8l.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=342&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/492257/original/file-20221028-27-7vme8l.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=342&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/492257/original/file-20221028-27-7vme8l.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=429&fit=crop&dpr=1 754w, https://images.theconversation.com/files/492257/original/file-20221028-27-7vme8l.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=429&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/492257/original/file-20221028-27-7vme8l.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=429&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The COVID team: The face of research. The diverse team includes members who came to Canada from India, Iran, England, Brazil, Iraq, China and Taiwan to pursue research here.</span>
<span class="attribution"><span class="source">(Stephen Archer)</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p><a href="https://youtu.be/cJlAsFoTWLg">The diverse team we put together also brought expertise</a> in mitochondrial biology, cardiopulmonary physiology, SARS-CoV-2, <a href="https://www.phgfoundation.org/blog/what-is-transcriptomics">transcriptomics</a>, synthetic chemistry, molecular imaging and infectious diseases. </p>
<p>Our discovery owes a lot to our virology collaborators. Early in the pandemic, University of Toronto virologist Gary Levy offered us a mouse coronavirus (MHV-1) to work with, which we used to make a model of COVID-19 pneumonia. Che Colpitts, a virologist at Queen’s University, helped us study the mitochondrial injury caused by another human beta coronavirus, HCoV-OC43. </p>
<p>Finally, Arinjay Banerjee and his expert SARS-CoV-2 virology team at <a href="https://www.vido.org">Vaccine and Infectious Disease Organization (VIDO)</a> in Saskatoon performed key studies of human SARS-CoV-2 in airway epithelial cells. VIDO is one of the few Canadian centres equipped to handle the highly infectious SARS-CoV-2 virus. </p>
<p>Our team’s super-resolution microscopy expert, Jeff Mewburn, notes the specific challenges the team had to contend with.</p>
<p>“Having to follow numerous and extensive COVID-19 protocols, they were still able to exhibit incredible flexibility to retool and refocus our laboratory specifically on the study of coronavirus infection and its effects on cellular/mitochondrial functions, so very relevant to our global situation,” he said.</p>
<p>Our discovery will hopefully be translated into new medicines to counter future pandemics.</p><img src="https://counter.theconversation.com/content/192597/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Stephen L Archer receives funding from the Canadian Institutes of Health Research for research on COVID-19. Dr Archer is convector on a patent for small molecule inhibitors of mitochondrial fission.</span></em></p>COVID-19 causes lung injury and lowers oxygen levels in patients because the SARS-CoV-2 virus attacks cells’ mitochondria. This attack is a throwback to a primitive war between viruses and bacteria.Stephen L Archer, Professor, Head of Department of Medicine, Queen's University, OntarioLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1904292022-09-29T20:05:08Z2022-09-29T20:05:08ZWhy has my cold dragged on so long? And how do I know when it’s morphed into something more serious?<figure><img src="https://images.theconversation.com/files/483890/original/file-20220912-7256-6grcdr.jpg?ixlib=rb-1.1.0&rect=0%2C9%2C6120%2C4076&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.pexels.com/photo/woman-lying-on-bed-while-blowing-her-nose-3807629/">Photo by Andrea Piacquadio/Pexels</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p>Common colds are caused by viruses. There are no effective cures, and antibiotics do not work on viruses, so treatment is targeted at managing the symptoms until your immune system has cleared the cold.</p>
<p>So why might someone go to a doctor at all for a cold?</p>
<p>Well, occasionally a cold might turn into something more serious requiring assessment and specific treatment, and a GP visit could be warranted. Or you may just want reassurance and advice.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/sore-throats-suck-do-throat-lozenges-help-at-all-184454">Sore throats suck. Do throat lozenges help at all?</a>
</strong>
</em>
</p>
<hr>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/483887/original/file-20220912-54657-jcnlj0.jpg?ixlib=rb-1.1.0&rect=0%2C50%2C6709%2C4416&q=45&auto=format&w=1000&fit=clip"><img alt="A woman blows her nose." src="https://images.theconversation.com/files/483887/original/file-20220912-54657-jcnlj0.jpg?ixlib=rb-1.1.0&rect=0%2C50%2C6709%2C4416&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/483887/original/file-20220912-54657-jcnlj0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/483887/original/file-20220912-54657-jcnlj0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/483887/original/file-20220912-54657-jcnlj0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/483887/original/file-20220912-54657-jcnlj0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/483887/original/file-20220912-54657-jcnlj0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/483887/original/file-20220912-54657-jcnlj0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Occasionally a cold might turn into something more serious requiring assessment and specific treatment.</span>
<span class="attribution"><a class="source" href="https://www.pexels.com/photo/woman-blowing-nose-7195040/">Photo by Karolina Grabowska/Pexels</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<h2>Don’t rush to the GP for something totally normal</h2>
<p>Problems arise when there too many unwarranted visits to GPs for cold symptoms.</p>
<p>Studies have shown <a href="https://www.annfammed.org/content/11/1/5">antibiotics</a> are <a href="https://onlinelibrary.wiley.com/doi/abs/10.5694/mja16.01042">still prescribed widely</a> for viral colds, even though they don’t help, and this contributes to antibiotic resistance. It hastens the arrival of an era when many antibiotics simply don’t work at all.</p>
<p>On average, children have <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7152362/">four to six colds</a> per year, while in adults the average is <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7152362/">two to three</a>.</p>
<p>Some people are more <a href="https://www.sciencedirect.com/science/article/abs/pii/S1530156705601189?via%3Dihub">prone</a> to colds, but we don’t know exactly why.</p>
<p>The usual cold persists about one week, although 25% last two weeks. In one <a href="https://journals.asm.org/doi/10.1128/jcm.35.11.2864-2868.1997">study</a> with 346 adults, the infection lasted 9.5 to 11 days. </p>
<p>Cold symptoms may last longer in younger children. One <a href="https://publications.aap.org/pediatrics/article-abstract/87/2/129/56810/Upper-Respiratory-Tract-Infections-in-Young?redirectedFrom=fulltext">study</a> showed an average duration of colds ranged from 6.6 to 9 days. But symptoms lasted more than 15 days in 6.5% of 1-3 year old children in home care, and 13.1% of 2-3 year old children in day care.</p>
<p>A cough tends to last longer than other symptoms, and often beyond the actual viral infection. The average <a href="https://www.annfammed.org/content/11/1/5">duration</a> of a cough is about 17.8 days.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/483889/original/file-20220912-54657-4uy5r1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A man coughs into his elbow." src="https://images.theconversation.com/files/483889/original/file-20220912-54657-4uy5r1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/483889/original/file-20220912-54657-4uy5r1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/483889/original/file-20220912-54657-4uy5r1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/483889/original/file-20220912-54657-4uy5r1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/483889/original/file-20220912-54657-4uy5r1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/483889/original/file-20220912-54657-4uy5r1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/483889/original/file-20220912-54657-4uy5r1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">A cough tends to last longer than other symptoms.</span>
<span class="attribution"><a class="source" href="https://www.pexels.com/photo/a-sick-man-covering-his-mouth-4031634/">Photo by Edward Jenner/Pexels</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<h2>Discoloured sputum, cough or snot</h2>
<p>Discoloured mucus in snot or cough is a common trigger for requesting antibiotics from a GP. But as we know, antibiotics are useless against a virus. They only work against bacterial infection. </p>
<p>In fact, thick or coloured nasal mucus secretion is common following colds. Only a tiny proportion <a href="https://europepmc.org/article/pmc/pmc7151789">involve</a> bacterial infection.</p>
<p>When it happens, this is termed <a href="https://www.nps.org.au/australian-prescriber/articles/treating-acute-sinusitis-3">acute rhinosinusitis</a>. But antibiotics are not recommended unless it lasts more than ten to 14 days and there are <a href="https://europepmc.org/article/pmc/pmc7151789">signs</a> of bacterial sinusitis infection, such as:</p>
<ul>
<li>symptoms worsening after improvement in the original cold</li>
<li>return of fever and</li>
<li>strong facial pain.</li>
</ul>
<p>A prolonged cough after colds is usually caused by an irritated throat or the clearing of sticky mucus coming down from the nose. The cough may sound moist (so wrongly called “chesty”) due to the phlegm, but only small amounts of phlegm are coughed up. </p>
<p>Yellow or green coloured mucus is often interpreted as a <a href="http://theconversation.com/health-check-what-you-need-to-know-about-mucus-and-phlegm-33192">sign</a> of bacterial infection.</p>
<p>But yellow or green sputum alone <a href="https://www.tandfonline.com/doi/full/10.1080/02813430902759663">does not</a> mean you have a serious bacterial infection. One study found being prescribed antibiotics under these circumstances <a href="https://erj.ersjournals.com/content/38/1/119">failed</a> to shorten recovery time. </p>
<p>Nasal saline sprays and washes can be used to rinse out the nose and sinuses and possibly <a href="https://dtb.bmj.com/content/57/4/56">shorten</a> rhinosinusitis and cough after colds.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/483891/original/file-20220912-68568-ej88qo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/483891/original/file-20220912-68568-ej88qo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/483891/original/file-20220912-68568-ej88qo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=429&fit=crop&dpr=1 600w, https://images.theconversation.com/files/483891/original/file-20220912-68568-ej88qo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=429&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/483891/original/file-20220912-68568-ej88qo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=429&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/483891/original/file-20220912-68568-ej88qo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=539&fit=crop&dpr=1 754w, https://images.theconversation.com/files/483891/original/file-20220912-68568-ej88qo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=539&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/483891/original/file-20220912-68568-ej88qo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=539&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">A cold can make you feel rubbish for quite a while.</span>
<span class="attribution"><a class="source" href="https://www.pexels.com/photo/apartment-bed-carpet-chair-269141/">Photo by Pixabay, via Pexels</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<h2>Could it just be hayfever, or another underlying issue?</h2>
<p>Hayfever or allergic rhinitis is a common cause for prolonged symptoms after a cold, especially cough and nasal congestion and maybe also sneezing. </p>
<p>The damage in the upper airways following a viral infection may allow airborne allergens to trigger hayfever. Self-medicating with antihistamines, nasal saline spray or intranasal steroids is worthwhile if <a href="https://theconversation.com/health-check-why-do-i-have-a-cough-and-what-can-i-do-about-it-119172">allergic rhinitis</a> is suspected. </p>
<p>There may be other reasons for persistence of cough, such as exacerbation of underlying asthma or chronic lung disease. If so, this may require a visit to your GP.</p>
<h2>What about bronchitis or pneumonia?</h2>
<p>Many people worry about developing a chest infection after a cold. </p>
<p>Acute bronchitis is a self-limiting infectious disease characterised by acute cough with or without sputum but without <a href="https://www.nhs.uk/conditions/pneumonia/">signs of pneumonia</a> (such as high temperatures and feeling breathless). Most acute bronchitis cases are caused by viruses. Antibiotics are often prescribed, but produce <a href="https://www.tandfonline.com/doi/full/10.1080/14787210.2016.1193435">no significant clinical improvement</a> compared with placebo, so are not recommended.</p>
<p>Pneumonia is a potentially serious secondary disease that <a href="https://pubmed.ncbi.nlm.nih.gov/28159155/">may follow</a> an episode of flu in a small number of cases, but is <a href="https://www.ncbi.nlm.nih.gov/books/NBK532961/">relatively rare</a> following a cold. Symptoms and signs of pneumonia feature heavily in the list of warning signs that signal the need for a medical assessment. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/486977/original/file-20220928-12-fzoana.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A man looks at his phone." src="https://images.theconversation.com/files/486977/original/file-20220928-12-fzoana.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/486977/original/file-20220928-12-fzoana.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/486977/original/file-20220928-12-fzoana.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/486977/original/file-20220928-12-fzoana.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/486977/original/file-20220928-12-fzoana.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/486977/original/file-20220928-12-fzoana.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/486977/original/file-20220928-12-fzoana.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Sometimes, contacting your GP is a good idea.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<h2>When should I seek medical help for a cough or a cold?</h2>
<p>Contact a GP if you experience:</p>
<ul>
<li>shortness of breath or trouble breathing</li>
<li>feeling faint or dizzy</li>
<li>chest pain</li>
<li>dehydration </li>
<li>fever or cough symptoms that improve but then return or worsen</li>
<li>worsening of chronic medical conditions such as asthma.</li>
</ul>
<p>This is not a complete list, but may guide you on what to expect and what to watch out for. </p>
<p>You might also contact your GP (perhaps for a telehealth consult) if you are finding your symptoms very unpleasant, or are concerned your condition is more serious or prolonged than expected. You might just need reassurance and education about self care options.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/forget-nose-spray-good-sex-clears-a-stuffy-nose-just-as-effectively-and-is-a-lot-more-fun-167901">Forget nose spray, good sex clears a stuffy nose just as effectively — and is a lot more fun</a>
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</em>
</p>
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<img src="https://counter.theconversation.com/content/190429/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>David King does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Problems arise when there are too many unwarranted visits to GPs for cold symptoms. Occasionally, though, a cold might turn into something that needs specific diagnosis and treatment.David King, Senior Lecturer in General Practice, The University of QueenslandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1857842022-07-07T13:32:58Z2022-07-07T13:32:58ZThere’s no cure for sickle cell disease, but spotting it early can improve treatment<figure><img src="https://images.theconversation.com/files/472526/original/file-20220705-16-nb4nkd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Ezume Images/Shutterstock</span></span></figcaption></figure><p><em>Most of the global cases of sickle cell disease are diagnosed in African countries. The Economist Intelligence Unit – the research and analysis division of the Economist media group – <a href="https://pages.eiu.com/rs/753-RIQ-438/images/EIU%20Healthcare%20-%20Sickle%20cell%20disease%20in%20Africa%20report%20V5%20%281%29.pdf">estimated</a> that in 2020 the total annual cost of treatment and impact on the economy of sickle cell disease across sub-Saharan Africa was US$9.1 billion. This was expected to rise to US$10.2 billion by 2030. The Conversation Africa’s Ina Skosana spoke to Yvonne Dei-Adomakoh, director of the Ghana Institute of Clinical Genetics (Adult Sickle Cell Clinic), and Head of the Department of Haematology, University of Ghana Medical School /Korle-Bu Teaching Hospital to find out more about this condition.</em></p>
<hr>
<h2>What is sickle cell disease?</h2>
<p>Sickle cell disease is a genetic disorder that causes misshapen red blood cells to clog blood vessels. The condition can cause extreme pain. People with sickle cell disease are at risk of life-threatening infections. These include pneumonia and meningitis. They are also at risk of other complications such as stroke or loss of vision. If left untreated, sickle cell disease can prove fatal. As a genetic condition, the disease is not preventable. But it can be managed with the proper treatment. Treatment is more effective if the disease is detected early in life. </p>
<p>The disease is a consequence of a gene mutation that granted a degree of protection against the threat of malaria. Research <a href="https://www.cell.com/ajhg/fulltext/S0002-9297(18)30048-X">suggests</a> the mutation originated in a single child in Africa roughly 7,300 years ago. It’s thought that the gene could limit the ability of the malaria parasite to infect host cells. The descendants of this child, with a greater resistance to malaria than those without the sickle cell trait, spread across the globe. Today, people with the gene are found in greater numbers in areas prone to malaria, such as sub-Saharan Africa.</p>
<p>When two individuals with the mutation pass copies of the gene to their child, the child will have sickle cell disease rather than sickle cell trait, and will not have the same resistance to malaria.</p>
<p>Those with the disorder are actually at <a href="https://bmcinfectdis.biomedcentral.com/articles/10.1186/s12879-019-4757-x">higher risk of severe illness</a> if admitted to hospital for malaria today.</p>
<h2>How big is sickle cell disease in Africa?</h2>
<p>An estimated 20 million people live with sickle cell disease globally. More than <a href="https://www.afro.who.int/news/rising-cases-sickle-cell-disease-prompts-calls-urgent-action">66%</a> of them are in sub-Saharan Africa. Around 300,000 children are born with sickle cell disease globally every year. Three out of four of these children are born in a <a href="https://www.afro.who.int/health-topics/sickle-cell-disease">geographic belt</a> from Senegal to Madagascar – translating to 1%-3% of children born in <a href="https://www.researchgate.net/figure/Map-of-the-distribution-of-the-S-gene-in-Africa-Note-The-map-is-based-on-representative_fig3_221717766">this belt</a>. Countries in Africa with the highest prevalence are Cameroon, Nigeria, the Democratic Republic of Congo and Ghana. </p>
<h2>What measures are in place to manage it?</h2>
<p>Just a few short <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3560868/">decades ago</a>, it was common for children with undiagnosed sickle cell disease to die from severe infections. But these cases are reducing with improvements in research and science. Newborn screening is preferable to testing following symptoms. </p>
<p>Early diagnosis, preventive care and active clinical management can prevent complications and death, and improve quality of life. If we know a child has sickle cell disease right from birth, we can put in place measures such as prophylaxis (screening for stroke or silent brain infarcts and starting disease modifying drugs such as hydroxyurea,annual assessment of organ function (liver and kidneys) and use antibiotics when required to ensure that severe infectious diseases do not occur.</p>
<p>Screening should be routine, because many children with sickle cell disease miss vital parts of their education.</p>
<p>Surveillance is conducted routinely in countries like the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7548901/">US</a>, the <a href="https://www.nhs.uk/pregnancy/your-pregnancy-care/screening-for-sickle-cell-and-thalassaemia/">UK</a> and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4655669/">Jamaica</a>, which have the infrastructure and resources to perform the screening. </p>
<p>A few countries in Africa, such as <a href="https://sicklecellanemianews.com/news/tracking-app-newborns-with-scd-be-introduced-african-countries/">Ghana</a> and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8424771/">Uganda</a>, have adopted routine surveillance programmes. My research group and colleagues have demonstrated that routine newborn screening is possible and can be done in a cost effective manner with rapid and <a href="https://www.researchgate.net/publication/353769629_Multispectral_Imaging_for_MicroChip_Electrophoresis_Enables_Point-of-Care_Newborn_Hemoglobin_Variant_Screening">accurate results</a>. Affordable paper-based point of care Hb electrophoresis would allow this even where resources are limited.</p>
<p>There has been a public-private-civil society partnership in Ghana since 2019. The <a href="https://devex.shorthandstories.com/bringing-innovation-to-sickle-cell-disease-patients-in-sub-saharan-africa/index.html">Africa Sickle Cell Disease programme</a> is a collaboration between the Ministry of Health of Ghana, the Ghana Health Service, the Sickle Cell Foundation of Ghana and the global medicines company Novartis. It has 59,121 babies currently registered and 24 health facilities involved. Newborns are screened and if sickle cell disease is detected, there is provision for follow-up. An app records patient treatment and experiences to build a profile of the patient. Data from laboratory tests are immediately shared with the app. Health workers can track progress more effectively, resulting in higher quality of care and faster time to treatment. </p>
<p>Partnerships like these use data and cutting-edge technology to allocate resources. They can improve the standard of care and address infrastructural gaps that may hinder the impact of healthcare in some areas. Because sickle cell disease management is complex, it requires partnerships for long term and sustainable projects.</p>
<h2>What is the treatment?</h2>
<p>We can’t yet cure sickle cell disease but we can manage the symptoms if we adapt the way we diagnose and treat it. Although it requires only a simple blood test, there was often little urgency about screening and diagnosis in the past, even among medical professionals, because care was simply supportive.</p>
<p>Effective treatment has considerably increased the chances of survival for those living with the condition. Since the turn of the century, we have used a medication called hydroxyurea to treat sickle cell disease. A formulation of hydroxyurea which is more suitable for young children will soon be available.</p>
<p>A clinical <a href="https://ichgcp.net/clinical-trials-registry/NCT03814746">trial</a> is under way in Ghana for a new treatment for sickle cell disease, crizanlizumab. This medicine is already available in Europe and the US. </p>
<p>Our study shows that an <a href="https://onlinelibrary.wiley.com/doi/pdf/10.1002/ajh.25356">89% decrease</a> in maternal mortality rates can be achieved with a multidisciplinary care approach through pregnancy. Women with the disease have a higher risk of maternal mortality. </p>
<p>Developing knowledge and training medical staff on standardised practices for treating sickle cell disease has also been <a href="https://ashpublications.org/bloodadvances/article/6/7/1977/484111/Sustainability-of-low-maternal-mortality-in">shown to be</a> effective in reducing mortality.</p><img src="https://counter.theconversation.com/content/185784/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Yvonne Dei-Adomakoh receives funding from NHLBI
</span></em></p>Of the 20 million people living with sickle cell disease globally, more than 66% are in sub-Saharan Africa.Yvonne Dei-Adomakoh, Senior lecturer in Haematology, University of GhanaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1756502022-06-10T12:29:55Z2022-06-10T12:29:55ZSepsis still kills 1 in 5 people worldwide – two ICU physicians offer a new approach to stopping it<figure><img src="https://images.theconversation.com/files/467853/original/file-20220608-22-nfife2.jpg?ixlib=rb-1.1.0&rect=59%2C0%2C6540%2C2642&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Sepsis begins with infection by bacteria or a virus. This panoramic ilustration inside a blood vessel shows rod-shaped bacteria, red blood cells and immune cells called leukocytes.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/illustration/bacteria-in-blood-illustration-royalty-free-illustration/685024929?adppopup=true">Kateryna Kon/Science Photo Library via Getty Images</a></span></figcaption></figure><p>Can an otherwise healthy young woman die from what starts out as something akin to a common cold? The answer is, <a href="https://www.bbc.com/news/uk-wales-45498914">shockingly, yes</a>, when certain telltale signs of a more serious problem go undetected. </p>
<p>Though many people haven’t even heard of it, sepsis – the body’s extreme response to infection – is <a href="https://www.natlawreview.com/article/sepsis-accounts-1-5-deaths-leading-cause-death-hospitals#">the leading killer of hospitalized patients</a> in the United States. Worldwide, sepsis is responsible <a href="https://doi.org/10.1016/S0140-6736(19)32989-7">for 1 in 5 deaths every year</a>. <a href="https://www.sccm.org/MyICUCare/THRIVE/Post-intensive-Care-Syndrome">Even among those who survive</a>, many will never be able to return to work, and some won’t be able to return home from the hospital, requiring life support or ongoing critical care.</p>
<p>We <a href="https://pre.ccm.pitt.edu/?q=content/rudd-kristina">are two researchers</a> and <a href="https://www.ccm.pitt.edu/node/1211">critical care doctors</a> at the University of Pittsburgh School of Medicine who are working to change the way scientists and doctors think about sepsis. We are interested in understanding and spreading awareness about how sepsis starts and how it can elude even the most astute physicians. </p>
<p>We are also learning more about how community factors are at play and how a better understanding of the communities we all live in could help everyday people and health care workers alike recognize and stop this deadly disease.</p>
<h2>What is sepsis?</h2>
<p>Sepsis is a medical emergency that begins with an infection – perhaps even a mild infection. Upon detecting bacteria or a virus, your body releases a choreographed cascade of chemicals into the bloodstream. This chemical alert beckons <a href="https://theconversation.com/how-long-does-protective-immunity-against-covid-19-last-after-infection-or-vaccination-two-immunologists-explain-177309">an artillery of immune cells</a> that work in concert to fight the bug. </p>
<p>When this system works well, your body clears the infection and you get better. But when the system doesn’t work well, sepsis can ensue.</p>
<p>The onset of sepsis occurs when your immune cells pivot from fighting the infection to fighting your own tissues and organs. This reaction can be similar to an autoimmune response, a condition in which <a href="https://medlineplus.gov/autoimmunediseases.html">the body’s immune system turns on itself</a>. Many people are familiar with chronic autoimmune diseases such as <a href="https://www.cdc.gov/arthritis/basics/rheumatoid-arthritis.html#">rheumatoid arthritis</a> or <a href="https://www.mayoclinic.org/diseases-conditions/crohns-disease/symptoms-causes/syc-20353304#">Crohn’s disease</a>, but sometimes this type of autoimmune response can occur even in healthy people. </p>
<p>When sepsis occurs, the immune system can commonly injure the heart, lungs, kidneys or blood cells, among other important body systems. Inflammation in the blood vessels can make them leaky, causing blood flow to the brain and other organs to become severely diminished. When this occurs, a person’s blood pressure may become dangerously low, which is a severe form of sepsis known as septic shock. </p>
<p>Without prompt and proper treatment – and sometimes even despite treatment – sepsis can cause organ damage and even death. Once shock develops, mortality from sepsis is estimated <a href="https://doi.org/10.1001/jama.2016.0287">to jump from 10% to as high as 40%</a>.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/6NdLnHbLZMU?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">An illustrated explanation of how sepsis attacks the body.</span></figcaption>
</figure>
<p>Sepsis can result from nearly any infection. Most commonly it develops from pneumonia or a urinary tract infection. Severe <a href="https://www.ama-assn.org/delivering-care/public-health/sepsis-survival-has-lessons-severe-covid-19-care-recovery">COVID-19 can also cause sepsis</a>. Often, sepsis patients are seen by a medical professional for infection symptoms <a href="https://doi.org/10.4037/ajcc2021456">in the week preceding sepsis hospitalization</a>. However, predicting which infected patients will go on to develop sepsis is very difficult.</p>
<h2>Treatment options</h2>
<p>The cornerstones of sepsis treatment are prompt recognition of sepsis symptoms, followed by antibiotics and fluids. But even the most careful and attentive physicians can miss the early signs of sepsis. </p>
<p>This is largely because there is no single test to positively diagnose sepsis. Sepsis symptoms may mimic other life-threatening conditions such as heart attacks, blood clots, bleeding or even an allergic reaction. Patients often display vague and variable symptoms such as weakness, lightheadedness and rapid breathing, making the diagnosis even more challenging. </p>
<p>For example, a young, otherwise healthy person with sepsis due to pneumonia may look much different from an older diabetic who develops sepsis from a smoldering skin infection.</p>
<p>Sepsis patients nearly always require admission to the hospital or even the ICU, and those with severe forms of sepsis often require life support. This may include dialysis or mechanical ventilation to support failing organs. The source of infection needs to be identified and, in some cases, surgically removed. Delaying sepsis treatment by even a few hours <a href="https://doi.org/10.1007/s00134-021-06506-y">can have deadly consequences</a>. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/I9UwETuh9IA?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Sepsis can affect those of any age, not just the elderly.</span></figcaption>
</figure>
<h2>Recognizing sepsis before it’s too late</h2>
<p>Differences in sepsis go beyond symptoms. COVID-19 has laid bare that severe illness isn’t a game of chance. Like COVID-19 infection, sepsis susceptibility – and who is most likely to get sick and die – is part of a complex interplay of social influences that <a href="https://doi.org/10.1001/jama.2021.22583">include racism, poverty, geography and community dynamics</a>.</p>
<p>Research strongly suggests that certain people are at <a href="https://doi.org/10.1093/ofid/ofy305">far higher risk of developing sepsis</a> than others. Much like COVID-19, older people with underlying chronic diseases like obesity and diabetes face a heightened risk for sepsis. Such factors as race, poverty and even driving distance to the hospital <a href="https://doi.org/10.1016/j.chest.2016.07.004">may have a significant impact</a> on who survives sepsis. </p>
<p>Most of the work done to improve sepsis detection and treatment has focused on the hospital setting. Doctors, researchers and even government agencies have concentrated their efforts on improving sepsis recognition and treatment once a patient reaches the hospital. Research aimed at understanding an individual’s sepsis risk has focused on personal health history and social and economic factors such as income and race, or community features such as primary care access. </p>
<p>While these approaches have advanced the field’s understanding of sepsis, they have led to little progress in reducing the incidence of sepsis in the U.S.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/69s6ezhwTWQ?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Sepsis is sometimes mistaken for the flu.</span></figcaption>
</figure>
<h2>New approaches to catching a killer</h2>
<p>Given what is known about the importance of early sepsis treatment, researchers like us are taking a closer look at the role of communities in improving sepsis detection and understanding sepsis risk.</p>
<p>The early stages of sepsis can evolve rapidly when a patient is at home. Scientists estimate that <a href="https://www.cdc.gov/sepsis/what-is-sepsis.html">87% of sepsis cases start outside the hospital</a>. When a patient does present for care, it’s often in a clinic or emergency medical services setting in the days and even hours <a href="https://doi.org/10.1164/rccm.201204-0713OC">preceding sepsis hospitalization</a>. These critical treatment windows may mean the difference between life and death for a sepsis patient. </p>
<p>Alongside researchers based at Kaiser Permanente Northern California, we are now working to advance sepsis care by studying sepsis patient symptoms, community factors, diagnosis and treatment patterns outside the hospital. We are also expanding work to <a href="https://doi.org/10.1038/s41746-022-00580-2">improve sepsis diagnosis among hospitalized patients</a>. This coast-to-coast collaboration will study patients cared for at over 40 hospitals, 30 EMS agencies and a critical mass of ambulatory clinics. We hope that our work will shed light on the early stages of sepsis, including signs that may signal that an infected patient is progressing to sepsis, and explore diagnostic and treatment approaches that could help stop sepsis before it advances too far. </p>
<p>We are also learning a great deal more about the complicated role of community factors like poverty on health outcomes, including sepsis. Using “syndemic theory” – a framework to describe synergistic epidemics that <a href="https://doi.org/10.1016/S0140-6736(17)30003-X">arise from harmful social conditions</a> – we are studying how two co-occurring epidemics, like poverty and asthma, can work together to increase negative health outcomes. Though this framework is only beginning to be used to study acute illness, it has the potential to transform the way we think about sepsis.</p><img src="https://counter.theconversation.com/content/175650/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Emily Brant works for the University of Pittsburgh School of Medicine and UPMC Health System. She has received grant funding from the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health (NIH) and the Gordon and Betty Moore Foundation. She has no relevant conflicts of interest to report. </span></em></p><p class="fine-print"><em><span>Kristina E. Rudd works for the University of Pittsburgh and UPMC Health System. She consults for Janssen Pharmaceuticals. She receives grant funding from the National Institute of General Medical Sciences and the National Heart, Lung, and Blood Institute (National Institutes of Health).</span></em></p>Sepsis onset can be difficult to recognize, in part because its symptoms can mimic those of many other conditions. A treatment delay of even a few hours can make the difference between life and death.Emily Brant, Assistant Professor of Critical Care and Emergency Medicine, University of PittsburghKristina E. Rudd, Assistant Professor of Critical Care Medicine, University of PittsburghLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1675442021-09-21T20:14:10Z2021-09-21T20:14:10ZHere’s what happens when you’re hospitalised with COVID<p>The number of people infected with COVID-19 and requiring treatment in hospital is <a href="https://www.health.gov.au/news/health-alerts/novel-coronavirus-2019-ncov-health-alert/coronavirus-covid-19-case-numbers-and-statistics">rapidly increasing</a>. </p>
<p>Vaccination provides very effective protection against severe COVID but at current levels of vaccination, outbreaks are still likely to result in large numbers of people requiring treatment in hospital. </p>
<p>Thankfully, there are reliable evidence-based <a href="https://covid19evidence.net.au/">guidelines</a> on how to best treat COVID. Here’s what they recommend.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/were-two-frontline-covid-doctors-heres-what-we-see-as-case-numbers-rise-167195">We're two frontline COVID doctors. Here's what we see as case numbers rise</a>
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<hr>
<h2>What happens when I test positive?</h2>
<p>If you test positive, you must self-isolate at home. </p>
<p>If you’re like many people with COVID, you won’t need to go to hospital, and can safely manage the illness at home. </p>
<p>If you’re vaccinated, your risk of severe illness is even lower, and you are very unlikely to need hospital care. Even so, it’s important to connect with an appropriate health-care service (usually your GP) who will monitor you and arrange additional care if needed. </p>
<h2>What are the early symptoms?</h2>
<p>Initially, you may experience flu-like symptoms like cough, sore throat, fever, aches, pains and headache. </p>
<p>You might lose your sense of smell and taste; or have nausea, vomiting and diarrhoea. </p>
<p>You’ll need rest, fluids and paracetamol for aches, pains or fever.</p>
<figure class="align-center ">
<img alt="Man sits up in bed, scrunching has face and cradling his head, with a headache." src="https://images.theconversation.com/files/422266/original/file-20210921-23-2pncjm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/422266/original/file-20210921-23-2pncjm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/422266/original/file-20210921-23-2pncjm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/422266/original/file-20210921-23-2pncjm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/422266/original/file-20210921-23-2pncjm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/422266/original/file-20210921-23-2pncjm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/422266/original/file-20210921-23-2pncjm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Early symptoms are similar to those you’d get with the flu.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/asian-man-has-headache-after-waking-2010530153">Shuttestock</a></span>
</figcaption>
</figure>
<p>Within the first five days of having symptoms, people who don’t require oxygen but have important <a href="https://app.magicapp.org/#/guideline/L4Q5An/section/E8kMVn">risk factors</a> for developing severe disease may receive a drug called <a href="https://covid19evidence.net.au/news/taskforce-makes-conditional-recommendation-for-use-of-sotrovimab/">sotrovimab</a>. </p>
<p>Sotrovimab is administered by an infusion into a vein, usually during a brief visit to hospital. <a href="https://www.medrxiv.org/content/10.1101/2021.05.27.21257096v1">Studies suggest</a> that in people at high risk of developing severe symptoms, sotrovimab probably reduces the risk of needing to stay in hospital. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/what-is-sotrovimab-the-covid-drug-the-government-has-bought-before-being-approved-for-use-in-australia-165802">What is sotrovimab, the COVID drug the government has bought before being approved for use in Australia?</a>
</strong>
</em>
</p>
<hr>
<h2>What happens if my symptoms get worse?</h2>
<p>If your symptoms worsen, you’ll need to contact your care provider.</p>
<p>Or if your symptoms are very serious, such as difficulty breathing, call 000 for an ambulance, and make sure you tell them you have COVID.</p>
<p>If you’re taken to hospital, it’s likely you will be treated in an area specially prepared for patients with COVID. </p>
<p>Doctors will measure your oxygen levels and perform a chest X-ray and blood tests to determine how sick you are. </p>
<p>If the clinical staff detect effects of the infection in your lungs, low oxygen levels or other <a href="https://app.magicapp.org/#/guideline/L4Q5An/section/nV2P3n">signs of severe infection</a>, you’ll stay in hospital and probably be given oxygen.</p>
<figure class="align-center ">
<img alt="An elderly man with a breathing mask lays in a hospital bed in a dark ward room." src="https://images.theconversation.com/files/422278/original/file-20210921-17-bv3mq7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/422278/original/file-20210921-17-bv3mq7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/422278/original/file-20210921-17-bv3mq7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/422278/original/file-20210921-17-bv3mq7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/422278/original/file-20210921-17-bv3mq7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/422278/original/file-20210921-17-bv3mq7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/422278/original/file-20210921-17-bv3mq7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">If you have low oxygen levels, you’ll need to stay in hospital.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/hospital-ward-portrait-elderly-man-wearing-1940771200">Shutterstock</a></span>
</figcaption>
</figure>
<p>If this is the case, you’ll also be given <a href="https://app.magicapp.org/#/guideline/L4Q5An/section/nJPlbj">dexamethasone</a>, an anti-inflammatory medicine which reduces the risk of dying from COVID. </p>
<p>Most patients with moderate COVID who receive dexamethasone in hospital recover well and don’t require any additional treatment. But some patients develop more severe disease. In these patients one of two medicines — <a href="https://app.magicapp.org/#/guideline/L4Q5An/section/EP66ZL">tocilizumab</a> or <a href="https://app.magicapp.org/#/guideline/L4Q5An/section/LpBo7E">bariticinib</a> — which dampen the inflammation and decrease the risk of dying may be prescribed. </p>
<p>An antiviral medicine called <a href="https://app.magicapp.org/#/guideline/L4Q5An/section/EQlPrn">remdesivir</a> may also be offered. Remdesivir reduces the time to recover from severe forms of COVID — and probably reduces the risk of dying for people who do not require mechanical ventilation.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/to-ensure-supply-of-the-top-3-drugs-used-to-treat-covid-19-its-time-to-boost-domestic-medicine-manufacturing-164948">To ensure supply of the top 3 drugs used to treat COVID-19, it's time to boost domestic medicine manufacturing</a>
</strong>
</em>
</p>
<hr>
<h2>What happens if my symptoms worsen again?</h2>
<p>If you become even more unwell, these treatments will continue but you may need more support for breathing.</p>
<p>Your care team will decide which is most appropriate for you. Options include:</p>
<ul>
<li><p>increasing the proportion of oxygen in the air you breathe and improving delivery of air into your lungs, using high-flow nasal oxygen (HFNO) or continuous positive airway pressure (CPAP)</p></li>
<li><p>supporting your breathing (mechanical ventilation) </p></li>
<li><p>increasing the levels of oxygen in your blood (extracorporeal membrane oxygenation, ECMO). </p></li>
</ul>
<figure class="align-center ">
<img alt="A clinician in full PPE treats a patient with breathing tubes." src="https://images.theconversation.com/files/422273/original/file-20210921-15-aa2wvd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/422273/original/file-20210921-15-aa2wvd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/422273/original/file-20210921-15-aa2wvd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/422273/original/file-20210921-15-aa2wvd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/422273/original/file-20210921-15-aa2wvd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/422273/original/file-20210921-15-aa2wvd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/422273/original/file-20210921-15-aa2wvd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Those needing extra help to breathe will be treated in intensive care.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/patient-seen-intensive-care-unit-coronavirus-1852548007">Shutterstock</a></span>
</figcaption>
</figure>
<p>If you need mechanical ventilation or ECMO you will be cared for in an ICU and will require medications to provide sedation and pain relief. </p>
<p>While you’re in ICU, your symptoms will be continually monitored. As they change, your care team may change the type or amount of support for breathing you receive. </p>
<p>As you recover, they will gradually reduce the amount of breathing support you receive so your body takes on more of the work of breathing as it can. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/when-covid-patients-are-intubated-in-icu-the-trauma-can-stay-with-them-long-after-this-breathing-emergency-167361">When COVID patients are intubated in ICU, the trauma can stay with them long after this breathing emergency</a>
</strong>
</em>
</p>
<hr>
<h2>What does recovery look like?</h2>
<p>Your recovery depends on many factors, including your age, health and fitness, and how sick you became with COVID. </p>
<p>If you’ve been in ICU, once you can breathe on your own and your heart and lung function are stable, you’ll be moved back to a hospital ward to continue your recovery. </p>
<p>Once your symptoms have mostly resolved, and tests and other information indicate you are no longer infectious, you will be able to return home. </p>
<p>The <a href="https://covid19evidence.net.au/">National COVID-19 Clinical Evidence Taskforce</a> will ensure that as soon as reliable, new evidence is available it will be included in clinical practice guidelines. But keep in mind, the best way to protect yourself is to get vaccinated.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/i-work-at-a-covid-19-vaccine-clinic-heres-what-people-ask-me-when-theyre-getting-their-shot-and-what-i-tell-them-167046">I work at a COVID-19 vaccine clinic. Here's what people ask me when they're getting their shot — and what I tell them</a>
</strong>
</em>
</p>
<hr>
<img src="https://counter.theconversation.com/content/167544/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Steven McGloughlin is co-chair of the National COVID-19 Clinical Evidence Taskforce's critical care panel and a member of the guidelines leadership group.</span></em></p><p class="fine-print"><em><span>Tari Turner is Director, Evidence and Methods, for the National COVID-19 Clinical Evidence Taskforce. The Taskforce receives funding from the Australian Government Department of Health, the Victorian Government Department of Health and Human Services, The Ian Potter Foundation, the Walter Cottman Endowment Fund, managed by Equity Trustees and the Lord Mayors’ Charitable Foundation</span></em></p><p class="fine-print"><em><span>Julian Elliott does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A lot has changed in COVID treatment since the pandemic began. Here are the treatments you can expect — from being diagnosed, to going to hospital, and for those who need to be cared for in ICU.Julian Elliott, Executive Director, National COVID-19 Clinical Evidence Taskforce, and Professor, School of Public Health and Preventive Medicine, Monash UniversitySteven McGloughlin, Director Intensive Care Unit Alfred Health and Adjunct Associate Professor Epidemiology and Preventative Medicine Monash University, The National Trauma Research InstituteTari Turner, Director, Evidence and Methods, National COVID-19 Clinical Evidence Taskforce; Associate Professor (Research), Cochrane Australia, School of Population Health and Preventive Medicine, Monash University, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1628212021-07-16T13:04:19Z2021-07-16T13:04:19ZKids aren’t just littler adults – here’s why they need their own clinical trials for a COVID-19 vaccine<figure><img src="https://images.theconversation.com/files/411505/original/file-20210715-32722-7lpsnj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The freedom of going mask-free is still a ways off for kids under age 12.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/american-little-caucasian-boy-posing-with-a-royalty-free-image/1216273821"> Juan Monino/E+ via Getty Images</a></span></figcaption></figure><p>Now that <a href="https://covid.cdc.gov/covid-data-tracker/#vaccinations">two-thirds of all adults</a> in the United States have received at least one dose of a SARS-CoV-2 vaccine as of mid-July 2021, life seems to be returning to some semblance of pre-pandemic times. People are again traveling, eating in restaurants with friends, attending in-person gatherings and flocking to <a href="https://www.forbes.com/sites/jonathanberr/2021/05/31/people-are-returning-to-the-movies-as-mask-requirements-end/?sh=12693670115f">movie theaters</a> and <a href="https://www.sportstravelmagazine.com/how-many-fans-will-be-allowed-at-major-league-baseball-games-this-season-capacity/">Major League baseball games</a>. </p>
<p>Yet for parents of children under the age of 12, who are not yet eligible for COVID-19 vaccines, there is still no collective sigh of relief. Many parents have concerns about <a href="https://www.nature.com/articles/d41586-021-01826-x">the upcoming school year</a> and the uncertainty surrounding the <a href="https://theconversation.com/whats-the-delta-plus-variant-and-can-it-escape-vaccines-an-expert-explains-163644">delta variant</a>. </p>
<p>Clinical research studies of the mRNA-based vaccines for children under 12 are ongoing, and authorization of a vaccine for this younger age group is still at least several months away. These trials are necessary because children have important differences in physiology and <a href="https://doi.org/10.1016/j.vaccine.2015.07.085">responses to vaccines</a> from those of adults. Conducting separate studies in children under age 12 is a vital step toward ending the pandemic.</p>
<p>As a <a href="https://www.pediatrics.pitt.edu/people/judith-m-martin-md">specialist in pediatric infectious diseases</a>, I have been conducting research on common infections in children and related vaccines for over 20 years. Here at the University of Pittsburgh, our <a href="https://covid19research.pitt.edu/pvtu/">Pittsburgh Vaccine Trials Unit</a> has carried out both adult and pediatric clinical trials for vaccines to fight COVID-19. </p>
<p>Ours was one of two COVID-19 vaccine clinical research trial sites in the Pittsburgh area and one of more than 100 sites across the U.S. that have participated in this effort through the <a href="https://www.coronaviruspreventionnetwork.org/about-covpn">COVID-19 Prevention Network</a>, which was formed by the National Institutes of Health to combat the spread of the coronavirus. Our team is about to begin the next phase of trials with the 6-11 year-old age group, which relies on volunteer participants. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/411517/original/file-20210715-25-er3g5n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A boy receives a shot" src="https://images.theconversation.com/files/411517/original/file-20210715-25-er3g5n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/411517/original/file-20210715-25-er3g5n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/411517/original/file-20210715-25-er3g5n.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/411517/original/file-20210715-25-er3g5n.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/411517/original/file-20210715-25-er3g5n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/411517/original/file-20210715-25-er3g5n.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/411517/original/file-20210715-25-er3g5n.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The FDA authorized the use of the Pfizer COVID-19 vaccine for 12-to-15-year-olds in May.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/aiden-arthurs-receives-the-pfizer-biontech-covid-19-vaccine-news-photo/1232867623?adppopup=true">Jeff Kowalsky/AFP via Getty Images</a></span>
</figcaption>
</figure>
<h2>Testing a vaccine for safety and efficacy</h2>
<p>Vaccines work by tricking the body’s immune system into making proteins, called antibodies, that fight disease – but without giving a person the disease. </p>
<p>Before a vaccine can be approved for use in the general public, it usually goes through clinical safety trials that can take anywhere from <a href="https://www.businessinsider.com/how-long-it-took-to-develop-other-vaccines-in-history-2020-7#measles-mumps-and-rubella-mmr-8">2 to 15 years</a>. The U.S. goverment’s <a href="https://doi.org/10.1016/S2214-109X(21)00140-6">Operation Warp Speed</a> accelerated this process in an unprecedented way, largely because it invested US$18 billion up front to help create lab spaces, build infrastructure, make research investments and pre-purchase vaccines. In December 2020, health care workers in the U.S. <a href="https://www.washingtonpost.com/nation/2020/12/14/first-covid-vaccines-new-york/">began receiving</a> the first COVID-19 vaccines authorized for adults.</p>
<p>Vaccine studies begin with experiments in the laboratory, where candidate vaccines are developed and tested in animals. After pharmaceutical companies and government labs perform initial testing on vaccine candidates, they then turn to research groups throughout the country and world to run <a href="https://theconversation.com/from-the-research-lab-to-your-doctors-office-heres-what-happens-in-phase-1-2-3-drug-trials-138197">several phases of clinical trials</a> in people. </p>
<p>In phase 1 trials, the primary goal is to establish the safety of the vaccine in humans. During phase 2, researchers continue to evaluate the safety of the vaccine, but with an eye to determining the exact dosage needed to achieve the necessary immune response to confer protection. Once a vaccine candidate enters phase 3 trials, the primary goal is to study how well people are protected from the infection or disease, while continuing to assess safety and monitor for potential side effects. </p>
<p>Once clinical trials are complete, vaccines must still undergo a <a href="https://www.fda.gov/vaccines-blood-biologics/development-approval-process-cber/vaccine-development-101">rigorous evaluation process</a> through the U.S. Food and Drug Administration, the regulatory body that oversees vaccine safety and effectiveness.</p>
<p>After <a href="https://www.nejm.org/doi/full/10.1056/nejmoa2034577">tens</a> <a href="https://www.nejm.org/doi/full/10.1056/NEJMoa2107659?">of thousands</a> <a href="https://www.statnews.com/2020/12/09/johnson-johnson-cuts-size-of-covid-19-vaccine-study-due-to-prevalence-of-disease-in-u-s/">of adults</a> participated in phase 3 clinical research studies of COVID-19 vaccines over several months in 2020 and early 2021, the U.S. now has <a href="https://covid19.trackvaccines.org/country/united-states-of-america/">three vaccines</a> <a href="https://www.fda.gov/vaccines-blood-biologics/vaccines/emergency-use-authorization-vaccines-explained">authorized for emergency use</a> by the FDA for people 18 years of age and older and one vaccine, Pfizer, authorized for use in children age 12 and older. </p>
<h2>How kids’ bodies differ from grown-ups’</h2>
<p>Children are not just littler grownups; their bodies differ from adults’ in important ways. </p>
<p>Their <a href="https://doi.org/10.1016/j.cobeha.2016.05.015">brains are developing rapidly</a>, and their immune systems have important differences too, particularly in toddlers and babies. For the first few months of life, infants’ immune systems still possess the <a href="https://doi.org/10.1016/j.vaccine.2015.07.085">antibodies they received from their mothers</a> across the placenta during late pregnancy. This changes how newborns respond to pathogens and makes them less able to mount an immune response to some vaccines. Young children’s bodies gradually ramp up their own immune systems as their protection from mom wears off.</p>
<p>So vaccines often need to be tailored specifically for young children. For instance, the <a href="https://www.cdc.gov/vaccines/vpd/pneumo/hcp/about-vaccine.html">Pneumococcal vaccine that prevents infections</a> like pneumonia in adults is made from sugar molecules called polysaccharides, which coat the outside of pneumococcal bacteria. But infants can’t mount an effective immune response to these sugar molecules. So researchers had to develop a <a href="https://www.chop.edu/centers-programs/vaccine-education-center/vaccine-details/pneumococcal-vaccine">unique version of the vaccine</a> for babies. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/411525/original/file-20210715-38837-1biu235.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Masked student receives temperature check on way in to school" src="https://images.theconversation.com/files/411525/original/file-20210715-38837-1biu235.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/411525/original/file-20210715-38837-1biu235.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=404&fit=crop&dpr=1 600w, https://images.theconversation.com/files/411525/original/file-20210715-38837-1biu235.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=404&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/411525/original/file-20210715-38837-1biu235.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=404&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/411525/original/file-20210715-38837-1biu235.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=507&fit=crop&dpr=1 754w, https://images.theconversation.com/files/411525/original/file-20210715-38837-1biu235.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=507&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/411525/original/file-20210715-38837-1biu235.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=507&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Masks and temperature checks will likely be the norm for many U.S. school-going kids until a COVID-19 vaccine is authorized for children under age 12.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/school-employee-checks-the-temperature-of-a-student-as-she-news-photo/1228142942?adppopup=true">NurPhoto/Getty Images</a></span>
</figcaption>
</figure>
<p>Even when a vaccine for adults is proven safe in children, there can be important differences in how their bodies respond to it. The vaccine dose that works best in adults might cause a high fever in children, for instance. So one key goal of the COVID-19 vaccine clinical trials in children will be to determine the optimal dosage for each age group.</p>
<p>Researchers need to be on alert for side effects that might only occur in youngsters and didn’t appear during vaccine tests on adults. Safety is critical and each study has many layers of safety mechanisms in place to ensure that researchers like us proceed cautiously and evaluate all of the data and information at every step along the way. </p>
<p>For example, trial participants keep daily diaries and report any side effects or changes. Vaccine clinical trials include frequent safety checks with participants, and unusual reactions are reported immediately to the study sponsor so that any problems can be identified quickly. Researchers also adhere to strict “pause” rules if a serious safety concern arises.</p>
<h2>Clinical trials for kids</h2>
<p>After setting up a new clinical trials space and gathering all the staff and necessary equipment, the Trials Unit here at the University of Pittsburgh was ready to host phase 3 clinical trials with volunteer participants.</p>
<p>Beginning in August 2020 and into the fall, we ran phase 3 adult clinical trials for both the Moderna and Johnson & Johnson vaccines. We recently enrolled kids ages 6-11 as well as 6 to 24 months of age in phase 2 of the pediatric Moderna trials, focusing on whether the vaccine is safe to use in these kids and at what dosages. </p>
<p>Our site is now set to move to phase 3 of the pediatric trials, currently slated to begin in mid-August for children age 6-11, throughout the U.S. and Canada. This final stage of the clinical trials will determine how well the vaccine really works to keep kids from getting COVID-19. We expect early results of these studies by this fall, after which they will be reviewed by the FDA.</p>
<p>[<em>Like what you’ve read? Want more?</em> <a href="https://theconversation.com/us/newsletters/the-daily-3?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=likethis">Sign up for The Conversation’s daily newsletter</a>.]</p>
<p>The FDA said on July 15 that emergency authorization for <a href="https://www.nbcnews.com/health/health-news/vaccines-kids-under-age-12-expected-mid-winter-fda-official-n1274057">vaccines for children under 12</a> is likely to come by early to mid-winter.</p>
<h2>The vital role of volunteers in ending the pandemic</h2>
<p>Volunteering for a research study is not for everyone. </p>
<p>When a family volunteers to enroll in a vaccine study, our research team has an in-depth discussion with them about the requirements, as well as the potential risks and benefits. We try to answer all of their questions so that they can decide if a study is a good fit for them. Ultimately, parents are trying to make a decision that is in the best interest of their child.</p>
<p>Often we hear from our volunteers that they wanted to help bring the pandemic to an end or felt it was their personal responsibility to help others. Their willingness to participate is crucial to finding a safe and effective vaccine that will hopefully help end the pandemic and to help parents – and kids – return to the freedoms of pre-pandemic life.</p><img src="https://counter.theconversation.com/content/162821/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Judy Martin works for the University of Pittsburgh which receives funding from the National Institutes of Health. The University of Pittsburgh receives funding from the National Institutes of Health to conduct the research studies of SARS-CoV-2 vaccines. </span></em></p>As many teens and adults in the US restart their social lives, parents of children under the age of 12 wonder when their kids will also be able to experience the freedom that comes with vaccination.Judy Martin, Professor of Pediatrics, University of PittsburghLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1615102021-05-28T10:42:17Z2021-05-28T10:42:17Z‘Dog coronavirus found in humans’ – why you shouldn’t worry<figure><img src="https://images.theconversation.com/files/403150/original/file-20210527-22-1q8kmex.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C3000%2C2001&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Relax, humans! I'm not going to start the next pandemic.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/funny-looking-french-bulldog-dog-ears-1516040714">Firn/Shutterstock</a></span></figcaption></figure><p>Scientists have found a <a href="https://www.independent.co.uk/news/science/coronavirus-malaysia-covid-dog-pneumonia-b1851509.html">new canine coronavirus</a> in a handful of people hospitalised with pneumonia. This may sound alarming, but once we unpack it, you will see that there’s no reason to lose any sleep.</p>
<p>The discovery of the canine coronavirus in eight people at a hospital in Sarawak, Malaysia, was reported in <a href="https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciab456/6278597">Clinical Infectious Diseases</a> by a group of highly regarded international scientists. So does this mean dogs can spread coronaviruses to humans? </p>
<p>The first thing to clarify is what canine coronavirus is. Importantly, it is quite distinct from SARS-CoV-2, the virus that causes COVID-19. The coronavirus family can be divided into four groups of viruses: alpha, beta, gamma and delta coronaviruses. SARS-CoV-2 falls within the betacoronaviruses group, whereas the canine coronaviruses are in the entirely separate alphacoronavirus group.</p>
<p>Scientists have known about canine coronaviruses for <a href="https://www.sciencedirect.com/topics/veterinary-science-and-veterinary-medicine/canine-coronavirus">almost 50 years</a>. These viruses have existed in relative obscurity over most of this period, being of interest only to veterinary virologists and occasional dog owners. There are no previous reports of these viruses infecting people. But the sudden international spotlight on all coronaviruses is finding coronaviruses in places we haven’t looked before.</p>
<p>The canine coronavirus infections recently identified in people were actually discovered serendipitously. Scientists were not specifically looking for canine coronavirus, and the patients involved had long since recovered. The researchers were trying to develop a new test that could detect all kinds of coronaviruses at the same time – a so-called <a href="https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciab456/6278597">pan-CoV test</a>.</p>
<p>After confirming the test worked on samples of viruses grown in laboratories, they <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7192118/">tested it on 192 human swabs</a> from hospitalised pneumonia patients in Malaysia. Nine of these samples tested positive for coronaviruses. </p>
<p>Further analysis showed that five out of the nine samples were ordinary human coronaviruses that can cause colds. But, surprisingly, four of the samples were canine coronavirus. Further study of patients from the same hospital revealed four more positive patients.</p>
<p>The researchers studied nose and throat swabs from all eight Malaysian patients to try to learn more about the canine coronaviruses. Samples were put onto dog cells in the lab to see if any live virus was present. Virus from a single sample replicated well, and virus particles could be seen using electron microscopy. The scientists were also able to sequence the virus’s genome.</p>
<p>The analysis found that this canine coronavirus was closely related to a few different alphacoronaviruses – including those from pigs and cats – and showed it had not previously been identified anywhere else.</p>
<h2>No evidence of onward spread</h2>
<p>Was canine coronavirus responsible for the pneumonia in the patients? At the moment, we simply can’t tell. Seven out of eight patients were simultaneously infected with another virus, either adenovirus, influenza or parainfluenza virus. We know that all of these viruses can cause pneumonia by themselves, so it is more likely that these were responsible for the disease. We can say there is an association between pneumonia and canine coronavirus in these patients, but we can’t say it is the cause.</p>
<p>There have been concerns that the canine coronavirus identified in these Malaysian patients could spread from person to person, resulting in a wider outbreak. What many <a href="https://metro.co.uk/2021/05/24/new-coronavirus-appears-to-have-jumped-from-dogs-to-humans-in-malaysia-14633579/">headlines</a> don’t clarify is that these human infections actually occurred in 2017 and 2018. This makes the likelihood of a canine coronavirus outbreak from this source even lower as there is no evidence of onward spread in the intervening three to four years.</p>
<p>As coronaviruses have become the centre of attention and we search for related viruses, we are inevitably going to find more positive samples in unexpected places. The vast majority of these will be of academic interest only, and need not raise alarm. However, it is critical that surveillance for new coronaviruses continues and expands so that we have the best possible chance of identifying significant cross-species jumps in the future.</p><img src="https://counter.theconversation.com/content/161510/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sarah L Caddy does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The risk of coronaviruses jumping species is low, but if you look for it, you will find it.Sarah L Caddy, Clinical Research Fellow in Viral Immunology and Veterinary Surgeon, University of CambridgeLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1597542021-05-06T09:24:02Z2021-05-06T09:24:02ZIt’s possible to build stronger systems to deliver oxygen: here’s what it takes<figure><img src="https://images.theconversation.com/files/397120/original/file-20210426-17-1vlz71d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Family members of COVID-19 infected patients stand in a queue with empty oxygen cylinders outside the oxygen filling centre in New Delhi, India</span> <span class="attribution"><span class="source">Photo by Naveen Sharma/SOPA Images/LightRocket via Getty Images</span></span></figcaption></figure><p>COVID-19 is overwhelming hospital oxygen systems. COVID-19 pneumonia creates breathing difficulties leading to low blood oxygen levels (hypoxaemia). Unable to get enough oxygen to supply vital organs, patients with hypoxaemia are at very high risk of death. Supplemental oxygen is the only treatment. </p>
<p>About <a href="https://doi.org/10.1001/jama.2020.2648">20% of COVID-19 patients</a> globally have required hospital admission for oxygen therapy. But <a href="https://dx.doi.org/10.2471/BLT.16.186676">oxygen access was already a challenge</a> for hospitals in low- and middle-income countries, particularly smaller facilities in more remote geographies. This is due to <a href="https://doi.org/10.1002/ppul.24656">three major challenges</a>:</p>
<ul>
<li><p>low-quality, poorly functioning equipment, with inadequate access to maintenance and repair support;</p></li>
<li><p>lack of clinical and technical education and protocols;</p></li>
<li><p>deficiencies in local infrastructure – such as unreliable power supply – and management systems.</p></li>
</ul>
<p>The COVID-19 pandemic has exposed these challenges, leading to horrifying situations, such as the one <a href="https://www.aljazeera.com/news/2021/5/3/india-covid-crisis-lack-of-oxygen-killed-him-not-the-virus">in India</a>. </p>
<p>While the magnitude of this oxygen crisis is unprecedented, the reality of caring for patients without adequate oxygen systems is not new. Every year, <a href="https://doi.org/10.1016/S0140-6736(21)00561-4">around 15 million children</a> are admitted to hospital with life-threatening low blood oxygen levels, due to pneumonia and other conditions like malaria, sepsis and premature birth. </p>
<p>We are part of a <a href="https://www.mcri.edu.au/Oxygen-access">team</a> of health workers, engineers and researchers who support hospitals and governments to build stronger oxygen systems. We’ve been doing this for more than two decades in Africa and Asia-Pacific regions. </p>
<p>Our <a href="https://doi.org/10.9745/GHSP-D-20-00224">new paper</a> outlines the practical ways hospitals can immediately strengthen their oxygen systems. They can improve testing for oxygen levels (pulse oximetry) and oxygen use, support biomedical engineers, and expand on existing oxygen systems with robust equipment and smart design. </p>
<p>Policy makers and programme managers can use our recommendations to ensure investments in oxygen systems are more effective and efficient.</p>
<h2>Poorly functioning systems</h2>
<p>An effective oxygen system requires prompt recognition of those who need oxygen. It then needs a reliable supply and safe delivery to get it to them. Prior to COVID-19, there were gross deficiencies in many countries, illustrated by our detailed <a href="https://doi.org/10.1093/inthealth/ihz009">analysis</a> in Nigeria.</p>
<ul>
<li><p>Less than one in 20 patients had their blood oxygen levels measured. Without access to, and routine use of, pulse oximeters (which measure the level of oxygen in the blood), healthcare workers had no reliable way of determining who to prioritise.</p></li>
<li><p>While more than 80% of hospitals had some oxygen supplies, only 5% of oxygen concentrators worked properly. These machines concentrate oxygen from ambient air. Without access to spare parts or basic maintenance tools, biomedical engineers and technicians faced an impossible task.</p></li>
<li><p>Oxygen costs were high for patients and families. It cost them more than all other admission and treatment costs combined.</p></li>
</ul>
<p>But it doesn’t have to be this way. Our work with hospitals in <a href="https://doi.org/10.1371/journal.pmed.1002951">Nigeria</a>, <a href="https://www.hewatele.org/">Kenya</a>, <a href="https://doi.org/10.1136/archdischild-2020-320107">Papua New Guinea</a> and elsewhere has shown that hospital oxygen systems can be improved and save lives.</p>
<h2>Improving systems</h2>
<p>To make oxygen delivery more effective and efficient, we offer these suggestions:</p>
<p><strong>Pulse oximetry and oxygen use training:</strong> Healthcare workers must be trained in the use of pulse oximetry and oxygen provision. Taking someone’s oxygen saturation level should be a standard procedure for all acutely unwell patients. It allows healthcare workers to target oxygen towards those who need it most and adjust the dose needed. </p>
<p>In many low- and middle-income countries, pulse oximetry and oxygen therapy are <a href="https://academic.oup.com/tropej/article/58/5/389/1656199">largely absent</a> from medical and nursing curricula and clinical guidelines. </p>
<p>Education and support for healthcare workers should also cover basic checks and maintenance of vital equipment. </p>
<p><strong>Assistance for biomedical engineers:</strong> Oxygen is a medicine that depends on technology. It requires effective teamwork between healthcare workers, technicians and managers. However, biomedical engineers and hospital technicians are frequently left out of decision-making processes. This means they often lack maintenance budgets or system support. </p>
<p>Engineers and technicians are already coming up with <a href="https://www.openo2.org/home">innovative solutions</a> to make oxygen delivery more reliable and efficient. With training, tools, spare parts and access to stronger maintenance and transport systems, engineers and technicians can do much to optimise existing oxygen equipment and supply chains. </p>
<p><strong>Expansion of existing oxygen systems:</strong> There are several oxygen source systems. These include: small oxygen bedside concentrators which concentrate oxygen from the air; oxygen plants used to fill oxygen cylinders for distribution; and bulk liquid oxygen which is produced by gas plants and delivered via tanker trucks to fill liquid oxygen tanks at major hospitals.</p>
<p>Robust equipment and smart design should be used to build on what exists. For instance, countries with extractive industries – such as mining – typically have better access to liquid oxygen. Recent experience in India shows that it is possible to <a href="https://economictimes.indiatimes.com/industry/healthcare/biotech/healthcare/while-industrial-oxygen-has-been-diverted-for-medical-use-problems-in-transportation-and-delivery-remain/articleshow/82234135.cms?from=mdr">divert</a> industrial oxygen supplies for medical use. However, this is only useful if hospitals have the infrastructure and ability to safely store and use liquid oxygen. </p>
<p>The World Health Organisation (WHO) and UNICEF have also released <a href="https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance">guidance</a> on oxygen-related equipment and specific guidance for COVID-19. This will help health providers to make better use of what they have. For instance, it includes recommendations on the use of low-cost oxygen bedside concentrators distributing oxygen to patients using simple plastic tubing. </p>
<h2>Benefits for the future</h2>
<p>Over the past year, donors have sought to support low- and middle-income countries to boost their oxygen supply systems. For instance, UNICEF <a href="https://www.unicef.org/supply/coronavirus-disease-covid-19">delivered</a> over 20,000 oxygen concentrators and about 15,000 pulse oximeters to 94 countries. </p>
<p>Hospitals can use our practical <a href="https://www.ghspjournal.org/content/suppl/2020/09/29/GHSP-D-20-00224.DCSupplemental">installation guidance</a> to put this equipment to use rapidly and effectively. Otherwise – without enough understanding on how to integrate them – there’s the risk that they end up in equipment graveyards.</p>
<p>Improving patient outcomes always hinges on doing the basics well. The COVID-19 pandemic offers the opportunity to refocus efforts on the basics of acute care, knowing that improvements in oxygen will benefit patients both now and in the future.</p>
<p><em>Dr Bernard Olayo – founder and chairman of the <a href="https://www.cphdev.org/">Center for Public Health and Development</a> – and Sheillah Bagayana – a Ugandan biomedical engineer – contributed to the research behind, and the writing of, this article</em></p><img src="https://counter.theconversation.com/content/159754/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Hamish Graham has received research funding from the Bill and Melinda Gates Foundation, WHO, USAID, UK FCDO, and Netherlands MFA. He is an advisor to WHO, UNICEF, Lifebox Foundation, and member of the Oxygen for Life Initiative, Every Breaths Counts, and United for Oxygen coalitions. </span></em></p><p class="fine-print"><em><span>Adegoke Falade has received research funding from the Bill and Melinda Gates Foundation. He is member of the Oxygen for Life Initiative, Every Breaths Counts, and United for Oxygen coalitions.</span></em></p>An effective oxygen system requires prompt recognition of who needs oxygen, a reliable oxygen supply and safe delivery to those who need it.Hamish Graham, Paediatrician, Royal Children's Hospital; Research Fellow, Centre for International Child Health, Royal Children's HospitalAdegoke Falade, Professor of Paediatrics, Department of Paediatrics, University of IbadanLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1564922021-03-09T19:06:34Z2021-03-09T19:06:34ZRSV is a common winter illness in children. Why did it see a summer surge in Australia this year?<figure><img src="https://images.theconversation.com/files/388442/original/file-20210309-19-1xk1uml.jpg?ixlib=rb-1.1.0&rect=8%2C0%2C5742%2C3837&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Winter typically brings a surge in respiratory viral infections, when we see many children running around with runny noses and phlegmy coughs. </p>
<p>But the 2020 Australian winter was very different. Public health measures in place to control the spread of COVID-19 saw a major shift in the typical seasonal pattern of other respiratory viruses. </p>
<p>This has perhaps been most notable with respiratory syncytial virus (RSV), a very common cause of hospitalisation in young children over winter months in <a href="https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(20)30322-2/fulltext">many parts of the world</a>, including <a href="https://www.mja.com.au/journal/2019/210/10/respiratory-syncytial-virus-associated-hospitalisations-australia-2006-2015">Australia</a>.</p>
<p>But following an abnormal winter that saw a significant drop in rates of RSV — we found there were <a href="https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciaa1475/5912591">98% fewer winter cases</a> in Western Australian children — paediatric hospitals around Australia have seen unexpectedly large numbers of children presenting with RSV over summer.</p>
<p>So, what is RSV, and why are these changing trends important?</p>
<h2>A winter lurgy</h2>
<p>RSV typically circulates during winter in temperate climates, <a href="https://theconversation.com/kids-are-more-vulnerable-to-the-flu-heres-what-to-look-out-for-this-winter-117748">much like influenza</a>.</p>
<p>It’s the <a href="https://www.sciencedirect.com/science/article/pii/S0140673617309388?via%3Dihub">major cause of lung infections in children</a>, commonly causing bronchiolitis. Symptoms of RSV <a href="https://www.rch.org.au/kidsinfo/fact_sheets/Respiratory_syncytial_virus_RSV/">include</a> a runny nose, cough, reduced feeding and fever. Complications include wheezing and difficulty breathing, which can develop into pneumonia. </p>
<p>Severe cases <a href="https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(17)30344-3/fulltext">occasionally lead to death</a>, predominantly in very young infants.</p>
<p>Almost all children have had an RSV infection <a href="https://www.cdc.gov/rsv/high-risk/infants-young-children.html">by age two</a>, but infants in their first year of life are more likely to experience severe infections requiring hospitalisation, because their airways are smaller. Babies have also not built up immunity to RSV from previous years (we call this being RSV-naïve).</p>
<p>RSV is spread through respiratory secretions, when an infected person sneezes or coughs. In this way it’s similar to COVID-19. But <a href="https://theconversation.com/coronavirus-school-closures-whats-the-evidence-154210">in contrast to the coronavirus</a>, children are more vulnerable to RSV infection than adults. As a result, RSV is readily spread among children, especially at daycare, kindergarten and school.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/is-it-really-the-flu-the-other-viruses-making-you-ill-in-winter-14895">Is it really the flu? The other viruses making you ill in winter</a>
</strong>
</em>
</p>
<hr>
<h2>How is RSV treated?</h2>
<p>Most children will recover without needing specialist care in hospital, and children with mild infection can be <a href="https://www.rch.org.au/kidsinfo/fact_sheets/Respiratory_syncytial_virus_RSV/">treated with rest at home</a>. </p>
<p>However, many children, particularly young infants, those born prematurely, and children with underlying health issues, are admitted to paediatric wards with severe RSV every year. </p>
<p>Treatment for RSV is focused on helping children with their breathing (for example, giving them oxygen) and feeding (for example, administering fluids through a drip).</p>
<p>There’s no licensed vaccine for RSV, but the <a href="https://www.who.int/immunization/research/development/ppc_rsv_vaccines/en/">World Health Organization</a> considers this a priority, and a number of vaccines are currently in development.</p>
<figure class="align-center ">
<img alt="A doctor holds a stethoscope to a baby's chest." src="https://images.theconversation.com/files/388446/original/file-20210309-19-1wi9rrq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/388446/original/file-20210309-19-1wi9rrq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=403&fit=crop&dpr=1 600w, https://images.theconversation.com/files/388446/original/file-20210309-19-1wi9rrq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=403&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/388446/original/file-20210309-19-1wi9rrq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=403&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/388446/original/file-20210309-19-1wi9rrq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=506&fit=crop&dpr=1 754w, https://images.theconversation.com/files/388446/original/file-20210309-19-1wi9rrq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=506&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/388446/original/file-20210309-19-1wi9rrq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=506&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Infants under one are more vulnerable to a serious case of RSV.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<h2>What happened to RSV in 2020?</h2>
<p>The stay-at-home orders across Australia from late March 2020, and the implementation of quarantine for international arrivals, coincided with the start of the usual RSV and <a href="https://theconversation.com/the-dreaded-duo-australia-will-likely-hit-a-peak-in-coronavirus-cases-around-flu-season-132964">influenza season in Australia</a>. </p>
<p>With these measures in place, <a href="https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciaa1256/5897048">RSV and influenza cases dropped dramatically</a> and <a href="https://www.eurosurveillance.org/content/10.2807/1560-7917.ES.2020.25.47.2001847">remained very low throughout winter</a>. </p>
<p>In Western Australia, despite a relaxation of COVID-related restrictions, including schools reopening from May 2020, there was still a <a href="https://www.telethonkids.org.au/news--events/news-and-events-nav/2020/october/rsv-and-influenza-detections-hit-record-low-levels/">dramatic reduction in RSV cases</a> through winter. This suggests border closures were important in reducing transmission from arriving overseas travellers.</p>
<p>RSV cases remained low until late spring, when a large surge was observed <a href="https://www.health.nsw.gov.au/Infectious/covid-19/Documents/covid-19-surveillance-report-20201212.pdf">in New South Wales</a> and <a href="https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciaa1906/6140790">WA</a>. </p>
<p>The <a href="https://ww2.health.wa.gov.au/-/media/Corp/Documents/Health-for/Infectious-disease/Paediatric-Respiratory-Pathogen-Weekly-Report/2020/Paediatric-Respiratory-Pathogen-Report-Week-53-2020.pdf">speed and magnitude of this increase</a> was greater than the usual winter peak of RSV. </p>
<p>More recently, other states including <a href="https://www.theage.com.au/national/victoria/doctors-on-high-alert-after-surge-in-serious-respiratory-illness-among-children-20210224-p575cu.html">Victoria</a> and <a href="https://www.abc.net.au/news/2021-02-24/rsv-cases-surging-in-south-east-queensland/13186788">Queensland</a> have seen a similar unseasonal rise in RSV cases. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/why-do-kids-tend-to-have-milder-covid-this-new-study-gives-us-a-clue-155555">Why do kids tend to have milder COVID? This new study gives us a clue</a>
</strong>
</em>
</p>
<hr>
<p>It’s likely reductions in COVID-19 restrictions have opened the door for increased RSV spread. Reduced immunity to RSV may also have contributed through both an increase in number of RSV-naïve children and possibly waning RSV immunity in older children related to the delayed season. </p>
<p>Studies seeking to understand exactly why we’ve seen a rise in RSV cases are ongoing.</p>
<h2>Why might the Australian surge be important elsewhere?</h2>
<p>Australia’s experience may carry important lessons for Northern Hemisphere countries, including <a href="https://www.cdc.gov/surveillance/nrevss/rsv/natl-trend.html">the United States</a> and <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/964754/Weekly_Flu_and_COVID-19_report_w8.pdf">the United Kingdom</a>, which saw similar reductions in RSV cases during their winter. </p>
<p>Relaxing of COVID restrictions, which is beginning in many Northern Hemisphere countries now, may provide an opportunity for rapid spread of RSV. Our experience should serve as a warning for paediatric hospitals in the Northern Hemisphere to ensure adequate staffing and available resources to meet the possible increased need.</p>
<figure class="align-center ">
<img alt="Three young children playing with various toys." src="https://images.theconversation.com/files/388448/original/file-20210309-23-1087dc2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/388448/original/file-20210309-23-1087dc2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=398&fit=crop&dpr=1 600w, https://images.theconversation.com/files/388448/original/file-20210309-23-1087dc2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=398&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/388448/original/file-20210309-23-1087dc2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=398&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/388448/original/file-20210309-23-1087dc2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=500&fit=crop&dpr=1 754w, https://images.theconversation.com/files/388448/original/file-20210309-23-1087dc2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=500&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/388448/original/file-20210309-23-1087dc2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=500&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Children mixing less as a result of COVID-19 restrictions likely contributed to the drop in RSV cases during winter.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
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</figure>
<p>Our RSV experience may also be applicable to influenza, which still <a href="https://www.who.int/influenza/surveillance_monitoring/updates/latest_update_GIP_surveillance/en/">remains at very low levels globally</a>. Reduced immunity to influenza due to the skipped 2020 season may result in a very severe season when influenza returns. Seasonal influenza vaccines could be particularly important in 2021 to protect against a possible large resurgence.</p>
<h2>Let’s hold on to our good COVID habits</h2>
<p>The COVID-19 pandemic has shown us the spread of respiratory viruses can be reduced by physical distancing and increased hygiene measures. </p>
<p>While we are (hopefully) unlikely to see prolonged stay-at-home orders again in Australia, ongoing basic measures including hand washing, cough etiquette and keeping snotty children at home can all help reduce the spread of RSV and influenza moving forward. </p>
<p>As we approach the 2021 Australian winter, by doing these simple things, as well as getting our flu vaccines, we can all help protect children, including those most vulnerable, from these important respiratory viruses.</p>
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Read more:
<a href="https://theconversation.com/kids-are-more-vulnerable-to-the-flu-heres-what-to-look-out-for-this-winter-117748">Kids are more vulnerable to the flu – here's what to look out for this winter</a>
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<img src="https://counter.theconversation.com/content/156492/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Daniel Yeoh is supported by an Australian Government Research Training Program Postgraduate Scholarship. </span></em></p><p class="fine-print"><em><span>Hannah Moore receives funding from the Australian National Health and Medical Research Council (NHMRC), Commonwealth and Western Australian State Government.
</span></em></p><p class="fine-print"><em><span>David Anthony Foley and Mejbah Bhuiyan do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Public health measures have helped control COVID-19 in Australia. But they’ve affected other winter viruses, too.Daniel Yeoh, Paediatrician and Infectious Diseases Physician, The University of MelbourneDavid Anthony Foley, Infectious diseases epidemiologist, Telethon Kids InstituteHannah C Moore, Co-Head, Infectious Diseases Epidemiology, Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids InstituteMejbah Bhuiyan, Post-Doctoral Researcher, Telethon Kids InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1489282020-11-04T14:42:11Z2020-11-04T14:42:11ZSouth Africa is testing digital technology to detect outbreaks of respiratory diseases<figure><img src="https://images.theconversation.com/files/367159/original/file-20201103-15-s7q2sv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">shutterstock</span> </figcaption></figure><p>Global mobility has increased and the world has become more connected. But this comes with a greater risk of the spread of respiratory diseases, particularly pneumonia, which is a leading <a href="https://www.who.int/news-room/fact-sheets/detail/children-reducing-mortality">cause of death</a> in children under the age of five and the elderly. Real-time and more accurate data about respiratory diseases are critical for public health response – especially during an outbreak. </p>
<p><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5030548/">Pneumonia</a> is a lower respiratory tract infection. It’s caused by very small organisms that cause the air sacs in the lungs to fill up with fluid. This makes breathing difficult and may lead to death. Data from respiratory disease surveillance programmes help public health officials to detect potential clusters that may lead to widespread outbreaks and implement strategies to minimise the impact. </p>
<p>Information collected in clinics and hospitals doesn’t provide the full picture of an illness. This information depends on people actually going to health facilities, which doesn’t always happen. Some people may not be severely ill, or may not be able to get to the health facility. And there may not be adequate laboratory capacity to run tests.</p>
<p>Relying on facilities for information about illnesses makes it difficult to detect an outbreak or seasonal increase as it happens – and hard to estimate the total case numbers. There can be a delay and under-reporting, which makes the public health response less effective. The sooner a cluster of cases is detected, the better it can be managed.</p>
<p>These days there are other ways to collect information about illnesses, using technology. They fall under the description of <a href="https://www.researchgate.net/publication/263742723_Public_health_for_the_people_Participatory_infectious_disease_surveillance_in_the_digital_age">digital participatory surveillance</a>. These are platforms that allow people to routinely report their own symptoms via the internet, on a mobile application or through social media <a href="https://pubmed.ncbi.nlm.nih.gov/24350723/">surveys</a>. They can also record questions about health-seeking behaviour. Health authorities can then analyse the digitally collected data, obtain a bigger picture of how prevalent a disease is in a population, and see trends that allow the health system to prepare and manage better.</p>
<p>The National Institute for Communicable Diseases in South Africa is planning a pilot phase of a digital participatory surveillance platform. The aim is to assess the feasibility and inform its structure, before incorporating it into the existing facility-based surveillance programmes. In particular, this pilot phase will be used to survey respiratory diseases such as influenza and potentially COVID-19.</p>
<p>Influenza is a vaccine preventable disease and one of the causes of pneumonia. It causes an estimated <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6692552/">11,000 deaths</a> every year in South Africa. With regard to COVID-19, which can also cause pneumonia, the pilot phase may potentially assist in detecting a big increase in cases at an early stage.</p>
<p>The success of a digital participatory surveillance programme depends on the consistent participation of the population.</p>
<p>South Africa already has another technological tool designed to combat the pandemic: the COVID-19 Alert app. But that is intended for contact tracing, by helping the user ascertain whether they have been in close proximity to a confirmed COVID-19 case. It’s different from digital participatory surveillance apps that are intended for long-term surveillance of respiratory diseases beyond COVID-19, and do not serve contact tracing purposes. </p>
<h2>Digital surveillance</h2>
<p>Digital participatory surveillance is relatively low-cost and easily scaleable to any disease of public health significance. Users report on a weekly basis whether they have experienced symptoms related to respiratory illness or not. This allows for real-time estimation of cases without relying on access to medical care or testing capacity. This data can also be used to <a href="https://www.researchgate.net/publication/315869302_Using_Participatory_Web-based_Surveillance_Data_to_Improve_Seasonal_Influenza_Forecasting_in_Italy">forecast</a> how outbreaks might spread in a community. </p>
<p>To date, digital participatory surveillance has not been widely used on the African continent, despite its potential value. But it’s been used in other parts of the world.</p>
<p>The first platform of this kind was launched in Europe in the 2003/2004 influenza season and they are now used in several countries, where they have been able to <a href="https://pubmed.ncbi.nlm.nih.gov/28076411/">detect flu outbreaks earlier</a>. The <a href="https://flunearyou.org/#!/">USA</a>, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3294562/">Australia</a> and Mexico have their own digital participatory surveillance programmes. Today, 11 European countries have established a continent-based digital participatory surveillance network called <a href="https://pubmed.ncbi.nlm.nih.gov/26616039/">InfluenzaNet</a>. This allows for a comparison of trends within and between countries in Europe. </p>
<p>Countries in Europe, and the US and Australia have increased and sustained participation on these platforms through media campaigns and public health messaging. The National Institute for Communicable Diseases is employing similar strategies through public relations and media in South Africa.</p>
<p>South Africa’s digital participatory surveillance will face some important challenges, though. </p>
<p>Firstly, information and communications technology is <a href="https://www.researchgate.net/publication/285593353_ICT_Adoption_in_South_Africa_-_Opportunities_Challenges_and_Implications_for_national_development">limited</a>. Some parts of the country may not have internet connectivity. </p>
<p>Secondly, the <a href="https://www.tandfonline.com/doi/full/10.1080/1369118X.2015.1065285?scroll=top&needAccess=true">digital divide</a> within a population means segments of the demographic may not be fully represented, because not everyone has access to smartphones or internet connectivity. </p>
<p>There may be some concerns and scepticism around <a href="https://sigmapubs.onlinelibrary.wiley.com/doi/full/10.1111/j.1741-6787.2012.00243.x">social media</a> and mobile apps with regard to data confidentiality and privacy. These are longstanding challenges that both government and various industries need to address.</p>
<h2>Moving forward</h2>
<p>As the digital world evolves, there is an opportunity to use technology to solve critical problems in public health. </p>
<p>Digital participatory surveillance allows the community to share in the responsibility of disease surveillance and contribute to the control and prevention of respiratory disease outbreaks.</p><img src="https://counter.theconversation.com/content/148928/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Cheryl Cohen receives funding from United States Centres for Disease Control and Prevention and Wellcome Trust UK. </span></em></p><p class="fine-print"><em><span>Mvuyo Makhasi is currently the project lead for digital participatory surveillance that will be launched by the National Institute for Communicable Diseases</span></em></p><p class="fine-print"><em><span>Sibongile Walaza does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Digital participatory surveillance allows the community to share in the responsibility of disease surveillance and contribute to the control and prevention of respiratory disease outbreaks.Cheryl Cohen, co-head of the Centre for Respiratory Disease and Meningitis, National Institute for Communicable DiseasesSibongile Walaza, Medical Epidemiologist at the National Institute of Communicable Diseases and Lecturer at the School of Public Health, University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1476932020-11-02T14:23:52Z2020-11-02T14:23:52ZNew diagnostic test rapidly identifies bugs responsible for pneumonia<figure><img src="https://images.theconversation.com/files/364468/original/file-20201020-14-1ag42p9.jpg?ixlib=rb-1.1.0&rect=8%2C0%2C5982%2C3709&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The device was tested at Addenbroke's hospit</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/doctor-examining-chest-xray-film-patient-548009926">create jobs 51/Shutterstock</a></span></figcaption></figure><p>Pneumonia is one of the world’s deadliest infectious diseases, killing around <a href="https://stoppneumonia.org/wp-content/uploads/2018/11/The-Missing-Piece_-0611_Spread.pdf">2.6 million people</a> a year. In severe pneumonia, the tiny air sacs inside the lungs become filled with so much fluid and pus that patients struggle to breathe. In many people, this is fatal. </p>
<p>Patients can deteriorate very quickly, which means treatment is often given based on the person’s symptoms without knowing the underlying pathogen causing the condition. Part of the problem is that it can take several days to culture a patient’s specimen. </p>
<p>Because of the slowness in getting laboratory results, doctors often give patients best-guess antibiotics, followed by a different antibiotic if the first course doesn’t work. Sadly, in many cases, none of the antibiotics work and, in some cases, they can even harm the patient. </p>
<p>A new, cheap and rapid diagnostic system, developed by scientists (including co-author of this article, Andrew Morris) at Addenbrooke’s Hospital in Cambridge, England, could transform pneumonia care. An early trial of the diagnostic, conducted in the adult intensive care unit at Addenbrooke’s Hospital, showed that it can identify the pathogen responsible for severe pneumonia in patients on ventilators in just <a href="https://www.medrxiv.org/content/10.1101/2020.06.02.20118489v3">four hours</a>. This compares with 61 hours needed to turn around a result using conventional culturing methods. It can also detect bacteria known to cause pneumonia often not picked up with conventional methods. </p>
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<img alt="Left, Martin Curran in his lab holding the array. Right, closeup of the card." src="https://images.theconversation.com/files/365213/original/file-20201023-19-12eqhl8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/365213/original/file-20201023-19-12eqhl8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/365213/original/file-20201023-19-12eqhl8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/365213/original/file-20201023-19-12eqhl8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/365213/original/file-20201023-19-12eqhl8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/365213/original/file-20201023-19-12eqhl8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/365213/original/file-20201023-19-12eqhl8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Martin Curran, the Cambridge scientist responsible for developing the array card.</span>
<span class="attribution"><span class="source">Lara Marks</span>, <span class="license">Author provided</span></span>
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<p>The new test uses what’s known as an array card. It contains tiny wells loaded with DNA sequences that match those of common microbes that cause pneumonia. If that DNA sequence is present in a patient sample, the array card amplifies it so that it can be detected.</p>
<p>The card includes genes from <a href="https://www.medrxiv.org/content/10.1101/2020.06.02.20118489v3">52 respiratory pathogens</a> commonly found in ventilated patients with pneumonia. Many different microbes can cause pneumonia. This includes viruses such as SARS-CoV-2 and flu as well as bacteria and fungi. A number of things determine which type of organism causes the disease, including where the patient picked up the disease – in the community or in a hospital – and the condition of their immune system.</p>
<p>Encouragingly the array card’s fast turnaround of results had a measurable effect on the choices ICU doctors at Addenbrooke’s Hospital made. Over half of the doctors changed their antibiotic prescriptions, with most changes leading to <a href="https://www.medrxiv.org/content/10.1101/2020.06.02.20118489v3">fewer antibiotics</a> being used.</p>
<p>The team also tested the diagnostic in patients admitted to the ICU with COVID-19, by loading sequences for the virus on to the array card. It proved very helpful in picking up secondary bacterial and fungal pneumonia in patients on ventilators. Patients with COVID-19 were found to be highly susceptible to these secondary cases of pneumonia, many of which were caused by hard-to-treat multidrug-resistant bugs. </p>
<h2>Customisable</h2>
<p>The array card is customisable. Single targets can be added or modified without having to re-optimise the entire panel. The team chose to target genes based on their local experience with pneumonia and antibiotic resistance. </p>
<p>The array card diagnostic is now integral to the management of the COVID-19 pandemic in the ICU at Addenbrooke’s Hospital. It has proven particularly useful for separating patients who have the virus from those who do not. This has helped to improve safety on the ward and free up beds and nursing staff. </p>
<p>The developers of the test hope to roll out the array card system globally. One of its attractions is that it can be quickly adjusted to take account of the different pathogens in different locations, as well as different patterns of drug resistance. This is vital for more precise antibiotic treatment and preventing the spread of antimicrobial resistance.</p>
<p>For those admitted to intensive care with pneumonia, the risk of dying is high, between <a href="https://respiratory-research.biomedcentral.com/articles/10.1186/s12931-016-0397-5">15% and 50%</a>. Many who survive are also often left with chronic ill health, including weakened muscles and heart problems. The speed and completeness of a patient’s recovery depend a lot on their <a href="https://erj.ersjournals.com/content/49/6/1700571">age and the pathogen</a> that caused their infection. </p>
<p>Thankfully, there is now a test that can rapidly identify the pathogen so that effective treatment can started sooner. The new test is particularly important because pneumonia remains a stubbornly persistent disease which imposes a major burden on healthcare resources. Pneumonia is the most common secondary infection patients acquire when in ICU. A <a href="https://jeccm.amegroups.com/article/view/4830/html">large proportion</a> of pneumonia acquired in the ICU is linked to mechanical ventilation.</p><img src="https://counter.theconversation.com/content/147693/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lara Marks has received funding from the UK Medical Research Council and the National Institute for Health Research Cambridge Biomedical Research Centre.</span></em></p><p class="fine-print"><em><span>Andrew Morris receives funding from the Wellcome Trust. </span></em></p>It takes around 61 hours to identify the pathogen causing a patient’s pneumonia. A new test reduces that to four hours.Lara Marks, Visiting Research Fellow, History of Biomedical Sciences, University of CambridgeAndrew Conway Morris, Senior Research Associate, Anaesthesia and Intensive Care Medicine, University of CambridgeLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1419402020-08-07T12:37:28Z2020-08-07T12:37:28ZHow COVID-19 might increase risk of memory loss and cognitive decline<figure><img src="https://images.theconversation.com/files/350502/original/file-20200730-13-i8elh1.jpg?ixlib=rb-1.1.0&rect=45%2C57%2C7622%2C5265&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">More and more studies are revealing the cognitive effects of COVID-19.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/rendering-illustration-coronavirus-x-rays-lung-show-royalty-free-image/1217077007?adppopup=true">Amornrat Phuchom / Getty Images</a></span></figcaption></figure><p>Of all frightening ways that the SARS-COV-2 virus affects the body, one of the more insidious is the effect of COVID-19 on the brain. </p>
<p>It is now clear that many patients suffering from COVID-19 exhibit neurological symptoms, from <a href="http://doi.org/10.1007/s12028-020-01049-4">loss of smell, to delirium, to an increased risk of stroke</a>. There are also longer-lasting consequences for the brain, including <a href="https://www.statnews.com/2020/07/21/chronic-fatigue-syndrome-keys-understanding-post-covid-syndrome/">myalgic encephalomyelitis /chronic fatigue syndrome</a> and <a href="https://theconversation.com/rare-neurological-disorder-guillain-barre-syndrome-linked-to-covid-19-141511">Guillain-Barre syndrome</a>. </p>
<p>These effects may be caused by direct viral infection of <a href="http://doi.org/10.1111/ene.14442">brain tissue</a>. But growing evidence suggests <a href="http://doi.org/10.1007/s12028-020-01049-4">additional indirect actions</a> triggered via the virus’s infection of epithelial cells and the cardiovascular system, or through the immune system and inflammation, contribute to lasting neurological changes after COVID-19.</p>
<p><a href="https://sites.lsa.umich.edu/tronson-lab/">I am a neuroscientist</a> specializing in how memories are formed, the role of immune cells in the brain and <a href="http://doi.org/10.1016/j.nlm.2019.01.003">how memory is persistently disrupted</a> <a href="http://doi.org/10.1016/j.neuroscience.2019.12.019">after illness and immune activation</a>. As I survey the emerging scientific literature, my question is: Will there be a COVID-19-related wave of memory deficits, cognitive decline and dementia cases in the future?</p>
<h2>The immune system and the brain</h2>
<p>Many of the symptoms we attribute to an infection are really due to the protective responses of the immune system. A runny nose during a cold is not a direct effect of the virus, but a result of the immune system’s response to the cold virus. This is also true when it comes to feeling sick. <a href="http://doi.org/10.1111/j.1749-6632.1998.tb09597.x">The general malaise, tiredness, fever and social withdrawal</a> are caused by activation of specialized immune cells in the brain, called neuroimmune cells, and signals in the brain. </p>
<p>These changes in brain and behavior, although annoying for our everyday lives, are highly adaptive and immensely beneficial. By resting, you allow the energy-demanding immune response to do its thing. A fever makes the body less hospitable to viruses and increases the efficiency of the immune system. Social withdrawal may help decrease spread of the virus. </p>
<p>In addition to changing behavior and regulating physiological responses during illness, the specialized immune system in the brain also plays a number of other roles. It has recently become clear that the <a href="http://doi.org/10.1016/J.CELL.2018.05.002">neuroimmune cells that sit at the connections</a> <a href="http://doi.org/10.1016/J.IT.2015.08.008">between brain cells (synapses)</a>, which <a href="http://doi.org/10.1002/glia.23250">provide energy</a> and <a href="http://doi.org/10.1016/j.psyneuen.2007.09.004">minute quantities of inflammatory signals</a>, are essential for normal memory formation. </p>
<p>Unfortunately, this also provides a way in which illnesses like COVID-19 can cause both acute neurological symptoms and <a href="http://doi.org/10.1186/s13195-020-00640-3">long-lasting issues in the brain</a>.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/351415/original/file-20200805-20-icyabz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/351415/original/file-20200805-20-icyabz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/351415/original/file-20200805-20-icyabz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/351415/original/file-20200805-20-icyabz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/351415/original/file-20200805-20-icyabz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=565&fit=crop&dpr=1 754w, https://images.theconversation.com/files/351415/original/file-20200805-20-icyabz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=565&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/351415/original/file-20200805-20-icyabz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=565&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Microglia are specialized immune cells in the brain. In healthy states, they use their arms to test the environment. During an immune response, microglia change shape to engulf pathogens. But they can also damage neurons and their connections that store memory.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/illustration/microglial-cell-illustration-royalty-free-illustration/1148112416?adppopup=true">JUAN GAERTNER/SCIENCE PHOTO LIBRARY / Getty Images</a></span>
</figcaption>
</figure>
<p>During illness and inflammation, the specialized immune cells in the brain become activated, spewing vast quantities of inflammatory signals, and modifying how they communicate with neurons. <a href="http://doi.org/10.1016/j.nlm.2013.07.002">For one type of cell, microglia,</a> this means changing shape, withdrawing the spindly arms and becoming blobby, mobile cells that envelop potential pathogens or cell debris in their path. But, in doing so, they also destroy and <a href="http://doi.org/10.1016/j.nlm.2013.07.002">eat the neuronal connections that are so important for memory storage</a>. </p>
<p>Another type of neuroimmune cell <a href="http://doi.org/10.1016/j.neuroscience.2018.11.010">called an astrocyte, typically wraps around the connection</a> between neurons during illness-evoked activation and dumps inflammatory signals on these junctions, effectively preventing the changes in connections between neurons that store memories. </p>
<p>Because COVID-19 involves a <a href="https://theconversation.com/blocking-the-deadly-cytokine-storm-is-a-vital-weapon-for-treating-covid-19-137690">massive release of inflammatory signals</a>, the impact of this disease on memory is particularly interesting to me. That is because there are both short-term effects on cognition (delirium), and the potential for long-lasting changes in memory, attention and cognition. There is also an <a href="https://pubmed.ncbi.nlm.nih.gov/30760633/">increased risk for cognitive decline and dementia,</a> including Alzheimer’s disease, during aging.</p>
<h2>How does inflammation exert long-lasting effects on memory?</h2>
<p>If activation of neuroimmune cells is limited to the duration of the illness, then how can inflammation cause long-lasting memory deficits or increase the risk of cognitive decline?</p>
<p>Both the brain and the immune system have specifically evolved to change as a consequence of experience, in order to neutralize danger and maximize survival. In the brain, changes in connections between neurons allows us to store memories and rapidly change behavior to escape threat, or seek food or social opportunities. The immune system has evolved to fine-tune the inflammatory response and antibody production against previously encountered pathogens.</p>
<p>Yet long-lasting changes in the brain after illness are also closely linked to increased risk for age-related cognitive decline and Alzheimer’s disease. The disruptive and destructive actions of neuroimmune cells and inflammatory signaling can permanently impair memory. This can occur through <a href="http://doi.org/10.1038/s41577-018-0112-5">permanent damage to the neuronal connections or neurons themselves</a> and also via more <a href="http://doi.org/10.1016/j.neuroscience.2019.12.019">subtle changes in how neurons function.</a></p>
<p>The potential connection between COVID-19 and persistent effects on memory are based on observations of other illnesses. For example, many patients who recover from <a href="http://doi.org/10.1097/ALN.0000000000001143;%20http://doi.org/10.1056/NEJM200102083440601">heart attack or bypass surgery</a> report lasting <a href="http://doi.org/10.1016/j.pnpbp.2012.06.011">cognitive deficits that become exaggerated during aging</a>. </p>
<p>Another major illness with a similar cognitive complications is <a href="http://doi.org/10.1016/S2213-2600(14)70246-2">sepsis</a> – multi-organ dysfunction triggered by inflammation. In animal models of these diseases, we also see impairments of memory, and changes in neuroimmune and neuronal function that persist weeks and months after illness. </p>
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<p>Even <a href="http://doi.org/10.1016/J.BBI.2018.10.002">mild inflammation</a>, <a href="http://doi.org/10.1016/j.ynstr.2018.05.003">including chronic stress</a>, are now recognized as risk factors for dementias and cognitive decline during aging. </p>
<p>In my own laboratory, I and my colleagues have also observed that even without bacterial or viral infection, triggering inflammatory signaling over a short-term period results in <a href="http://doi.org/10.1016/j.neuroscience.2019.12.019">long-lasting changes in neuronal function in memory-related brain regions</a> and <a href="http://doi.org/10.1016/j.nlm.2019.01.003">memory impairments</a>.</p>
<h2>Does COVID-19 increase risk for cognitive decline?</h2>
<p>It will be many years before we know whether the COVID-19 infection causes an increased risk for cognitive decline or Alzheimer’s disease. But this risk may be decreased or mitigated through prevention and treatment of COVID-19. </p>
<p>Prevention and treatment both rely on the ability to decrease the severity and duration of illness and inflammation. Intriguingly, very new research suggests that common vaccines, including the <a href="https://www.alz.org/aaic/downloads2020/AAIC2020-Vaccines.pdf">flu shot and pneumonia vaccines, may reduce risk for Alzheimer’s</a>. </p>
<p>Additionally, several emerging treatments for COVID-19 are drugs that <a href="http://doi.org/10.1093/cid/ciaa812">suppress excessive immune activation</a> <a href="http://doi.org/10.1126/sciimmunol.abd0110">and inflammatory state</a>. Potentially, these treatments will also reduce the impact of inflammation on the brain, and decrease the impact on long-term brain health.</p>
<p>COVID-19 will continue to impact health and well-being long after the pandemic is over. As such, it will be critical to continue to assess the effects of COVID-19 illness in vulnerability to later cognitive decline and dementias.</p>
<p>In doing so, researchers will likely gain critical new insight into the role of inflammation across the life-span in age-related cognitive decline. This will aid in the development of more effective strategies for prevention and treatment of these debilitating illnesses.</p><img src="https://counter.theconversation.com/content/141940/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Natalie C. Tronson receives funding from the National Institutes of Health. </span></em></p>Many patients suffering from COVID-19 exhibit neurological symptoms, from loss of smell to delirium to a higher risk of stroke. Down the road, will COVID-19 survivors face a wave of cognitive issues?Natalie C. Tronson, Associate Professor of Psychology, University of MichiganLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1425232020-07-13T14:54:40Z2020-07-13T14:54:40ZCoronavirus: Kazakhstan denies ‘unknown pneumonia’ reports but has imposed second national lockdown<figure><img src="https://images.theconversation.com/files/347062/original/file-20200713-62-10o09gc.JPG?ixlib=rb-1.1.0&rect=60%2C80%2C2627%2C1696&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Industrial premises being disinfected in Kazakhstan's capital, Nur-Sultan city.</span> <span class="attribution"><span class="source">Turar Kazangapov</span></span></figcaption></figure><p>Kazakhstan became the first country in the world to enter <a href="https://thediplomat.com/2020/07/kazakhstan-locks-down-again-as-covid-19-cases-rise/">a second nationwide lockdown</a> on July 5 following a spike in coronavirus cases. The two-week lockdown, which could be extended if the spread of the virus continues, restricts public gatherings and bans family and holiday gatherings. Citizens over 65 are expected to stay home, but others are allowed to exercise outdoors on their own. </p>
<p>The number of coronavirus cases in Kazakhstan has grown tenfold since the first lockdown measures began to be lifted. By May 11, the last day of the state of emergency and lockdown, Kazakhstan <a href="https://informburo.kz/novosti/koronavirus-v-kazahstane-situaciya-na-11-maya-live.html">had registered</a> 5,207 coronavirus cases and 32 deaths. As of July 13, <a href="https://www.worldometers.info/coronavirus/country/kazakhstan/">there were</a> 59,899 confirmed coronavirus cases and 375 deaths in the country. But the situation is evolving quickly and could be a lot worse than this. </p>
<p>On July 8, the Chinese embassy in Kazakhstan <a href="https://edition.cnn.com/2020/07/10/asia/kazakhstan-pneumonia-intl-hnk-scli-scn/index.html">warned Chinese citizens</a> that the country had an “unknown pneumonia” outbreak more deadly than COVID-19. The following day, the Kazakhstani health ministry <a href="https://edition.cnn.com/2020/07/10/asia/kazakhstan-pneumonia-intl-hnk-scli-scn/index.html">acknowledged</a> the presence of viral pneumonias of “unspecified” cause, but denied that the outbreak was new or unknown. The newly appointed health minister, Alexey Tsoy, declared that the claim published by Chinese media “<a href="https://www.themoscowtimes.com/2020/07/10/kazakhstan-denies-chinas-claim-of-new-deadly-virus-a70839">does not correspond to reality</a>”. </p>
<p>Serious concerns have been raised about the pneumonia data. Between July 1 and 8, Kazakhstan registered <a href="https://www.zakon.kz/5031511-tokaev-o-pnevmonii-situatsiya.html">56,809 cases of pneumonia</a> – on top of the confirmed cases of COVID-19. These pneumonia cases included the “usual pneumonia” – viral (7,348) and bacterial (9,759) – as well as 39,702 “unspecified” viral pneumonia cases which have a similar course of disease as coronavirus, according to the health minister. Pneumonia patients with <a href="https://www.bbc.com/news/world-asia-53363024">negative coronavirus tests</a> are not included in the government’s official statistics of coronavirus. </p>
<p>Mike Ryan, head of the WHO’s emergencies programme, suggested that many cases linked to the highly lethal pneumonia could be in fact “<a href="https://www.reuters.com/article/us-health-coronavirus-who-kazakhstan-idUSKBN24B2GA">undiagnosed cases of COVID-19</a>” – which would show the government is nowhere near in control of the pandemic. </p>
<p>How has Kazakhstan, <a href="https://www.washingtontimes.com/news/2020/may/20/kazakhstan-is-an-anti-pandemic-model-for-central-a/">referred to</a> in May as “an anti-pandemic model for Central Asia” turned into such a bad example of <a href="https://www.telegraph.co.uk/news/2020/07/04/kazakhstan-becomes-first-country-re-impose-nationwide-lockdown/">how not to do COVID</a>?</p>
<h2>Success unravels</h2>
<p>Kazakhstan was quick to introduce a <a href="https://theconversation.com/how-central-asias-authoritarian-regimes-have-used-coronavirus-to-their-advantage-138498">Soviet-style military lockdown</a> and quarantine measures – which included suppressing dissent. It also introduced a <a href="https://www.inform.kz/en/kzt-150b-allocated-from-government-and-regional-budget-during-pandemic-tokayev_a3671292">substantial package</a> of financial measures to fight the pandemic, and <a href="https://thediplomat.com/2020/05/kazakhstans-coronavirus-payments-the-quest-for-42500-tenge/">monthly payments</a> for people who lost their income during the state of emergency in April and May. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/346973/original/file-20200712-42-4i53yu.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/346973/original/file-20200712-42-4i53yu.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/346973/original/file-20200712-42-4i53yu.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/346973/original/file-20200712-42-4i53yu.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/346973/original/file-20200712-42-4i53yu.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/346973/original/file-20200712-42-4i53yu.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/346973/original/file-20200712-42-4i53yu.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A new normality for Kazakhstani citizens in Nur-Sultan city in June.</span>
<span class="attribution"><span class="source">Turar Kazangapov</span></span>
</figcaption>
</figure>
<p>But once the quarantine measures eased, many Kazakhstani citizens began to ignore social-distancing guidance. Many <a href="https://astanatimes.com/2020/06/kazakh-minister-of-healthcare-worried-people-not-following-lockdown-measures/">underestimated the risks</a> of the virus: they hurried to offices, cafes, pubs, parks and fitness centres. Families gathered for large weddings, birthdays and funerals. Soon, <a href="https://www.gallup-international.bg/en/43073/the-coronavirus-a-vast-scared-majority-around-the-world-according-to-the-snap-poll-by-gallup-international-association/">initial optimism</a> about the government’s handling of the virus would be replaced with panic, helplessness and disillusion.</p>
<p>In June, Kazakhstan’s former president, Nursultan Nazarbayev, <a href="https://www.euronews.com/2020/06/18/kazakhstan-s-former-president-and-health-minister-test-positive-for-coronavirus">tested positive for coronavirus</a>. Soon after, many ministers, MPs and local mayors tested positive and self-isolated. On June 25, the health minister, Yelzhan Birtanov, who developed pneumonia from a COVID-19 infection, <a href="https://www.reuters.com/article/us-health-coronavirus-kazakhstan/kazakh-health-minister-resigns-amid-coronavirus-crisis-idUSKBN23W1NT">announced his resignation</a>. </p>
<p><a href="https://www.themoscowtimes.com/2020/05/28/russia-to-stop-counting-asymptomatic-coronavirus-cases-deaths-health-ministry-a70404">Following Russia’s example</a>, in June the Kazakhstani health ministry started recording asymptomatic infections separately from the official number of the coronavirus cases. The <a href="https://vlast.kz/novosti/40078-minzdrav-kazahstana-obasnil-razdelenie-pacientov-s-simptomami-covid-19-i-bez-nih-raznym-urovnem-zaraznosti.html">government claimed</a> that this was justified because symptomatic patients pose a greater epidemiological danger to others and require clinical observation. But on July 1, the health ministry made a U-turn, and began <a href="https://akipress.com/news:644610:Kazakhstan_adds_asymptomatic_cases_into_tally_of_confirmed_COVID-19_cases,_41,065_in_total/">updating COVID-19</a> statistics without dividing the cases into symptomatic and asymptomatic, which boosted the official number of cases.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/347047/original/file-20200713-22-9abnnw.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/347047/original/file-20200713-22-9abnnw.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/347047/original/file-20200713-22-9abnnw.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/347047/original/file-20200713-22-9abnnw.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/347047/original/file-20200713-22-9abnnw.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/347047/original/file-20200713-22-9abnnw.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/347047/original/file-20200713-22-9abnnw.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Disinfection of a public bus in Kazakhstan’s capital, Nur-Sultan city.</span>
<span class="attribution"><span class="source">Turar Kazangapov</span></span>
</figcaption>
</figure>
<h2>Rising anger</h2>
<p>As a result of the spike in coronavirus and pneumonia cases, citizens have <a href="https://eurasianet.org/kazakhstan-grapples-uneasily-with-its-second-coronavirus-wave">complained about</a> overcrowded hospitals, lack of COVID-19 tests, <a href="https://www.bbc.com/news/world-asia-53363024">long queues</a> for testing laboratories and pharmacies, and a <a href="https://en.fergana.news/articles/119759/">deficit of medicines</a>. </p>
<p><a href="https://kazakh-tv.kz/en/view/society/page_214607_president-tokayev-urges-against-panic-buying-of-medicines">Panic-buying of medicines</a> has led to speculation and the sale of drugs on the black market at much higher prices. At the outbreak of the pandemic, Kazakhstan received international humanitarian support, including from the <a href="https://kz.usembassy.gov/the-u-s-provides-additional-assistance-to-kazakhstan-to-respond-to-covid-19/">US</a>, <a href="https://www.inform.kz/en/china-sends-5-tons-of-humanitarian-aid-to-kazakhstan_a3636117">China</a> and <a href="https://www.inform.kz/en/russia-sends-humanitarian-aid-to-kazakhstan-to-fight-covid-19_a3670329">Russia</a>. Now <a href="https://tengrinews.kz/kazakhstan_news/skandal-sotssetyah-farmatsevtov-obvinili-prodaje-407693/">social media has been flooded</a> with photos of medicines bought at pharmacies with stickers showing they were donated as humanitarian aid and so should not be for sale.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/347059/original/file-20200713-50-p28ouo.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/347059/original/file-20200713-50-p28ouo.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=899&fit=crop&dpr=1 600w, https://images.theconversation.com/files/347059/original/file-20200713-50-p28ouo.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=899&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/347059/original/file-20200713-50-p28ouo.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=899&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/347059/original/file-20200713-50-p28ouo.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1129&fit=crop&dpr=1 754w, https://images.theconversation.com/files/347059/original/file-20200713-50-p28ouo.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1129&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/347059/original/file-20200713-50-p28ouo.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1129&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Fireworks amid the mourning: Capital Day was celebrated in Nur-Sultan city on July 6.</span>
<span class="attribution"><span class="source">Turar Kazangapov</span></span>
</figcaption>
</figure>
<p><a href="https://www.palgrave.com/gp/book/9789811506093">Communication</a> has never been a strong point of the Kazakhstani authorities. Amid the pandemic and citizens’ mourning for their family members, online concerts and fireworks were organised on July 6 <a href="https://www.inform.kz/en/kazakhstan-celebrates-capital-day_a3669537">to celebrate</a> Capital Day in Nur-Sultan city, which coincided with the <a href="https://www.neweurope.eu/article/kazakhstan-celebrates-capital-day-nazarbayevs-birthday/">80th birthday of Nazarbayev</a>, known as the “leader of the nation”. The official authorities said that they hoped to cheer up <a href="https://eurasianet.org/kazakhstan-nur-sultan-revelry-sparks-ire-as-coronavirus-crisis-escalates">front-line medical workers</a>. </p>
<p>In response to the overwhelming public criticism, the <a href="https://astanatimes.com/2020/07/kazakhstan-declares-july-13-as-day-of-national-mourning-for-covid-19-victims/">government declared</a> July 13 a day of national mourning for COVID-19 victims. Such <a href="https://link.springer.com/referenceworkentry/10.1007/978-3-030-03008-7_55-1">public acknowledgement</a> of failure by a central Asian government is exceptional. </p>
<p>The Kazakhstani president, Qasym-Jomart Toqayev, <a href="https://astanatimes.com/2020/07/tokayev-chairs-expanded-government-meeting-considers-firing-officials-for-failing-to-handle-pandemic/">announced the possible dissolution</a> of the entire cabinet if the situation does not improve by the end of July. </p>
<p>The pandemic has exposed the weaknesses of a government built on <a href="https://onlinelibrary.wiley.com/doi/full/10.1002/pad.1873">endemic corruption</a>, patronage and <a href="https://journals.sagepub.com/doi/10.1177/0734371X19888009">personal loyalty to politicians</a>. Kazakhstan is now paralysed amid a crisis which requires strong and effective government institutions, evidence-based decision-making and public accountability – none of which are strengths of this authoritarian government.</p><img src="https://counter.theconversation.com/content/142523/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Saltanat Janenova is affiliated with the Graduate School of Public Policy, Nazarbayev University (Kazakhstan). </span></em></p>How Kazakhstan failed to deal with COVID-19 and became the first country to enter a second national lockdown.Saltanat Janenova, Teaching Fellow in Public Policy and Management, University of BirminghamLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1414622020-07-12T08:33:13Z2020-07-12T08:33:13ZWhy people don’t get emergency medical care in time: a study in South Africa<figure><img src="https://images.theconversation.com/files/346975/original/file-20200712-189216-froesn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Queue of seated outpatients, waiting patiently inside Provincial Hospital corridor in Port Elizabeth</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Many medical conditions, such as serious injuries, sepsis and heart attacks, need high quality emergency care quickly – or the patient may die. These time-critical conditions cause around <a href="https://www.ncbi.nlm.nih.gov/books/NBK333513/">half</a> of all deaths worldwide, it’s been estimated, and they are more common in countries with lower incomes. </p>
<p>Dangerous delays may happen at three points: the patient deciding to seek care, reaching a healthcare facility, or receiving quality care at that facility. The <a href="https://apps.who.int/gb/ebwha/pdf_files/WHA72/A72_R16-en.pdf?ua=1">World Health Assembly</a> has called for improved care for time-critical conditions, but the necessary development and research hasn’t always received enough funding.</p>
<p>One of the reasons for this lack of attention may be a scarcity of information. It’s difficult to record deaths and their causes accurately in settings where <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(07)61307-5/fulltext">civil registration systems</a> and health records are poor. But in some countries <a href="https://www.who.int/healthinfo/statistics/verbalautopsystandards/en/">verbal autopsies</a>, which are interviews with the relative or carer of the deceased, are performed to find out more about the circumstances around a death and what most likely caused it. Also, during a verbal autopsy, information is asked about where and when the patient sought care.</p>
<p>We carried out a study in the <a href="https://www.agincourt.co.za/">Agincourt</a> area of Mpumalanga province, South Africa, to find out more about deaths from time-critical conditions. We wanted to know what prevented people from seeking, reaching and receiving quality care in this rural area of South Africa, where access to multiple healthcare facilities via paved roads is possible. </p>
<p>Our <a href="https://gh.bmj.com/content/5/4/e002289">study reviewed</a> 15,305 verbal autopsies. We developed a locally appropriate definition of time-critical conditions and looked at the numbers of deaths due to these, how numbers have changed over time, and how the numbers differed by age and sex. We also looked at delays in accessing care for these conditions and where people went for care (if they did try to get any care). </p>
<p>We found that time-critical conditions are responsible for a substantial burden of deaths in this rural South African population. Delays in seeking and receiving quality care were more prominent than delays in reaching care. </p>
<h2>What we found</h2>
<p>We used the <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)60707-2/fulltext">definition of time-critical conditions</a> as “those requiring prompt medical care within 12 hours from the onset of symptoms recognised by a layperson to prevent death.” Some of the most common conditions we saw in the study were obstetric haemorrhage (bleeding too much in pregnancy or around the time of birth), pneumonia, and assault.</p>
<p>We <a href="https://gh.bmj.com/content/5/4/e002289">found</a> that between 1993 and 2015, 38.45% of all deaths in the study population were due to time-critical conditions. The proportion increased and accounted for nearly 50% of all deaths in 2014. Most of those who died were either very young or over 60 years old. About three-quarters of deaths in the first 28 days of life were due to time-critical conditions. About half of all time-critical deaths were due to non-infectious conditions.</p>
<p>Most commonly, delays in accessing care were seen at the stage of making the decision to seek care. In fact, on looking at patterns of seeking care before death, most commonly, patients did not seek any care and died without going to a healthcare facility. The most prominent single issue identified in causing delays was cost. This is despite the fact that public healthcare in the area is free of charge. It may be that people don’t know this, or that they worry about costs such as transport to a facility or loss of income while in hospital. They may also not seek care because they do not trust the ability of the healthcare system to treat them. </p>
<p>Our study also found that for people who did reach a healthcare facility, quality issues were prominent. Relatives reported that patients experienced problems in timely referral, waiting to be seen, and communication.</p>
<p>Our research supports findings from <a href="https://emj.bmj.com/content/33/11/794.long">others</a> that time-critical conditions are problematic in low and middle-income countries. It also shows that these conditions affect all ages, and are increasing, so dealing with them will have a widespread impact.</p>
<p>Patients infected with COVID-19 could also need urgent care, so the findings may help suggest ways to get them the care they need.</p>
<p>Provision of healthcare that is free at the point of use is necessary. But that alone is not enough. Timely access to quality healthcare is essential. This is not only because it can save lives; it’s also because poor quality care influences future decisions of patients or their carers to get help in time.</p>
<p>The type of care available is an issue too. Many of the healthcare services in South Africa have been tailored to infectious diseases or improving maternal and neonatal health. But about half of the urgent conditions in our study were non-infectious. They may not be well provided for in healthcare facilities in South Africa. </p>
<h2>Way forward</h2>
<p>To prevent more deaths, research and solutions should focus on patients’ behaviour when seeking healthcare and on quality care provision.</p>
<p>There urgently needs to be investment in interconnected health services that prevent and provide quality care for time-critical conditions.</p>
<p>Our study shows that verbal autopsy is a useful method to explore barriers in access to healthcare.</p><img src="https://counter.theconversation.com/content/141462/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Justine Ina Davies receives funding from UK NIHR, MRC, and Wellcome Trust. </span></em></p><p class="fine-print"><em><span>Andrew Fraser does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Dangerous delays may happen at three points: the patient deciding to seek care, reaching a healthcare facility, or receiving quality care at that facility.Justine Ina Davies, Professor of Global Health, Institute for Applied Research, University of BirminghamLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1410292020-06-24T12:19:39Z2020-06-24T12:19:39ZWhat doctors know about lingering symptoms of coronavirus<figure><img src="https://images.theconversation.com/files/343545/original/file-20200623-188882-1o8g7tu.jpg?ixlib=rb-1.1.0&rect=0%2C28%2C3733%2C2488&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Geoffrey McKillop (front) with his partner Nicola Dallet McConaghie as they left the hospital where he was discharged after surviving coronavirus. </span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/geoffrey-mckillop-with-his-partner-nicola-dallet-mcconaghie-news-photo/1213058444?adppopup=true">Liam McBurney/PA Images via Getty Images</a></span></figcaption></figure><p><a href="https://www.nytimes.com/interactive/2020/us/coronavirus-us-cases.html">With over 2 million cases in the U.S.</a> since the coronavirus pandemic began in late December, there are now many people who have recovered from COVID-19. At the same, there have been <a href="https://www.theatlantic.com/health/archive/2020/06/covid-19-coronavirus-longterm-symptoms-months/612679/">reports</a> of people who continue to have long-term side effects from the infection. <a href="https://uvahealth.com/findadoctor/profile/william-petri">I am a professor and physician</a> and I specialize in infectious diseases of adults. I not only care for patients with bacterial, parasitic and viral infections - including COVID-19 – but actively teach and perform research into diseases that infectious pathogens cause.</p>
<p>Here I offer a summary of what is known today about recovering from COVID-19 – and where there are important gaps in our knowledge. Much of this information, which has been gleaned from studies that began after the 2003 SARS outbreak, is important for those recovering and their family and friends who should know what to anticipate.</p>
<h2>Confusion or the post-intensive care syndrome</h2>
<p>In the most seriously ill patients who receive care in the ICU, there is a substantial risk of delirium. Delirium is characterized by confusion, difficulty in paying attention, reduced awareness of person, place and time, and even the inability to interact with others. </p>
<p>Delirium is not a specific complication of COVID-19 but unfortunately is <a href="http://doi.org/10.1056/NEJMoa1301372">a common complication of ICU care</a>. Risk factors in addition to being in the ICU include advanced age and pre-existing illness. Some studies <a href="http://doi.org/10.1056/NEJMoa1301372">say as many as 75% of patients</a> treated in the ICU experience delirium. The problem is not only with confusion during the hospitalization, but for months after. For example, at three and nine months after discharge many of those who recovered still had difficulty with short-term memory, the ability to comprehend written and spoken words and to learn new things. Some even had difficulty knowing where they were and what today’s date was. And, executive function scores were significantly worse in those who had suffered from delirium.</p>
<p>Physicians are dedicating considerable effort to <a href="http://doi.org/10.1056/NEJMra1208705">reduce delirium in patients in the ICU</a>. Approaches that may help include reducing the use of sedatives, repeated reorientation of the patient to date, time and location, early mobilization, noise reduction and cognitive stimulation.</p>
<h2>Lungs – will there be chronic shortness of breath?</h2>
<p>The most severely ill patients with COVID-19 often suffer from pneumonia and acute respiratory distress syndrome, or <a href="https://theconversation.com/exercise-may-help-reduce-risk-of-deadly-covid-19-complication-ards-136922">ARDS</a>, while ill. Doctors have not followed patients who have recovered from the new coronavirus long enough to know if there will be long-term problems with breathing. </p>
<p>However, a study of health care workers in China who contracted SARS, caused by the SARS-CoV coronavirus which circulated during the 2003 outbreak, are reassuring. Lung damage (measured by interstitial changes seen on CT scans of the lung and pulmonary function test results) <a href="http://doi.org/10.1038/s41413-020-0084-5">mostly healed within two years after the illness</a>.</p>
<h2>Smell and taste</h2>
<p>Most patients with <a href="https://theconversation.com/covid-19-smell-and-taste-how-is-covid-19-different-from-other-respiratory-diseases-139543">COVID-19 experience a loss of taste and or smell</a>. Only a quarter of patients had noted some improvement in a week’s time, <a href="https://doi.org/10.1177/0194599820922992">but by 10 days most patients had recovered</a>.</p>
<h2>Post-infection fatigue syndrome</h2>
<p>While again it may be too early to tell, in the case of the original SARS outbreak almost half of <a href="http://doi.org/10.1001/archinternmed.2009.384">survivors interviewed more than three years after recovery complained of fatigue</a>. </p>
<p>The Centers for Disease Control and Prevention criteria for diagnosis of the chronic fatigue syndrome were met in <a href="https://www.cdc.gov/me-cfs/symptoms-diagnosis/index.html">a quarter of COVID-19 patients</a>. It will likely be important to target mental health interventions to COVID-19 survivors to help them deal with a prolonged convalescence characterized by fatigue.</p>
<h2>Blood clots</h2>
<p><a href="http://doi.org/10.1016/j.thromres.2020.04.013">Blood clots may arise</a> in up to a fourth of critically ill COVID-19 patients. Blood clots can cause serious long-term complications if the clots break loose from blood vessels and migrate to the lung and cause a <a href="https://www.nhlbi.nih.gov/health-topics/venous-thromboembolism">pulmonary embolism</a> or go to the brain and cause a stroke. </p>
<p>To prevent blot clots, <a href="http://doi.org/10.1038/d41586-020-01403-8">physicians are now instituting blood thinners</a> prophylactically when there is a rise in the concentration of the D-dimer, which is a fragment of fibrin – a protein that makes blood clot.</p>
<h2>Heart</h2>
<p>In one study, inflammation of the heart muscle, called myocarditis or cardiomyopathy, was observed in <a href="http://doi.org/10.1001/jama.2020.4326">a third of severely ill COVID-19 patients</a>. Arrhythmias – an irregular heartbeat – are also seen. It is not known if this is due to direct infection of the heart or secondary to the stress caused by the inflammatory response to this infection.</p>
<p>Most importantly, the long-term consequences in survivors are not understood.</p>
<h2>Diabetes</h2>
<p><a href="https://www.medrxiv.org/content/10.1101/2020.06.18.20134353v1">Diabetics are at increased risk of severe COVID-19</a>, which may in part be attributable to an <a href="https://www.medrxiv.org/content/10.1101/2020.06.18.20134353v1">overreaction from immune response to the infection</a>.</p>
<p>But the COVID-19 and diabetes interaction may go in the other direction as well. <a href="http://doi.org/10.1056/NEJMc2018688">Elevations in glucose</a> are seen in severe cases of COVID-19 in some patients who do not have a prior history of diabetes. Because the virus <a href="https://theconversation.com/what-is-the-ace2-receptor-how-is-it-connected-to-coronavirus-and-why-might-it-be-key-to-treating-covid-19-the-experts-explain-136928">interacts with the angiotensin-converting enzyme 2, or ACE2</a>, on human cells, it is plausible that changes in ACE2 activity could be one cause of diabetes in patients with the new coronavirus. In any case, it will be important long-term to follow up.</p>
<p>The bottom line is that the new coronavirus infection has profound effects on many different organ systems in the body. The good news is that we expect that the damage caused by COVID-19 will heal in the vast majority of patients. However, it is important to appreciate that some long-term conditions can be anticipated, and prevented or managed to benefit patients.</p>
<p>[<em><a href="https://theconversation.com/us/newsletters/the-daily-3?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=experts">Expertise in your inbox. Sign up for The Conversation’s newsletter and get expert takes on today’s news, every day.</a></em>]</p><img src="https://counter.theconversation.com/content/141029/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>William Petri receives funding from the NIH and the Bill and Melinda Gates Foundation.</span></em></p>Is it possible that people who recover from COVID-19 will be plagued with long term side effects from the infection? An infectious disease physician reviews the evidence so far.William Petri, Professor of Medicine, University of VirginiaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1403982020-06-18T13:51:05Z2020-06-18T13:51:05ZCoronavirus can cause lasting lung damage – but the effects may ease over time<figure><img src="https://images.theconversation.com/files/342480/original/file-20200617-94036-84roiy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/exhausted-runner-man-resting-on-beach-179825489">Antonio Guillem/Shutterstock</a></span></figcaption></figure><p>We know a lot about the symptoms of severe COVID-19, but relatively little about what happens after someone recovers. Could there be long-term effects? Let’s look at what we know so far about the effect of COVID-19 on the body – particularly the lungs – and the potential for lasting damage.</p>
<p>The lungs are the organ most commonly affected by COVID-19, with a spectrum of severe effects. One is pneumonia, where inflammation causes the small air sacs that make up the lung to fill with fluid. In COVID-19, pneumonia <a href="https://www.thelancet.com/pdfs/journals/laninf/PIIS1473-3099(20)30086-4.pdf">tends to affect both lungs</a>.
If large parts of the lungs are affected, people struggle to absorb enough oxygen and are admitted to hospital.</p>
<p>Another severe effect is acute respiratory distress syndrome (ARDS) – also known as “wet lung”. This sees severe inflammation spread quickly throughout the lungs. People who develop this may need mechanical ventilation in an intensive care unit, sometimes for a prolonged period.</p>
<p>COVID-19 has a further, unusual effect on the body. Compared to other respiratory viruses, it causes <a href="https://www.thelancet.com/journals/lanrhe/article/PIIS2665-9913(20)30121-1/fulltext">marked clotting in the small blood vessels of the lungs</a> and other organs.</p>
<h2>How the virus damages the lungs</h2>
<p>Although the lungs <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7251349/">can recover from severe COVID-19</a>, they can also sustain longer-term damage of varying severity.</p>
<p>The SARS-CoV-2 virus enters the cells of the airway through the <a href="https://theconversation.com/ace2-the-molecule-that-helps-coronavirus-invade-your-cells-138369">angiotensin-converting enzyme 2 (ACE2) receptor</a>, a molecule that connects the inside of our cells to the outside via the cell membrane. When this happens, some people react to the virus’s presence by producing an intense immune response, known as a <a href="https://www.thelancet.com/journals/lanrhe/article/PIIS2665-9913(20)30121-1/fulltext">“cytokine storm”</a>, along with increased blood clotting, all of which leads to damage to lung cells. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/342717/original/file-20200618-41200-1766dcm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/342717/original/file-20200618-41200-1766dcm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/342717/original/file-20200618-41200-1766dcm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/342717/original/file-20200618-41200-1766dcm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/342717/original/file-20200618-41200-1766dcm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/342717/original/file-20200618-41200-1766dcm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/342717/original/file-20200618-41200-1766dcm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Being on a ventilator – which may be necessary with ARDS – can also cause cell damage.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/coronavirus-pandemic-patient-pneumonia-critical-state-1692063865">Kiryl Lis/Shutterstock</a></span>
</figcaption>
</figure>
<p>The body replaces cells damaged by the virus with scar tissue, which is thick and stiff. This can result in a condition called “pulmonary fibrosis”, which has been <a href="https://www.ajronline.org/doi/10.2214/AJR.20.22954">seen</a> in people with COVID-19 and is probably more likely to develop if the lungs are severely affected by the infection. The condition can make people breathless doing activities that they would usually manage without difficulty. Drugs that reduce scarring may have a role in
<a href="https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(20)30225-3/fulltext">preventing it</a>.</p>
<p>We don’t yet know what the impact of pulmonary fibrosis is after infection, but it may lead to long-term symptoms and a progressive fall in lung function. That’s why it’s important <a href="https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(20)30222-8/fulltext">to watch out for the condition</a>
in people who suffer from severe COVID-19. </p>
<p>However, we can look at other coronaviruses – severe acute respiratory syndrome (Sars) and Middle East respiratory syndrome (Mers) – to try to predict long-term outcomes.</p>
<p>We know that <a href="https://pubs.rsna.org/doi/10.1148/radiol.2283030726">Sars can cause pulmonary fibrosis</a>, and a <a href="https://www.medicaljournals.se/jrm/content/html/10.2340/16501977-2694">large analysis</a>
of Sars and Mers patients showed weakened lung function and exercise capability in some survivors up to six months after hospital discharge. However, a
<a href="https://www.nature.com/articles/s41413-020-0084-5">15-year follow-up</a>
of patients showed improvement in lung function and less damage visible on CT scans over time. An <a href="https://respiratory-research.biomedcentral.com/articles/10.1186/s12931-020-01385-1">early study</a>
of people recovering from COVID-19 found that such damage also improves in the first few weeks after discharge from hospital.</p>
<h2>What about other organs?</h2>
<p>COVID-19 may also cause illness in other parts of the body, ranging from <a href="https://blogs.bmj.com/bmj/2020/05/05/paul-garner-people-who-have-a-more-protracted-illness-need-help-to-understand-and-cope-with-the-constantly-shifting-bizarre-symptoms/">several weeks of non-specific symptoms</a>
to impairment of the
<a href="https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(20)30229-0/fulltext">kidneys</a>,
<a href="https://jamanetwork.com/journals/jamacardiology/article-abstract/2763844">heart</a>,
<a href="https://gut.bmj.com/content/69/6/973">gastrointestinal tract</a>,
<a href="https://jamanetwork.com/journals/jamaneurology/fullarticle/2764549">nervous system</a> and <a href="https://www.thelancet.com/journals/lanhae/article/PIIS2352-3026(20)30145-9/fulltext">clotting system</a>. Some effects could be <a href="https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(20)30229-0/fulltext">partly caused by clots</a> forming in the small blood vessels supplying these organs. There’s also likely to be an <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7260522/">impact on mental health</a>.</p>
<p>Just as important is the impact on a person’s general fitness. People needing mechanical ventilation for a long time <a href="https://www.nejm.org/doi/full/10.1056/NEJMoa022450">lose a significant degree of muscle mass</a>, leaving them weak even after their lungs have recovered.</p>
<p>People with limited reserves to begin with (such as older people) can become deconditioned even after “mild” COVID-19. This may reduce their ability to live independently, so it has important implications for demand on
<a href="https://academic.oup.com/ageing/advance-article/doi/10.1093/ageing/afaa118/5848215">rehabilitation</a>
and social care services.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/342719/original/file-20200618-41221-1r9cp2a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/342719/original/file-20200618-41221-1r9cp2a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/342719/original/file-20200618-41221-1r9cp2a.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/342719/original/file-20200618-41221-1r9cp2a.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/342719/original/file-20200618-41221-1r9cp2a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/342719/original/file-20200618-41221-1r9cp2a.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/342719/original/file-20200618-41221-1r9cp2a.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Widespread persistent lung damage could mean more people using medical oxygen at home.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/medical-oxygen-cylinders-515744077">Chaikom/Shutterstock</a></span>
</figcaption>
</figure>
<p>We are still only six months beyond the first emergence of COVID-19, so it’s too early to tell what the extent of any long-term impacts will be. There are still many questions. Who is most at risk of long-term effects following COVID-19? And what could prevent these? <a href="http://www.qmul.ac.uk/covidence">COVIDENCE UK</a> is a research study looking at these questions, and is recruiting adults who both have and haven’t had COVID-19 to try to find answers. </p>
<p>While the vast majority who contract COVID-19 will make a full recovery, we’re likely to see more people with pulmonary fibrosis or persistent lung damage following ARDS caused by COVID-19. Many will be severely debilitated for some time following severe infection, and some will need home oxygen. Meeting such people’s longer-term health and care needs will pose a significant challenge.</p><img src="https://counter.theconversation.com/content/140398/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Severe COVID-19 may leave lasting scars in the lungs, but some recovery could happen over time.Shanya Sivakumaran, Clinical Research Fellow in Respiratory Medicine, Swansea UniversityGwyneth Davies, Professor of Respiratory Medicine, Swansea UniversityMohammad Al Sallakh, Research Officer in Asthma, Swansea UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1389422020-06-05T10:14:06Z2020-06-05T10:14:06ZWe’ve discovered how these deadly bacteria use a common sugar to spread through the body. It could help us stop them<figure><img src="https://images.theconversation.com/files/339967/original/file-20200605-176595-nbrexv.jpg?ixlib=rb-1.1.0&rect=9%2C9%2C3285%2C2534&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://phil.cdc.gov/Details.aspx?pid=23253">CDC/Antibiotic Resistance Coordination and Strategy Unit. Medical Illustrator: Meredith Newlove</a></span></figcaption></figure><p>Although bacteria are single-celled and microscopically small, they still need energy to survive, just like us. One of the most efficient ways of acquiring energy for bacteria is through sweet, soluble carbohydrates: sugars. </p>
<p>In fact, the keen ability of the deadly bacteria <em>Streptococcus pneumoniae</em> to use the plant-derived sugar <a href="https://www.sciencedirect.com/topics/biochemistry-genetics-and-molecular-biology/raffinose">raffinose</a> may explain how it <a href="https://www.nature.com/articles/s41579-018-0001-8">spreads through the human body</a>.</p>
<p><em>S. pneumoniae</em> is a bacteria that can quickly develop antibiotic resistance. Each year it causes <a href="https://emedicine.medscape.com/article/225811-overview#a8">millions of infections and about one million deaths</a>. Its “ecological niche”, which refers to the natural position of a species within an ecosystem, is our noses and throats, where it doesn’t cause disease.</p>
<p>But from there, <em>S. pneumoniae</em> can spread into the lungs, blood and brain, or more locally into the ear, to cause diseases such as pneumonia, <a href="https://www.healthline.com/health/bacteremia">bacteremia</a>, <a href="https://www.healthdirect.gov.au/meningitis">meningitis</a> and <a href="https://www.healthdirect.gov.au/otitis-media">otitis media</a> (middle ear inflammation).</p>
<p>Unfortunately, <em>S. pneumoniae</em> is a <a href="https://www.asmscience.org/content/journal/microbiolspec/10.1128/microbiolspec.GPP3-0025-2018">genetically diverse pathogen</a>, which means it has many different strains. This complicates research efforts to identify how the bacteria spreads into specific sites of the body.</p>
<p>New research <a href="https://www.nature.com/articles/s42003-020-1018-x?fbclid=IwAR25KbOp_QtjMxu75Y1d6q_bQjzXjNbr-sgkiDFKepRXooLhesy006I63ng">published today in Nature Communications Biology</a> by my colleagues and I circumvented these genetic diversity issues by studying closely related strains of <em>S. pneumoniae</em>. We discovered a difference in a gene between two bacterial strains that regulated their use of raffinose, and this resulted in one being more likely to spread and cause disease.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/scientists-still-searching-for-causes-of-mysterious-pneumonia-outbreak-in-china-130129">Scientists still searching for causes of mysterious pneumonia outbreak in China</a>
</strong>
</em>
</p>
<hr>
<h2>Sickly sweet, sugars and bacterial disease</h2>
<p>In our <a href="https://mbio.asm.org/content/10/1/e02596-18">previous research</a>, two closely related strains of <em>S. pneumoniae</em> were isolated, one from the blood of a patient and another from the ear. Their sequenced genomes were aligned to pick out differences that may impact how they spread to different parts of the body, and hence how they cause disease. </p>
<p>We found a difference in the regulating gene <em>rafR</em> which is responsible for raffinose uptake. This difference allowed the bacteria in the blood sample to use raffinose more efficiently than in the ear sample. </p>
<p>When infecting mice lungs with <em>S. pneumoniae</em> through their nose, we found the blood sample remained in the lungs, causing invasive disease. However, the ear sample was cleared from the lungs, and was unable to cause disease.</p>
<p>Remarkably, swapping the <em>rafR</em> gene between the strains switched their ability to use raffinose, and the way the disease progressed in each case reversed too. This confirmed the <em>rafR</em> gene was indeed playing a large role in causing disease.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/339968/original/file-20200605-176585-umouop.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/339968/original/file-20200605-176585-umouop.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/339968/original/file-20200605-176585-umouop.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=407&fit=crop&dpr=1 600w, https://images.theconversation.com/files/339968/original/file-20200605-176585-umouop.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=407&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/339968/original/file-20200605-176585-umouop.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=407&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/339968/original/file-20200605-176585-umouop.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=511&fit=crop&dpr=1 754w, https://images.theconversation.com/files/339968/original/file-20200605-176585-umouop.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=511&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/339968/original/file-20200605-176585-umouop.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=511&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption"><em>Streptococcus pneumoniae</em> imaged with a scanning electron microscope. This bacteria is a major cause of pneumonia. When present in the nose or throat (its ‘ecological niche’) it benefits from the human body without harming it.</span>
<span class="attribution"><a class="source" href="https://wellcomecollection.org/works/xuqru2dc">Debbie Marshall</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<p>In our most recent work, we wanted to figure out how this sugar-regulating gene was so profoundly impacting disease progression. </p>
<p>Using a <a href="https://doi.org/10.1038/s42003-%20020-1018-x">cutting-edge sequencing technique</a> during live mice infections, we discovered the difference in the <em>rafR</em> gene altered how both the mice and the bacteria responded to infection. Notably, strains containing the <em>rafR</em> from the ear sample resulted in more neutrophils, an important immune cell, at the site of infection. </p>
<p>In experiments where neutrophils were depleted in the lungs, the ear sample was not cleared, and the risk of disease was more. This research highlights how this single difference in the gene increased neutrophil levels during infection, preventing <em>S. pneumoniae</em> from causing invasive disease.</p>
<h2>Potential research impacts</h2>
<p>Raffinose is mainly found in vegetables, grains and legumes. It’s not known whether the human body ever has high enough levels of it to dramatically impact the likelihood of disease. It may be a carbohydrate similar in structure to raffinose is activating the raffinose regulator <em>rafR</em> instead.</p>
<p>Nonetheless, our research provides insight into how <em>S. pneumoniae</em> causes disease. As we understand what enables this deadly bacteria’s spread through the body, more paths will open up to stopping it. </p>
<p>If this raffinose phenomenon proves to be widespread across <em>S. pneumoniae</em> strains, blocking their ability to use raffinose may prevent them from surviving in, and thus invading, the lungs.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/339970/original/file-20200605-176580-1arm711.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/339970/original/file-20200605-176580-1arm711.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/339970/original/file-20200605-176580-1arm711.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=588&fit=crop&dpr=1 600w, https://images.theconversation.com/files/339970/original/file-20200605-176580-1arm711.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=588&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/339970/original/file-20200605-176580-1arm711.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=588&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/339970/original/file-20200605-176580-1arm711.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=739&fit=crop&dpr=1 754w, https://images.theconversation.com/files/339970/original/file-20200605-176580-1arm711.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=739&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/339970/original/file-20200605-176580-1arm711.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=739&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">This illustration depicts a gram stained specimen under a microscope, with a number of <em>Streptococcus pneumoniae</em> bacteria (the small black dashes).</span>
<span class="attribution"><a class="source" href="https://phil.cdc.gov/Details.aspx?pid=2111">CDC</a></span>
</figcaption>
</figure>
<p>Treatments that prevent <em>S. pneumoniae</em> from spreading around the body may be better for preventing disease compared to simply inhibiting or killing the bacteria, as is current practice. </p>
<p><em>S. pneumoniae</em> can stay in our nose and throats, where it does not cause disease. It plays an import role in this ecosystem. When this bacteria is killed, other deadly bacteria may take its place and spread to sites such as the lungs to cause disease.</p>
<h2>The risk in failing to find new treatments</h2>
<p><em>S. pneumoniae’s</em> ability to rapidly develop antibiotic resistance has led the <a href="https://www.who.int/news-room/detail/27-02-2017-who-publishes-list-of-bacteria-for-which-new-antibiotics-are-urgently-needed">World Health Organisation</a> and <a href="https://www.cdc.gov/drugresistance/biggest-threats.html">US Centres for Disease Control and Prevention</a> to list it as a priority pathogen. </p>
<p>Though vaccines are available, they’re far from perfect and fail to cover all the different strains of <em>S. pneumoniae</em>. If new treatments and vaccines aren’t created soon, the already deadly impact of this bacteria may increase. </p>
<p>Despite the known dangers, research into discovering new antibiotics has been slow. Many treatments in the pipeline <a href="https://www.who.int/news-room/detail/17-01-2020-lack-of-new-antibiotics-threatens-global-efforts-to-contain-drug-resistant-infections">don’t provide much benefit over existing antibiotics</a>. Also, effective new treatments usually aren’t implemented widely, and are instead used as a back up in case all else fails. This greatly reduces their profitability, which in turn decreases incentives to make them. </p>
<p>In a worst case scenario, antibiotic-resistant bacteria could kill up to <a href="https://www.who.int/news-room/detail/29-04-2019-new-report-calls-for-urgent-action-to-avert-antimicrobial-resistance-crisis">ten million people each year by 2050</a>. To avoid such catastrophe, more research is needed on how bacteria cause disease. And with this knowledge we may be able to lessen the likelihood of future pandemics. </p>
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Read more:
<a href="https://theconversation.com/saving-lives-in-poor-countries-is-about-adapting-to-whats-already-working-there-75459">Saving lives in poor countries is about adapting to what's already working there</a>
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<img src="https://counter.theconversation.com/content/138942/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Vikrant Minhas is a co-founder of the space research company ResearchSat</span></em></p>S. pneumoniae, the bacteria responsible for pneumonia, causes about one million deaths each year. Now we know how it uses the sugar raffinose to spread through the body to cause disease.Vikrant Minhas, PhD candidate, University of AdelaideLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1373552020-04-29T12:10:31Z2020-04-29T12:10:31ZWhat does ‘survival of the fittest’ mean in the coronavirus pandemic? Look to the immune system<figure><img src="https://images.theconversation.com/files/331099/original/file-20200428-110770-16mrqg6.jpg?ixlib=rb-1.1.0&rect=23%2C23%2C3858%2C2560&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">What would Darwin consider the best adaptation to protect against the coronavirus?</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/charles-darwin-portrait-engraving-royalty-free-image/177052338">rolbos / Getty Images </a></span></figcaption></figure><p>Charles Darwin popularized the concept of survival of the fittest as a mechanism underlying the natural selection that drives the evolution of life. Organisms with genes better suited to the environment are selected for survival and pass them to the next generation. </p>
<p>Thus, when a new infection that the world has never seen before erupts, the process of natural selection starts all over again. </p>
<p>In the context of the coronavirus pandemic, who is the “fittest”? </p>
<p>This is a challenging question. But <a href="https://sc.edu/study/colleges_schools/medicine/about_the_school/faculty-staff/nagarkatti_prakash.php">as immunology</a> <a href="https://sc.edu/study/colleges_schools/medicine/about_the_school/faculty-staff/nagarkatti_mitzi.php">researchers</a> at the University of South Carolina, we can say one thing is clear: With no effective treatment options, survival against the coronavirus infection depends completely on the patient’s immune response. </p>
<p><a href="https://www.ncbi.nlm.nih.gov/pubmed/?term=nagarkatti+p">We have been working on how the immune response</a> is a double-edged sword – on one hand helping the host to fight infections, while on the other hand causing significant damage in the form of autoimmune diseases. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/331102/original/file-20200428-110775-95le8d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/331102/original/file-20200428-110775-95le8d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/331102/original/file-20200428-110775-95le8d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=473&fit=crop&dpr=1 600w, https://images.theconversation.com/files/331102/original/file-20200428-110775-95le8d.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=473&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/331102/original/file-20200428-110775-95le8d.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=473&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/331102/original/file-20200428-110775-95le8d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=595&fit=crop&dpr=1 754w, https://images.theconversation.com/files/331102/original/file-20200428-110775-95le8d.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=595&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/331102/original/file-20200428-110775-95le8d.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=595&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Darwin recognized that finches with beaks adapted to the specific food sources present on an island were more likely to survive and pass their genes to the next generation. Birds with the right beaks were defined as the fittest.</span>
<span class="attribution"><span class="source">Photos.com</span></span>
</figcaption>
</figure>
<h2>The two phases of the immune response</h2>
<p>The immune response is like a car. To reach a destination safely, you need both an accelerator (phase 1) and a brake (phase 2) that are functioning well. Failure in either can have significant consequences.</p>
<p>An effective immune response against an infectious agent rests in the delicate balance of two phases of action. When an infectious agent attacks, the body begins phase 1, which promotes inflammation – a state in which a variety of immune cells gather at the site of infection to destroy the pathogen. </p>
<p>This is followed by phase 2, during which immune cells called regulatory T cells suppress inflammation so that the infected tissues can completely heal. A deficiency in the first phase can allow uncontrolled growth of the infectious agent, such as a virus or bacteria. A defect in the second phase can trigger massive inflammation, tissue damage and death.</p>
<p>The coronavirus infects cells by attaching to a receptor called the angiotensin-converting enzyme 2 (<a href="https://www.sciencedirect.com/topics/biochemistry-genetics-and-molecular-biology/angiotensin-converting-enzyme-2">ACE2</a>), which is present in many tissues throughout the body, including the respiratory tract and cardiovascular system. This infection triggers a phase 1 immune response, in which the antibody-producing B-cells pump out neutralizing antibodies that can bind to the virus and prevent it from attaching to ACE2. This inhibits the virus from infecting more cells. </p>
<p>During phase 1, the immune cells also produce <a href="https://www.sciencedirect.com/topics/neuroscience/cytokines">cytokines</a>, a group of proteins that recruit other immune cells as well as fight infection. Also joining the fight are killer T cells that destroy the virus-infected cells, preventing the virus from replicating.</p>
<p>If the immune system is compromised and works poorly during phase 1, the virus can replicate rapidly. People with compromised immune systems include the elderly, organ transplant recipients, patients with autoimmune diseases, cancer patients undergoing chemotherapy and individuals who are born with immunodeficiency diseases. Many of these individuals may not produce enough antibodies or killer T cells to counter the virus, which allows the virus to multiply unchecked and cause a severe infection.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/331109/original/file-20200428-110779-1ck9y7x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/331109/original/file-20200428-110779-1ck9y7x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/331109/original/file-20200428-110779-1ck9y7x.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/331109/original/file-20200428-110779-1ck9y7x.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/331109/original/file-20200428-110779-1ck9y7x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=565&fit=crop&dpr=1 754w, https://images.theconversation.com/files/331109/original/file-20200428-110779-1ck9y7x.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=565&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/331109/original/file-20200428-110779-1ck9y7x.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=565&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Molecular model of a coronavirus spike (S) protein (red) bound to an angiotensin-converting enzyme 2 (ACE2) receptor (blue) on a human cell. Once inside the cell, the virus uses the cells’ machinery to make more copies of itself.</span>
<span class="attribution"><span class="source">JUAN GAERTNER/SCIENCE PHOTO LIBRARY</span></span>
</figcaption>
</figure>
<h2>Lung injury resulting from inflammation</h2>
<p>Increased replication of SARS-CoV-2 triggers additional complications in the lungs and other organs. </p>
<p>Normally, there is a wide range of microorganisms, both harmful and benign, that live in harmony in the lungs. However, as the coronavirus spreads, it is likely that the infection and the inflammation that ensues will disrupt this balance, allowing harmful bacteria present in the lungs to dominate. This leads to development of pneumonia, in which the lungs’ air sacs, called alveoli, get filled with fluid or pus, making it difficult to breathe. </p>
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<a href="https://images.theconversation.com/files/331115/original/file-20200428-110757-1yv1dp1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/331115/original/file-20200428-110757-1yv1dp1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/331115/original/file-20200428-110757-1yv1dp1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=441&fit=crop&dpr=1 600w, https://images.theconversation.com/files/331115/original/file-20200428-110757-1yv1dp1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=441&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/331115/original/file-20200428-110757-1yv1dp1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=441&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/331115/original/file-20200428-110757-1yv1dp1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=554&fit=crop&dpr=1 754w, https://images.theconversation.com/files/331115/original/file-20200428-110757-1yv1dp1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=554&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/331115/original/file-20200428-110757-1yv1dp1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=554&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">When the alveoli, the location where oxygen is absorbed and carbon dioxide is expelled, is filled with liquid there is less space to absorb oxygen.</span>
<span class="attribution"><span class="source">ttsz / Getty Images</span></span>
</figcaption>
</figure>
<p>This triggers additional inflammation in the lungs, leading to Acute Respiratory Distress Syndrome (ARDS), which is <a href="https://doi.org/10.1001/jamainternmed.2020.0994">seen in a third of COVID-19 patients</a>. The immune system, unable to control viral infection and other emerging pathogens in the lungs, mounts an even stronger inflammatory response by releasing more cytokines, a condition known as “cytokine storm.” </p>
<p>At this stage, it is also likely that the phase 2 immune response aimed at suppressing inflammation fails and can’t control the cytokine storm. Such cytokine storms can trigger friendly fire – destructive, corrosive chemicals meant to destroy infected cells that are released by the body’s immune cells which can lead to severe damage to the lungs and other organs. </p>
<p>Also, because ACE2 is present throughout the body, the killer T cells from phase 1 can destroy virus-infected cells across multiple organs, causing more widespread destruction. Thus, patients that produce excessive cytokines and T cells can die from injury not only to the lungs but also to other organs such as the heart and kidneys.</p>
<h2>The immune system’s balancing act</h2>
<p>The above scenario raises several questions regarding prevention and treatment of COVID-19. Because the <a href="https://www.cnn.com/2020/04/04/health/recovery-coronavirus-tracking-data-explainer/index.html">majority of people recover from coronavirus infection</a>, it is likely that a vaccine that triggers neutralizing antibodies and T cells to block the virus from getting into the cells and replicate is likely to be successful. The key to an effective vaccine is that it doesn’t trigger excessive inflammation. </p>
<p>Additionally, in patients who transition to a more severe form such as ARDS and cytokine storm, which is often lethal, there is an urgent need for novel <a href="https://www.the-scientist.com/news-opinion/could-curbing-runaway-immune-responses-treat-covid-19--67450">anti-inflammatory drugs</a>. These drugs can broadly suppress the cytokine storm without causing excessive suppression of immune response, thereby enabling the patients to clear the coronavirus without damage to the lung and other tissues.</p>
<p>There may be only a narrow window of opportunity during which these immunosuppressive agents can be effectively used. Such agents should not be started at an early stage of infection when the patient needs the immune system to fight the infection, but it cannot be delayed too long after ARDS development, when the massive inflammation is uncontrollable. This window of anti-inflammatory treatment can be determined by monitoring the antibody and cytokine levels in patients.</p>
<p>With COVID-19, then, the “fittest” are individuals who mount a normal phase 1 and phase 2 immune response. This means a strong immune response in phase 1 to clear the primary coronavirus infection and inhibit its spread in the lungs. Then this should be followed by an optimum phase 2 response to prevent excessive inflammation in the form of “cytokine storm.” </p>
<p>Vaccines and anti-inflammatory treatments need to carefully manage this delicate balancing act to be successful.</p>
<p>With this coronavirus, it isn’t easy to know who are the fittest individuals. It isn’t necessarily the youngest, strongest or most athletic individuals who are guaranteed to survive this coronavirus. The fittest are those with the “right” immune response who can clear the infection rapidly without mounting excessive inflammation, which can be deadly. </p>
<p>[<em>Get facts about coronavirus and the latest research.</em> <a href="https://theconversation.com/us/newsletters?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=upper-coronavirus-facts">Sign up for The Conversation’s newsletter.</a>]</p><img src="https://counter.theconversation.com/content/137355/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Prakash Nagarkatti receives funding from the National Institutes for Health and the National Science Foundation.</span></em></p><p class="fine-print"><em><span>Mitzi Nagarkatti receives funding from the National Institutes of Health (NIH). </span></em></p>Who is most likely to survive an infection of the new coronavirus? Two immunologists explain that it is those who mount exactly the right immune response – not too weak, not too strong.Prakash Nagarkatti, Vice President for Research and Carolina Distinguished Professor, University of South CarolinaMitzi Nagarkatti, SmartState Endowed Chair of Center for Cancer Drug Discovery, Carolina Distinguished Professor and Chair, Dept. of Pathology, Microbiology and Immunology, University of South CarolinaLicensed as Creative Commons – attribution, no derivatives.