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Background: SARS-CoV-2 vaccines are safe and effective against infection and severe COVID-19 disease worldwide. Certain co-morbid conditions cause immune dysfunction and may reduce immune response to vaccination. In contrast, those with co-morbidities may practice infection prevention strategies. Thus, the real-world clinical impact of co-morbidities on SARS-CoV-2 infection in the recent post-vaccination period is not well established. This study was performed to understand the epidemiology of Omicron breakthrough infection and evaluate associations with number of comorbidities in a vaccinated and boosted population., Methods and Findings: A retrospective clinical cohort study was performed utilizing the Northwestern Medicine Enterprise Data Warehouse. Our study population was identified as fully vaccinated adults with at least one booster. The primary risk factor of interest was the number of co-morbidities. The primary outcome was the incidence and time to the first positive SARS-CoV-2 molecular test in the Omicron predominant era. Multivariable Cox modeling analyses to determine the hazard of SARS-CoV-2 infection were stratified by calendar time (Period 1: January 1 -June 30, 2022; Period 2: July 1 -December 31, 2022) due to violations in the proportional hazards assumption. In total, 133,191 patients were analyzed. During Period 1, having 3+ comorbidities was associated with increased hazard for breakthrough (HR = 1.16 CI 1.08-1.26). During Period 2 of the study, having 2 comorbidities (HR = 1.45 95% CI 1.26-1.67) and having 3+ comorbidities (HR 1.73, 95% CI 1.51-1.97) were associated with increased hazard for Omicron breakthrough. Older age was associated with decreased hazard in Period 1 of follow-up. Interaction terms for calendar time indicated significant changes in hazard for many factors between the first and second halves of the follow-up period., Conclusions: Omicron breakthrough is common with significantly higher risk for our most vulnerable patients with multiple co-morbidities. Age plays an important role in breakthrough infection with the highest incidence among young adults, which may be due to age-related behavioral factors. These findings reflect real-world differences in immunity and exposure risk behaviors for populations vulnerable to COVID-19., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Moreno Echevarria et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

COVID-19 has been associated with a higher incidence of acute myocardial infarction and related complications. We sought to assess the impact of COVID-19 diagnosis on hospitalizations with an index admission of AMI. The National inpatient sample 2020 was queried for hospitalizations with an index admission of AMI, further stratified for admissions with and without COVID-19. The 2 groups' mortality, procedure, and complication rates were compared using suitable statistical tests. Multivariate regression analysis was further performed to study the impact of COVID-19 on mortality as the primary outcome and length of stay and total hospital cost as secondary outcomes. A total of 555,540 admissions for AMI were identified, of which 5818 (1.04%) had concomitant COVID-19. Hospitalizations in the COVID-19 cohort of both groups had a lower procedure rate for coronary angiography. Thrombolysis use was higher in the STEMI patients with COVID-19. Most cardiac complications in AMI patients were higher when infected with SARS-CoV-2. Multivariate regression analysis revealed that COVID-19 led to higher odds of mortality and total length of stay in AMI hospitalizations. COVID-19 portends a worse prognosis in hospitalizations with AMI. These admissions have a significantly higher mortality rate and increased complications., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Host immune responses play a key role in COVID-19 pathogenesis. The underlying phenomena are orchestrated by signaling molecules such as cytokines/chemokines and lipid mediators. These immune molecules, including anti-SARS-CoV-2 antibodies, interact with immune cells and regulate host responses, contributing to inflammation that drives the disease. We investigated 48 plasma cytokines/chemokines, 21 lipid mediators, and anti-S protein (RBD) antibodies in COVID-19 patients (n = 56) and non-COVID-19 respiratory disease controls (n = 49), to identify immune-biomarker profiles. Cytokines/chemokines (IL-6, CXCL-10 (IP-10), HGF, MIG, MCP-1, and G-CSF) and lipid mediators (TxB2, 11-HETE, 9-HODE, 13-HODE, 5-HETE, 12-HETE, 15-HETE, 14S-HDHA, 17S-HDHA, and 5-oxo ETE) were significantly elevated in COVID-19 patients compared to controls. In patients exhibiting severe disease, pro-inflammatory cytokines/chemokines (IL-6, CXCL-10, and HGF) and anti-SARS-CoV-2 antibodies were significantly elevated. In contrast, lipid mediators involved in the reduction/resolution of inflammation, in particular, 5-HETE, 11-HETE, and 5-oxoETE, were significantly elevated in mild/moderate disease. Taken together, these immune-biomarker profiles provide insight into immune responses related to COVID-19 pathogenesis. Importantly, our findings suggest that elevation in plasma concentrations of IL-6, CXCL-10, HGF, and anti-SARS-CoV-2 antibodies can predict severe disease, whereas elevation in lipid mediators peaks early (compared to cytokines) and includes induction of mechanisms leading to reduction of inflammation, associated complications, and maintenance of homeostasis.

Introduction: Recent developments characterizing the pathophysiological basis of infection in the Coronavirus disease - 19 (COVID-19) have stirred great interest in studying this disease outside the purview of respiratory involvement and especially focusing on the gastrointestinal (GI) system. The present study involving a large cohort of COVID-19-infected patients reports on the characteristics of GI manifestations in patients infected with COVID-19 as well as the predictive role in their association with disease severity and adverse outcomes., Methods: A retrospective cohort study was carried out in a tertiary care hospital in northern India. Descriptive analysis of GI symptoms was carried out followed by predictive analysis assessing COVID-19 severity and with the primary endpoint of 28-day in-hospital all-cause mortality., Results: Of 3842 hospitalized COVID-19 patients, 2113 (55%) were symptomatic. GI symptoms were present in 163 (7.1%) patients. Common GI symptoms were diarrhea 65 (3.1%), anorexia 61 (2.9%) and vomiting 37 (1.8%). Mild and moderate-to-severe disease was seen in 1725 (81.6%) and 388 (18.4%) patients, respectively. Logistic regression showed greater odds of moderate-to-severe disease in patients with any GI symptoms (odds ratio [OR] 1.849, 95% CI 1.289-2.651 [p = 0.001]) and anorexia in particular (OR 2.797, 95% CI 1.647-4.753 [p = 0.001]); however, on multivariable-analysis, this association lost its significance. A total of 172 patients succumbed to illness. In the Cox proportional hazards model for mortality, patients with any GI symptom (HR 2.184, 95 CI 1.439-3.317 [p < 0.001]) and anorexia (HR 3.556, 95% CI 2.155-5.870 [p < 0.001]) had higher risk. In multi-variable analysis after adjustment to age, sex, oxygen saturation and comorbidities, the presence of any GI symptom was a significant predictor of mortality (hazard ratio adjusted [HR adj ] 1.758, 95% CI 1.147-2.694 [p = 0.010])., Conclusion: GI symptoms were common among patients infected with COVID-19. The presence of any GI symptom was a significant predictor of the risk of mortality after adjustment to respiratory failure, age, sex and pre-existing comorbidities. The clinical and pathophysiological basis of these associations has been explored., (© 2023. Indian Society of Gastroenterology.)

Background: The COVID-19 pandemic negatively impacted the quality of life of individuals around the world, including health care professionals. There has been little research that examines the role of resilience concerning the impact of COVID-19 on the quality of life of nursing students. This study aimed to determine how resilience influenced the quality of life among nursing students during the COVID-19 pandemic., Methods: A cross-sectional research design was adopted for this study. A total of two hundred sixty-eight nursing students from three universities, South India responded in the web-based survey. Data was collected using self-reported questionnaires in June 2021., Results: Our findings revealed that the participants' resilience was normal, which had a moderate impact on the quality of life of nursing students during the COVID-19 pandemic. The COVID-19 impact on QoL significantly differed with year of education (F = 3.087; p < 0.02) and university (F = 6.697, p < 0.001). Bivariate analysis revealed significant inverse relationships between the impact of COVID-19 on quality of life with resilience (r = -0.259; p < 0.001) and perceived knowledge on COVID-19(r = -0.168; p < 0.006)., Conclusion: In our study, we found that resilience had a moderate impact on the quality of life of nursing students during the COVID-19 pandemic. Therefore, it is important to promote students' resilience and improve their quality of life during stressful situations., Competing Interests: Conflict of interest None., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Redondoviruses are circular Rep-encoding single-stranded DNA (CRESS) viruses of high prevalence in healthy humans. Redondovirus abundance is increased in oro-respiratory samples from individuals with periodontitis, acute illness, and severe COVID-19. We investigated potential host cells supporting redondovirus replication in oro-respiratory samples and uncovered the oral amoeba Entamoeba gingivalis as a likely host. Redondoviruses are closely related to viruses of Entamoeba and contain reduced GC nucleotide content, consistent with Entamoeba hosts. Redondovirus and E. gingivalis co-occur in metagenomic data from oral disease and healthy human cohorts. When grown in xenic cultures with feeder bacteria, E. gingivalis was robustly positive for redondovirus RNA and DNA. A DNA proximity-ligation assay (Hi-C) on xenic culture cells showed enriched cross-linking of redondovirus and Entamoeba DNA, supporting E. gingivalis as the redondovirus host. While bacteria are established hosts for bacteriophages within the human virome, this work shows that eukaryotic commensals also contribute an abundant human-associated virus., Competing Interests: Declaration of interests The authors declare no competing interests., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objectives: Autoantibody seroconversion has been extensively studied in the context of COVID-19 infection but data regarding post-vaccination autoantibody production is lacking. Here we aimed to determine the incidence of common autoantibody formation following mRNA COVID-19 vaccines in patients with inflammatory arthritis (IA) and in healthy controls., Methods: Autoantibody seroconversion was measured by serum ELISA in a longitudinal cohort of IA participants and healthy controls before and after COVID-19 mRNA-based immunization., Results: Overall, there was a significantly lower incidence of ANA seroconversion in participants who did not contract COVID-19 prior to vaccination compared with those who been previously infected (7.4% vs 24.1%, P = 0.014). Incidence of de novo anti-CCP seroconversion in all participants was low at 4.9%. Autoantibody levels were typically of low titre, transient, and not associated with increase in IA flares., Conclusions: In both health and inflammatory arthritis, the risk of autoantibody seroconversion is lower following mRNA-based immunization than following natural SARS-CoV-2 infection. Importantly, seroconversion does not correlate with self-reported IA disease flare risk, further supporting the encouragement of mRNA-based COVID-19 immunization in the IA population., (© The Author(s) 2022. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

The SARS-CoV-2 pandemic began by viral spillover from animals to humans; today multiple animal species are known to be susceptible to infection. White-tailed deer, Odocoileus virginianus, are infected in North America at substantial levels, and genomic data suggests that a variant in deer may have spilled back to humans. Here, we characterize SARS-CoV-2 in deer from Pennsylvania (PA) sampled during fall and winter 2021. Of 123 nasal swab samples analyzed by RT-qPCR, 20 (16.3%) were positive for SARS-CoV-2. Seven whole genome sequences were obtained, together with six more partial spike gene sequences. These annotated as alpha and delta variants, the first reported observations of these lineages in deer, documenting multiple new jumps from humans to deer. The alpha lineage persisted in deer after its displacement by delta in humans, and deer-derived alpha variants diverged significantly from those in humans, consistent with a distinctive evolutionary trajectory in deer. IMPORTANCE Coronaviruses have been documented to replicate in numerous species of vertebrates, and multiple spillovers of coronaviruses from animals into humans have founded human epidemics. The COVID-19 epidemic likely derived from a spillover of SARS-CoV-2 from bats into humans, possibly via an intermediate host. There are now several examples of SARS-CoV-2 jumping from humans into other mammals, including mink and deer, creating the potential for new animal reservoirs from which spillback into humans could occur. For this reason, data on formation of new animal reservoirs is of great importance for understanding possible sources of future infection. Here, we identify extensive infection in white-tailed deer in Pennsylvania, including what appear to be multiple independent transmissions. Data further suggests possible transmission among deer. These data thus help identify a potential new animal reservoir and provide background information relevant to its management.

Understanding health concerns and preferences of underserved adolescents has potential to shape health interventions. The objective of this study is to better understand these adolescents' current and preferred health resources, prior to the COVID-19 pandemic. High school students from underrepresented communities in six US cities completed a pre-pipeline program survey in which they reported level of personal concern, as well as current and preferred sources of information about 1) depression/anxiety, 2) nutrition, 3) sexual health, 4) trauma/violence, and 5) alcohol/drugs. 259 participants completed the survey (avg. age 15.7, 79% female, 58.3% Hispanic, and 36.0% Black). At least a moderate level of concern and some degree of prior knowledge (>3 on 5-point Likert scale) were reported across all health topics. Participants reported the lowest level of knowledge on the topic of trauma/violence. Students reported family (24%) and teachers (21%) as the most utilized current sources of information. Students reported doctors as the preferred source of information across all health topics. The difference between students' current source of information and preferred source of information was significant across four topics: depression/anxiety, sexual health, trauma, and alcohol/drugs (p <0.01). These results underscore the important role of physicians as educators and suggest a need for improved education on trauma/violence. These results also establish a pre-COVID-19 baseline for adolescent health concerns, current, and preference health resources. This baseline understanding may shift because of pandemic changes., (Copyright © 2022 National Medical Association. Published by Elsevier Inc. All rights reserved.)

Introduction: Recently, India witnessed an unprecedented surge of coronavirus disease 2019 (COVID-19)-associated mucormycosis (CAM) cases. In addition to patient management issues, environmental Mucorales contamination possibly contributed to the outbreak. A recent study evaluated environment contamination by Mucorales in the hospital setting. However, a considerable number of CAM patients were never admitted to a hospital before the development of the disease. The present study, therefore, planned to evaluate Mucorales contamination of patients' residences., Methods: The residential environment of 25 patients with CAM living in north India was surveyed. Air samples were collected from indoor and immediate outdoor vicinity of the patients' residence and cultured on Dichloran Rose-Bengal Chloramphenicol (DRBC) agar with benomyl for selective isolation of Mucorales. Surface swab samples were also collected from the air coolers fitted in those residences and cultured on DRBC agar. The isolates were identified by phenotypic and genotypic methods. Amplified fragment length polymorphism (AFLP) was employed to evaluate the genetic relatedness of the environmental and patients' clinical isolates., Results: The median spore count (mean ± SD, cfu/m 3 ) of Mucorales in the air of patients' bedrooms was significantly higher than in the air in other rooms in those residences (3.55 versus 1.5, p = 0.003) or the air collected directly from the front of the air cooler (p < 0.0001). The Mucorales spore count in the environment did not correlate with either ventilation of the room or hygiene level of the patients' residences. Rhizopus arrhizus was isolated from the environment of all patients' residences (n = 25); other Mucorales species isolated were Cunninghamella bertholletiae (n = 14), Rhizopus microsporus (n = 6), Rhizopus delemar (n = 6), Syncephalastrum racemosum (n = 1), Lichtheimia corymbifera (n = 1), and Mucor racemosus (n = 1). Genetic relatedness was observed between 11 environmental isolates from the patients' bedrooms and respective clinical isolates from patients., Discussion: The study supported the view that the patients might have acquired Mucorales from the home environment during the post-COVID-19 convalescence period. Universal masking at home during patients' convalescence period and environmental decontamination could minimize exposure in those susceptible patients., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Ghosh, Singh, Reddy, Singh, Rudramurthy, Kaur, Choudhary and Chakrabarti.)

Background: Despite having milder symptoms than adults, children are still susceptible to and can transmit SARS-CoV-2. Vaccination across all age groups is therefore necessary to curtail the pandemic. Among the available COVID-19 vaccine platforms, an inactivated vaccine platform has the advantage of excellent safety profile across all age groups; hence, we conducted an age de-escalation study to assess the safety, reactogenicity, and immunogenicity of an inactivated COVID-19 vaccine, BBV152 (COVAXIN; Bharat Biotech International, Hyderabad, India), in children aged 2-18 years., Methods: In this phase 2/3 open-label, non-randomised, multicentre study done in six hospitals in India, healthy children (male or female) aged 2-18 years were eligible for inclusion into the study. Children who had positive SARS-CoV-2 nucleic acid and serology tests at baseline, or any history of previous SARS-CoV-2 infection, or with known immunosuppressive condition were excluded. Children were sequentially enrolled into one of three groups (>12 to ≤18 years [group 1], >6 to 12 years [group 2], or ≥2 to 6 years [group 3]) and administered with adult formulation of BBV152 as two 0·5 mL intramuscular doses on days 0 and 28. Co-primary endpoints were solicited adverse events for 7 days post-vaccination and neutralising antibody titres on day 56, 28 days after the second dose. Immunogenicity endpoints were compared with Biodefense and Emerging Infections, Research Resources Repository (BEI) reference serum samples and from adults who received two doses of BBV152 in the same schedule in a previously reported phase 2 study. The trial is registered with the Clinical Trials Registry, India (CTRI/2021/05/033752) and ClinicalTrials.gov (NCT04918797)., Findings: From May 27, 2021, to July 10, 2021, we enrolled 526 children sequentially into groups 1 (n=176), 2 (n=175), and 3 (n=175). Vaccination was well tolerated, with no differences in reactogenicity between the three age groups, and no serious adverse events, deaths, or withdrawals due to an adverse event. Local reactions mainly consisted of mild injection site pain in 46 (26%) of 176 participants in group 1, 61 (35%) of 175 in group 2, and 39 (22%) of 175 in group 3 after dose 1; and 39 (22%) of 176 in group 1, 43 of 175 (25%) in group 2, and 14 of 175 (8%) in group 3 after dose 2; there were no cases of severe pain and few reports of other local reactions. After dose 1, the most frequent solicited systemic adverse event was mild-to-moderate fever, reported in eight (5%) of 176 participants in group 1, 17 (10%) of 175 in group 2, and 22 (13%) of 175 in group 3. No case of severe fever was reported, and rates of all fever were all 4% or less after dose 2. Geometric mean titres (GMTs) of microneutralisation antibodies at day 56 in groups 1 (138·8 [95% CI 111·0-173·6]), 2 (137·4 [99·1-167·5]), and 3 (197·6 [176·4-221·4]) were similar to titres in vaccinated adults (160·1 [135·8-188·8]) and with BEI reference serum samples (103·3 [50·3-202·1]). Similar results were obtained using the plaque reduction neutralisation test (PRNT), in which 166 (95%) of 175 participants in group 1, 165 (98%) of 168 in group 2, and 169 (98%) of 172 in group 3 seroconverted at day 56. The GMT ratio of PRNT titres in children and adults was 1·76 (95% CI 1·32-2·33), indicating a superior response in children compared with adults., Interpretation: BBV152 was well tolerated in children aged 2-18 years, and induced higher neutralising antibody responses than those observed in adults, in whom the efficacy (ie, the prevention or decrease in the severity of COVID-19 infection) has been demonstrated., Funding: Bharat Biotech International., Competing Interests: Declaration of interests This work was funded by Bharat Biotech International. KMV, SRe, BG, HJ, and SPrasad, are employees of Bharat Biotech, with no stock options or incentives. Co-author, KE, is the Chairman and Managing Director of Bharat Biotech and owns equity in the company. RE and WB are independent clinical development and statistical consultants, respectively (who received fees from Bharat Biotech). NM, VNT, CS, VK, SPrasan, and SRa were principal investigators representing the study sites., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Background: The ongoing novel coronavirus disease 2019 (COVID-19) pandemic has a significant mortality rate of 3-5%. The principal causes of multiorgan failure and death are cytokine release syndrome and immune dysfunction. Stress, anxiety, and depression has been aggravated by the pandemic and its resultant restrictions in day-to-day life which may contribute to immune dysregulation. Thus, immunity strengthening and the prevention of cytokine release syndrome are important for preventing and minimizing mortality in COVID-19 patients. However, despite a few specific remedies that now exist for the SARS-CoV-2virus, the principal modes of prevention include vaccination, masking, and holistic healing methods, such as yoga. Currently, extensive research is being conducted to better understand the neuroendocrinoimmunological mechanisms by which yoga alleviates stress and inflammation. This review article explores the anti-inflammatory and immune-modulating potentials of yoga, along with its role in reducing risk for immune dysfunction and impaired mental health., Methods: We conducted this narrative review from published literature in MEDLINE, EMBASE, COCHRANE databases. Screening was performed for titles and abstracts by two independent review authors; potentially eligible citations were retrieved for full-text review. References of included articles and articles of major non-indexed peer reviewed journals were searched for relevance by two independent review authors. A third review author checked the excluded records. All disagreements were resolved through discussion amongst review authors or through adjudication by a fourth review author. Abstracts, editorials, conference proceedings and clinical trial registrations were excluded., Observations: Yoga is a nonpharmacological, cost-effective, and safe intervention associated with several health benefits. Originating in ancient India, this vast discipline consists of postures (asanas), breathing techniques (pranayama), meditation (dhyana/dharana), and relaxation. Studies have demonstrated yoga's ability to bolster innate immunity and to inhibit cytokine release syndrome. As an intervention, yoga has been shown to improve mental health, as it alleviates anxiety, depression, and stress and enhances mindfulness, self-control, and self-regulation. Yoga has been correlated with numerous cardioprotective effects, which also may play a role in COVID-19 by preventing lung and cardiac injury., Conclusion and Relevance: This review paves the path for further research on yoga as a potential intervention for enhancing innate immunity and mental health and thus its role in prevention and adjunctive treatment in COVID-19., (© 2022. The Author(s).)

Background: Alabama is one of seven priority states for the National Ending the HIV Epidemic Initiative due to a large rural burden of disease. Mental health (MH) and substance use disorders (SUD) represent obstacles to HIV care in rural areas lacking Medicaid expansion and infrastructure. Evidence-informed technologies, such as telehealth, may enhance SUD and MH services but remain understudied in rural regions., Methods: We conducted a readiness assessment using a mixed methods approach to explore opportunities for enhanced SUD and MH screening using electronic patient reported outcomes (ePROs) and telehealth at five Ryan White HIV/AIDS Program-funded clinics in AL. Clinic providers and staff from each site (N = 16) completed the Organizational Readiness to Implement Change (ORIC) assessment and interviews regarding existing services and readiness to change. People with HIV from each site (PLH, N = 18) completed surveys on the acceptability and accessibility of technology for healthcare., Results: Surveys and interviews revealed that all clinics screen for depression annually by use of the Patient Health Questionnaire-9 (PHQ9). SUD screening is less frequent and unstandardized. Telehealth is available at all sites, with three of the five sites beginning services due to the COVID-19 pandemic; however, telehealth for MH and SUD services is not standardized across sites. Results demonstrate an overall readiness to adopt standardized screenings and expand telehealth services beyond HIV services at clinics. There were several concerns including Wi-Fi access, staff capacity, and patients' technological literacy. A sample of 18 people with HIV (PWH), ages 18 to 65 years, participated in surveys; all demonstrated adequate technology literacy. A majority had accessed telehealth and were not concerned about it being too complicated or limiting communication. There were some concerns around lack of in-person interaction and lack of a physical exam and high-quality care with telehealth., Conclusion: This study of PWH and the clinics that serve them reveals opportunities to expand SUD and MH services in rural regions using technology. Areas for improvement include implementing routine SUD screening, expanding telehealth while maintaining opportunities for in-person interaction, and using standardized ePROs that are completed by patients, in order to minimize stigma and bias., (© 2022. The Author(s).)

This is a comprehensive report on immunogenicity of COVAXIN ® booster dose against ancestral and Variants of Concern (VOCs) up to 12 months. It is well known that neutralizing antibodies induced by COVID-19 vaccines wane within 6 months of vaccination leading to questions on the effectiveness of two-dose vaccination against breakthrough infections. Therefore, we assessed the persistence of immunogenicity up to 6 months after a two or three-dose with BBV152 and the safety of a booster dose in an ongoing phase 2, double-blind, randomized controlled trial (ClinicalTrials.gov: NCT04471519). We report persistence of humoral and cell mediated immunity up to 12 months of vaccination, despite decline in the magnitude of antibody titers. Administration of a third dose of BBV152 increased neutralization titers against both homologous (D614G) and heterologous strains (Alpha, Beta, Delta, Delta Plus and Omicron) with a slight increase in B cell memory responses. Thus, seronversion rate remain high in boosted recipients compared to non-booster, even after 6 months, post third dose against variants. No serious adverse events observed, except pain at the injection site, itching and redness. Hence, these results indicate that a booster dose of BBV152 is safe and necessary to ensure persistent immunity to minimize breakthrough infections of COVID-19, due to newly emerging variants.Trial registration: Registered with the Clinical Trials Registry (India) No. CTRI/2021/04/032942, dated 19/04/2021 and on Clinicaltrials.gov: NCT04471519., (© 2022. The Author(s).)

Background: Telemedicine use has increased significantly during the COVID-19 pandemic. It remains unclear if its rapid growth exacerbates disparities in healthcare access. We aimed to characterize telemedicine use among a large oncology population in the Deep South during the COVID-19 pandemic., Materials and Methods: A retrospective cohort study was performed at the only National Cancer Institute designated-cancer center in Alabama March 2020 to December 2020. With a diverse (26.5% Black, 61% rural) population, this southeastern demographic uniquely reflects historically vulnerable populations. All non-procedural visits at the cancer center from March to December 2020 were included in this study excluding those with a department that had fewer than 100 visits during this time period. Patient and clinic level characteristics were analyzed using t-test and Chi-square to compare characteristics between visit types (in-person versus telemedicine, and video versus audio within telemedicine). Generalized estimating equations were used to identify independent factors associated with telemedicine use and type of telemedicine use., Results: There were 50 519 visits and most were in-person (81.3%). Among telemedicine visits, most were phone based (58.3%). Black race and male sex predicted in-person visits. Telemedicine visits were less likely to have video among patients who were Black, older, male, publicly insured, and from lower income areas., Conclusions: Telemedicine use, specifically with video, is significantly lower among historically vulnerable populations. Understanding barriers to telemedicine use and preferred modalities of communication among different populations will help inform insurance reimbursement and interventions at different socioecological levels to ensure the continued evolution of telemedicine is equitable., (© The Author(s) 2022. Published by Oxford University Press.)

As of 2 September 2021, United States nursing homes have reported >675,000 COVID-19 cases and >134,000 deaths according to the Centers for Medicare & Medicaid Services (CMS). More than 205,000,000 persons in the United States had received at least one dose of a COVID-19 vaccine (62% of total population) as of 2 September 2021. We investigate the role of vaccination in controlling future COVID-19 outbreaks. We developed a stochastic, compartmental model of SARS-CoV-2 transmission in a 100-bed nursing home with a staff of 99 healthcare personnel (HCP) in a community of 20,000 people. We parameterized admission and discharge of residents in the model with CMS data, for a within-facility basic reproduction number (R 0 ) of 3.5 and a community R 0 of 2.5. The model also included: importation of COVID-19 from the community, isolation of SARS-CoV-2 positive residents, facility-wide adherence to personal protective equipment (PPE) use by HCP, and testing. We systematically varied coverage of mRNA vaccine among residents, HCP, and the community. Simulations were run for 6 months after the second dose in the facility, with results summarized over 1,000 simulations. Expected resident cases decreased as community vaccination increased, with large reductions at high HCP coverage. The probability of a COVID-19 outbreak was lower as well: at HCP vaccination coverage of 60%, probability of an outbreak was below 20% for community coverage of 50% or above. At high coverage, stopping asymptomatic screening and facility-wide testing yielded similar results. Results suggest that high coverage among HCP and in the community can prevent infections in residents. When vaccination is high in nursing homes, but not in their surrounding communities, asymptomatic and facility-wide testing remains necessary to prevent the spread of COVID-19. High adherence to PPE may increase the likelihood of containing future COVID-19 outbreaks if they occur., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Published by Elsevier Ltd.)

We investigate electropolymerized molecularly imprinted polymers (E-MIPs) for the selective recognition of SARS-CoV-2 whole virus. E-MIPs imprinted with SARS-CoV-2 pseudoparticles (pps) were electrochemically deposited onto screen printed electrodes by reductive electropolymerization, using the water-soluble N-hydroxmethylacrylamide (NHMA) as functional monomer and crosslinked with N,N'-methylenebisacrylamide (MBAm). E-MIPs for SARS-CoV-2 showed selectivity for template SARS-CoV-2 pps, with an imprinting factor of 3:1, and specificity (significance = 0.06) when cross-reacted with other respiratory viruses. E-MIPs detected the presence of SARS-CoV-2 pps in <10 min with a limit of detection of 4.9 log 10 pfu/mL, suggesting their suitability for detection of SARS-CoV-2 with minimal sample preparation. Using electrochemical impedance spectroscopy (EIS) and principal component analysis (PCA), the capture of SARS-CoV-2 from real patient saliva samples was also evaluated. Fifteen confirmed COVID-19 positive and nine COVID-19 negative saliva samples were compared against the established loop-mediated isothermal nucleic acid amplification (LAMP) technique used by the UK National Health Service. EIS data demonstrated a PCA discrimination between positive and negative LAMP samples. A threshold real impedance signal (Z Re ) ≫ 4000 Ω and a corresponding charge transfer resistance (R CT ) ≫ 6000 Ω was indicative of absence of virus (COVID-19 negative) in agreement with values obtained for our control non-imprinted polymer control. A Z Re at or below a threshold value of 600 Ω with a corresponding R CT of <1200 Ω was indicative of a COVID-19 positive sample. The presence of virus was confirmed by treatment of E-MIPs with a SARS-CoV-2 specific monoclonal antibody., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 The Author(s). Published by Elsevier B.V. All rights reserved.)

Background: The second COVID-19 wave in India has been associated with an unprecedented increase in cases of COVID-19 associated mucormycosis (CAM), mainly Rhino-orbito-cerebral mucormycosis (ROCM)., Methods: This retrospective cohort study was conducted at Noble hospital and Research Centre (NHRC), Pune, India, between 1 April, 2020, and 1 August, 2021, to identify CAM patients and assess their management outcomes. The primary endpoint was incidence of all-cause mortality due to CAM., Results: 59 patients were diagnosed with CAM. Median duration from the first positive COVID-19 RT PCR test to diagnosis of CAM was 17 (IQR: 12,22) days. 90% patients were diabetic with 89% having uncontrolled sugar level (HbA1c >7%). All patients were prescribed steroids during treatment for COVID-19. 56% patients were prescribed steroids for non-hypoxemic, mild COVID-19 (irrational steroid therapy), while in 9%, steroids were prescribed in inappropriately high dose. Patients were treated with a combination of surgical debridement (94%), intravenous liposomal Amphotericin B (91%) and concomitant oral Posaconazole (95.4%). 74.6% patients were discharged after clinical and radiologic recovery while 25.4% died. On relative risk analysis, COVID-19 CT severity index ≥18 (p = .017), presence of orbital symptoms (p = .002), presence of diabetic ketoacidosis (p = .011) and cerebral involvement (p = .0004) were associated with increased risk of death., Conclusions: CAM is a rapidly progressive, angio-invasive, opportunistic fungal infection, which is fatal if left untreated. Combination of surgical debridement and antifungal therapy leads to clinical and radiologic improvement in majority of cases., (© 2022 Wiley-VCH GmbH.)

"Guitar pick sign," also referred to as posterior globe tenting, is a radiological surrogate marker of tense orbit and profound vision loss. It is seen commonly in traumatic retrobulbar hemorrhage and carotico-cavernous fistula and less frequently in orbital cellulitis, subperiosteal abscess, and invasive fungal infections. We report a case series of Coronavirus disease-19-associated rhino-orbito-cerebral mucormycosis with guitar pick sign, of which none survived, and discuss the causative pathomechanisms, severity grade, and the clinical relevance of this unique radiological finding., Competing Interests: None

Neutralizing antibody-based passive immunotherapy could be an important therapeutic option against COVID-19. Herein, we demonstrate that equines hyper-immunized with chemically inactivated SARS-CoV-2 elicited high antibody titers with a strong virus-neutralizing potential, and F(ab') 2 fragments purified from them displayed strong neutralization potential against five different SARS-CoV-2 variants. F(ab') 2 fragments purified from the plasma of hyperimmunized horses showed high antigen-specific affinity. Experiments in rabbits suggested that the F(ab') 2 displays a linear pharmacokinetics with approximate plasma half-life of 47 h. In vitro microneutralization assays using the purified F(ab') 2 displayed high neutralization titers against five different variants of SARS-CoV-2 including the Delta variant, demonstrating its potential efficacy against the emerging viral variants. In conclusion, this study demonstrates that F(ab') 2 generated against SARS-CoV-2 in equines have high neutralization titers and have broad target-range against the evolving variants, making passive immunotherapy a potential regimen against the existing and evolving SARS-CoV-2 variants in combating COVID-19., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Introduction: As healthcare systems are adapting due to COVID-19, there has been an increased need for telehealth in the outpatient setting. Not all patients have been comfortable with this transition. We sought to determine the relationship between health literacy and technological comfort in our cancer patients., Methods: We conducted a survey of patients that presented to the oncology clinics at a single-center over a 2-month period. Patients were given a voluntary, anonymous, survey during their visit containing questions regarding demographics, health literacy and technological comfort., Results: 344 surveys were returned (response-rate 64.3%). The median patient age was 61 years, 70% of responders were female and the most common race was White (67.3%). Increasing patient age, male gender, Black and Native-American race, decreased health literacy and lack of home broadband were associated with lower technological comfort score., Conclusion: In our cohort, patients with lower health literacy scores, older and male patients, or who have poor internet access showed a lower level of technological comfort. At risk patients can be identified and provided additional support in their use of telehealth services., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Nursing home residents and staff were included in the first phase of coronavirus disease 2019 vaccination in the United States. Because the primary trial endpoint was vaccine efficacy (VE) against symptomatic disease, there are limited data on the extent to which vaccines protect against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and the ability to infect others (infectiousness). Assumptions about VE against infection and infectiousness have implications for changes to infection prevention guidance for vaccinated populations, including testing strategies., Methods: We use a stochastic agent-based Susceptible-Exposed-Infectious (Asymptomatic/Symptomatic)-Recovered model of a nursing home to simulate SARS-CoV-2 transmission. We model 3 scenarios, varying VE against infection, infectiousness, and symptoms, to understand the expected impact of vaccination in nursing homes, increasing staff vaccination coverage, and different screening testing strategies under each scenario., Results: Increasing vaccination coverage in staff decreases total symptomatic cases in the nursing home (among staff and residents combined) in each VE scenario. In scenarios with 50% and 90% VE against infection and infectiousness, increasing staff coverage reduces symptomatic cases among residents. If vaccination only protects against symptoms, and asymptomatic cases remain infectious, increased staff coverage increases symptomatic cases among residents. However, this is outweighed by the reduction in symptomatic cases among staff. Higher frequency testing-more than once weekly-is needed to reduce total symptomatic cases if the vaccine has lower efficacy against infection and infectiousness, or only protects against symptoms., Conclusions: Encouraging staff vaccination is not only important for protecting staff, but might also reduce symptomatic cases in residents if a vaccine confers at least some protection against infection or infectiousness., (Published by Oxford University Press for the Infectious Diseases Society of America 2021.)

Background: We report the clinical efficacy against COVID-19 infection of BBV152, a whole virion inactivated SARS-CoV-2 vaccine formulated with a toll-like receptor 7/8 agonist molecule adsorbed to alum (Algel-IMDG) in Indian adults., Methods: We did a randomised, double-blind, placebo-controlled, multicentre, phase 3 clinical trial in 25 Indian hospitals or medical clinics to evaluate the efficacy, safety, and immunological lot consistency of BBV152. Adults (age ≥18 years) who were healthy or had stable chronic medical conditions (not an immunocompromising condition or requiring treatment with immunosuppressive therapy) were randomised 1:1 with a computer-generated randomisation scheme (stratified for the presence or absence of chronic conditions) to receive two intramuscular doses of vaccine or placebo administered 4 weeks apart. Participants, investigators, study coordinators, study-related personnel, the sponsor, and nurses who administered the vaccines were masked to treatment group allocation; an unmasked contract research organisation and a masked expert adjudication panel assessed outcomes. The primary outcome was the efficacy of the BBV152 vaccine in preventing a first occurrence of laboratory-confirmed (RT-PCR-positive) symptomatic COVID-19 (any severity), occurring at least 14 days after the second dose in the per-protocol population. We also assessed safety and reactogenicity throughout the duration of the study in all participants who had received at least one dose of vaccine or placebo. This report contains interim results (data cutoff May 17, 2021) regarding immunogenicity and safety outcomes (captured on days 0 to 56) and efficacy results with a median of 99 days for the study population. The trial was registered on the Indian Clinical Trials Registry India, CTRI/2020/11/028976, and ClinicalTrials.gov, NCT04641481 (active, not recruiting)., Findings: Between Nov 16, 2020, and Jan 7, 2021, we recruited 25 798 participants who were randomly assigned to receive BBV152 or placebo; 24 419 received two doses of BBV152 (n=12 221) or placebo (n=12 198). Efficacy analysis was dependent on having 130 cases of symptomatic COVID-19, which occurred when 16 973 initially seronegative participants had at least 14 days follow-up after the second dose. 24 (0·3%) cases occurred among 8471 vaccine recipients and 106 (1·2%) among 8502 placebo recipients, giving an overall estimated vaccine efficacy of 77·8% (95% CI 65·2-86·4). In the safety population (n=25 753), 5959 adverse events occurred in 3194 participants. BBV152 was well tolerated; the same proportion of participants reported adverse events in the vaccine group (1597 [12·4%] of 12 879) and placebo group (1597 [12·4%] of 12 874), with no clinically significant differences in the distributions of solicited, unsolicited, or serious adverse events between the groups, and no cases of anaphylaxis or vaccine-related deaths., Interpretation: BBV152 was highly efficacious against laboratory-confirmed symptomatic COVID-19 disease in adults. Vaccination was well tolerated with no safety concerns raised in this interim analysis., Funding: Bharat Biotech International and Indian Council of Medical Research., Competing Interests: Declaration of interests This work was funded by Bharat Biotech International and co-funded by the Indian Council of Medical Research. RE, KMV, SPr, SRe, VKA and VS are employees of Bharat Biotech International, with no stock options or incentives. KE is the chairman and managing director of Bharat Biotech International and owns equity in the company. WB is an independent statistical development consultant. VP, PY, GS, PA, NG, BB, SK, and SPa are employees of the Indian Council of Medical Research. All other authors declare no competing interests., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background and Aims: During the COVID-19 vaccination program in India, the healthcare workers were given the first priority. There are concerns regarding the occurrence of breakthrough infections after vaccination. We aimed to investigate the effictiveness of COVID-19 vaccines in preventing and reducing the severity of post-vaccination infections., Methods: This retrospective test-negative case-control study examined 28342 vaccinated healthcare workers for symptomatic SARS-CoV-2 infections between January 16 to June 15, 2021. They worked at 43 Apollo Group hospitals in 24 Indian cities. These cohorts received either ChAdOx nCOV-19 (Recombinant) or the whole virion inactivated Vero cell vaccines. Various demographic, vaccination related and clinical parameters were evaluated., Results: Symptomatic symptomatic post-vaccination infections occurred in a small number of vaccinated cohorts (5.07%, p < 0.001), and these were predominantly mild and did not result in hospitalization (p < 0.0001), or death. Both vaccines provided similar protection, with symptomatic infections in 5.11% and 4.58%, following ChAdOx nCOV-19 (Recombinant) and the whole virion inactivated Vero cell vaccines, respectively (p < 0.001). Nursing and Clinical staff and cohorts >50 years contracted more infections (p < 0.001). Two-dose vaccination has significantly lower odds of developing symptomatic infection (0.83, 95%CI - 0.72 to 0.97). Maximum infections occurred during the peak of the second COVID-19 wave from mid-April to May 2021 (p < 0.001). No significant difference existed in the infection between sex, vaccine type, and the number of vaccine doses received (p ≥ 0.05)., Conclusion: Symptomatic infections occurred in a small percentage of healthcare workers after COVID vaccination. Vaccination protected them from not only infection but also severe disease., Competing Interests: Declaration of competing interest None., (Copyright © 2021 Diabetes India. Published by Elsevier Ltd. All rights reserved.)

Introduction: Coronavirus disease 2019 (COVID-19) pandemic led to a sudden drop in renal transplant numbers across India in the initial months of 2020. Although the transplant numbers increased with easing of lockdown, the outcome of these transplants remains unknown., Methods: This was a retrospective, observational, multi-center study done across eight different transplant centers in India. All the transplants done from January 30, 2020 to December 31, 2020 were included. The primary outcomes studied were patient and death censored graft survival as well as incidence of COVID-19 infection and its outcomes., Results: During the study period a total of 297 kidney transplants were done. After a median follow up of 265 days the patient and death censored graft survival was 95.3% and 97.6%, respectively. Forty-one patients (13.8%) developed COVID-19 post-transplant. Majority (58.5%) were asymptomatic to mildly symptomatic and the case fatality ratio was 14.6%. On multivariable logistic regression analysis older age was associated with higher likelihood of COVID-19 infection (odds ratio 1.038; CI 1.002-1.077)., Conclusions: Patient and graft outcome of kidney transplants done during the COVID-19 pandemic in India was acceptable. The incidence of COVID-19 was 13.8% with a high case fatality ratio., (© 2021 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Background: As the health systems around the world struggled to meet the challenges of COVID-19 pandemic, care of many non-COVID emergencies was affected., Aims: The present study examined differences in the diagnosis, evaluation and management of stroke patients during a defined period in the ongoing pandemic in 2020 when compared to a similar epoch in year 2019., Methods: The COVID stroke study group (CSSG) India, included 18 stroke centres spread across the country. Data was collected prospectively between February and July 2020 and retrospectively for the same period in 2019. Details of demographics, stroke evaluation, treatment, in-hospital and three months outcomes were collected and compared between these two time points., Results: A total of 2549 patients were seen in both study periods; 1237 patients (48.53%) in 2019 and 1312 (51.47%) in 2020. Although the overall number of stroke patients and rates of thrombolysis were comparable, a significant decline was observed in the month of April 2020, during the initial period of the pandemic and lockdown. Endovascular treatment reduced significantly and longer door to needle and CT to needle times were observed in 2020. Although mortality was higher in 2020, proportion of patients with good outcome were similar in both the study periods., Conclusions: Although stroke admissions and rates of thrombolysis were comparable, some work flow metrics were delayed, endovascular stroke treatment rates declined and mortality was higher during the pandemic study period. Reorganization of stroke treatment pathways during the pandemic has likely improved the stroke care delivery across the globe., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Aims: To evaluate calculated total plasma osmolality as a marker of outcome prediction, fluid and metabolic balance, thrombotic risk in severe COVID-19 patients., Methods: Retrospective data of RT-PCR confirmed hospitalized severe COVID-19 patients (total: n = 175 patients, including diabetic subset: n = 102) were analyzed. Clinically applicable cut-offs were derived using receiver operating characteristic (ROC) curve analysis for calculated total osmolality, eGFR, and D-dimer, and their correlations were studied., Results: Among 175 severe COVID-19 patients, a significant association with mortality was seen with respect to calculated total osmolality (p < 0.001), eGFR (p < 0.001), and D-dimer (p < 0.001). In the total cohort, applicable cut-offs based on ROC curve in predicting outcome were, for total osmolality 299 mosm/kg (area under the curve (AUC)-0.773, odds ratio (OR)-1.09), eGFR 61.5 ml/min/m2 (AUC-0.789, OR-0.96), D-dimer 5.13 (AUC-0.814, OR-2.65) respectively. In diabetic subset, the cut-offs for total osmolality were 298 mosm/kg (AUC-0.794, OR-1.12), eGFR 44.9 ml/min/m2 (AUC-0.774, OR-0.96) and D-dimer 1.59 (AUC-0.769, OR-1.52) respectively., Conclusions: Applicable cut-offs for calculated total plasma osmolality, eGFR, and D-dimer predicts clinical outcome in severe COVID-19 with and without diabetes. Correlation studies validated calculated total osmolality as a marker of the combined effect of fluid and metabolic imbalance, compromised renal function and hypercoagulability., Competing Interests: Declaration of competing interest The authors whose names are listed immediately below certify that they have NO affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript., (Copyright © 2021 Diabetes India. Published by Elsevier Ltd. All rights reserved.)

Objective: The effect of the COVID-19 pandemic on community-based rheumatology care and the use of telehealth is unclear. We undertook this study to investigate the impact of the pandemic on rheumatology care delivery in a large community practice-based network., Methods: Using a community practice-based rheumatologist network, we examined trends in in-person versus telehealth visits versus canceled visits in 3 time periods: pre-COVID-19, COVID-19 transition (6 weeks beginning March 23, 2020), and post-COVID-19 transition (May-August). In the transition period, we compared patients who received in-person care versus telehealth visits versus those who cancelled all visits. We used multivariable logistic regression to identify factors associated with canceled or telehealth visits., Results: Pre-COVID-19, there were 7,075 visits/week among 60,002 unique rheumatology patients cared for by ~300 providers practicing in 92 offices. This number decreased substantially (24.6% reduction) during the COVID-19 transition period for in-person visits but rebounded to pre-COVID-19 levels during the post-COVID-19 transition. There were almost no telehealth visits pre-COVID-19, but telehealth increased substantially during the COVID-19 transition (41.4% of all follow-up visits) and slightly decreased during the post-COVID-19 transition (27.7% of visits). Older age, female sex, Black or Hispanic race/ethnicity, lower socioeconomic status, and rural residence were associated with a greater likelihood of canceling visits. Most factors were also associated with a lower likelihood of having telehealth versus in-office visits. Patients living further from the rheumatologists' office were more likely to use telehealth., Conclusion: COVID-19 led to large disruptions in rheumatology care; these disruptions were only partially offset by increases in telehealth use and disproportionately affected racial/ethnic minorities and patients with lower socioeconomic status. During the COVID-19 era, telehealth continues to be an important part of rheumatology practice, but disparities in access to care exist for some vulnerable groups., (© 2021, American College of Rheumatology.)

Acute polio, once epidemic and a significant source of paralysis and disability, has been dramatically reduced through global vaccination programs. Although vaccination efforts have experienced a setback because of COVID-19, resulting in increased number of vaccine-associated and wild virus infections, polio eradication is still a realistic goal that will result in significant cost savings. The secondary health issues related to aging with the residual effects of polio, including postpolio syndrome, will persist for many years posteradication. Continued education of medical professionals is essential to ensure provision of the necessary care to this population., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: BBV152 is a whole-virion inactivated SARS-CoV-2 vaccine (3 μg or 6 μg) formulated with a toll-like receptor 7/8 agonist molecule (IMDG) adsorbed to alum (Algel). We previously reported findings from a double-blind, multicentre, randomised, controlled phase 1 trial on the safety and immunogenicity of three different formulations of BBV152 (3 μg with Algel-IMDG, 6 μg with Algel-IMDG, or 6 μg with Algel) and one Algel-only control (no antigen), with the first dose administered on day 0 and the second dose on day 14. The 3 μg and 6 μg with Algel-IMDG formulations were selected for this phase 2 study. Herein, we report interim findings of the phase 2 trial on the immunogenicity and safety of BBV152, with the first dose administered on day 0 and the second dose on day 28., Methods: We did a double-blind, randomised, multicentre, phase 2 clinical trial to evaluate the immunogenicity and safety of BBV152 in healthy adults and adolescents (aged 12-65 years) at nine hospitals in India. Participants with positive SARS-CoV-2 nucleic acid and serology tests were excluded. Participants were randomly assigned (1:1) to receive either 3 μg with Algel-IMDG or 6 μg with Algel-IMDG. Block randomisation was done by use of an interactive web response system. Participants, investigators, study coordinators, study-related personnel, and the sponsor were masked to treatment group allocation. Two intramuscular doses of vaccine were administered on day 0 and day 28. The primary outcome was SARS-CoV-2 wild-type neutralising antibody titres and seroconversion rates (defined as a post-vaccination titre that was at least four-fold higher than the baseline titre) at 4 weeks after the second dose (day 56), measured by use of the plaque-reduction neutralisation test (PRNT 50 ) and the microneutralisation test (MNT 50 ). The primary outcome was assessed in all participants who had received both doses of the vaccine. Cell-mediated responses were a secondary outcome and were assessed by T-helper-1 (Th1)/Th2 profiling at 2 weeks after the second dose (day 42). Safety was assessed in all participants who received at least one dose of the vaccine. In addition, we report immunogenicity results from a follow-up blood draw collected from phase 1 trial participants at 3 months after they received the second dose (day 104). This trial is registered at ClinicalTrials.gov, NCT04471519., Findings: Between Sept 5 and 12, 2020, 921 participants were screened, of whom 380 were enrolled and randomly assigned to the 3 μg with Algel-IMDG group (n=190) or 6 μg with Algel-IMDG group (n=190). Geometric mean titres (GMTs; PRNT 50 ) at day 56 were significantly higher in the 6 μg with Algel-IMDG group (197·0 [95% CI 155·6-249·4]) than the 3 μg with Algel-IMDG group (100·9 [74·1-137·4]; p=0·0041). Seroconversion based on PRNT 50 at day 56 was reported in 171 (92·9% [95% CI 88·2-96·2] of 184 participants in the 3 μg with Algel-IMDG group and 174 (98·3% [95·1-99·6]) of 177 participants in the 6 μg with Algel-IMDG group. GMTs (MNT 50 ) at day 56 were 92·5 (95% CI 77·7-110·2) in the 3 μg with Algel-IMDG group and 160·1 (135·8-188·8) in the 6 μg with Algel-IMDG group. Seroconversion based on MNT 50 at day 56 was reported in 162 (88·0% [95% CI 82·4-92·3]) of 184 participants in the 3 μg with Algel-IMDG group and 171 (96·6% [92·8-98·8]) of 177 participants in the 6 μg with Algel-IMDG group. The 3 μg with Algel-IMDG and 6 μg with Algel-IMDG formulations elicited T-cell responses that were biased to a Th1 phenotype at day 42. No significant difference in the proportion of participants who had a solicited local or systemic adverse reaction in the 3 μg with Algel-IMDG group (38 [20·0%; 95% CI 14·7-26·5] of 190) and the 6 μg with Algel-IMDG group (40 [21·1%; 15·5-27·5] of 190) was observed on days 0-7 and days 28-35; no serious adverse events were reported in the study. From the phase 1 trial, 3-month post-second-dose GMTs (MNT 50 ) were 39·9 (95% CI 32·0-49·9) in the 3μg with Algel-IMDG group, 69·5 (53·7-89·9) in the 6 μg with Algel-IMDG group, 53·3 (40·1-71·0) in the 6 μg with Algel group, and 20·7 (14·5-29·5) in the Algel alone group., Interpretation: In the phase 1 trial, BBV152 induced high neutralising antibody responses that remained elevated in all participants at 3 months after the second vaccination. In the phase 2 trial, BBV152 showed better reactogenicity and safety outcomes, and enhanced humoral and cell-mediated immune responses compared with the phase 1 trial. The 6 μg with Algel-IMDG formulation has been selected for the phase 3 efficacy trial., Funding: Bharat Biotech International., Translation: For the Hindi translation of the abstract see Supplementary Materials section., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background and Aims: The COVID-19 pandemic continues to challenge us. Despite several strides in management, steroids remain the mainstay for treating moderate to severe disease and with it arises challenges such as hyperglycemia. The review aims to enhance awareness amongst physicians on steroid use and hyperglycemia., Methods: An advisory document describing various strategies for hyperglycemia management was prepared in the public interest by DiabetesIndia., Results: The review provides awareness on steroids and hyperglycemia, adverse outcomes of elevated blood glucose levels and, advice at the time of discharge., Conclusions: The article emphasizes enhancing awareness on effective management of hyperglycemia during COVID-19., (Copyright © 2021 Diabetes India. Published by Elsevier Ltd. All rights reserved.)

In Coronavirus disease 2019 (COVID-19), early identification of patients with a high risk of mortality can significantly improve triage, bed allocation, timely management, and possibly, outcome. The study objective is to develop and validate individualized mortality risk scores based on the anonymized clinical and laboratory data at admission and determine the probability of Deaths at 7 and 28 days. Data of 1393 admitted patients (Expired-8.54%) was collected from six Apollo Hospital centers (from April to July 2020) using a standardized template and electronic medical records. 63 Clinical and Laboratory parameters were studied based on the patient's initial clinical state at admission and laboratory parameters within the first 24 h. The Machine Learning (ML) modelling was performed using eXtreme Gradient Boosting (XGB) Algorithm. 'Time to event' using Cox Proportional Hazard Model was used and combined with XGB Algorithm. The prospective validation cohort was selected of 977 patients (Expired-8.3%) from six centers from July to October 2020. The Clinical API for the Algorithm is  http://20.44.39.47/covid19v2/page1.php being used prospectively. Out of the 63 clinical and laboratory parameters, Age [adjusted hazard ratio (HR) 2.31; 95% CI 1.52-3.53], Male Gender (HR 1.72, 95% CI 1.06-2.85), Respiratory Distress (HR 1.79, 95% CI 1.32-2.53), Diabetes Mellitus (HR 1.21, 95% CI 0.83-1.77), Chronic Kidney Disease (HR 3.04, 95% CI 1.72-5.38), Coronary Artery Disease (HR 1.56, 95% CI - 0.91 to 2.69), respiratory rate > 24/min (HR 1.54, 95% CI 1.03-2.3), oxygen saturation below 90% (HR 2.84, 95% CI 1.87-4.3), Lymphocyte% in DLC (HR 1.99, 95% CI 1.23-2.32), INR (HR 1.71, 95% CI 1.31-2.13), LDH (HR 4.02, 95% CI 2.66-6.07) and Ferritin (HR 2.48, 95% CI 1.32-4.74) were found to be significant. The performance parameters of the current model is at AUC ROC Score of 0.8685 and Accuracy Score of 96.89. The validation cohort had the AUC of 0.782 and Accuracy of 0.93. The model for Mortality Risk Prediction provides insight into the COVID Clinical and Laboratory Parameters at admission. It is one of the early studies, reflecting on 'time to event' at the admission, accurately predicting patient outcomes.

Background and Aims: COVID-19 pandemic has strained the health infrastructure globally, providing an opportunity to identify cost-effective biomarkers. We aimed to identify simple hematological prognostic markers in hospitalized severe COVID-19 patients with and without diabetes., Methods: Retrospective study of RT-PCR confirmed hospitalized severe COVID-19 patients (total: n = 154 patients, including diabetic subset n = 57) were analyzed. Clinically applicable cut-offs were derived using receiver operating characteristic (ROC) curve analysis for total leucocyte count (TLC), absolute neutrophil count (ANC), neutrophil lymphocyte ratio (NLR), and derived neutrophil lymphocyte ratio (dNLR) in order to prognosticate the outcome., Results: Among 154 severe COVID-19 patients, significant association with mortality was seen with respect to TLC(p < 0.001), ANC (p < 0.001), NLR(p < 0.001) and dNLR(p < 0.001). In the total cohort, applicable cut-offs based on ROC curve in predicting outcome were, for TLC 8950 cells/mm 3 (area under curve (AUC)-0.764, odds ratio (OR)-7.53), ANC 7679 cells/mm 3 (AUC-0.789, OR-8.14), NLR 5.13 (AUC-0.741, OR-4.77), dNLR 3.44 (AUC -0.741, OR-4.43) respectively.In diabetic subset, the cut-offs for TLC was 8950 cells/mm 3 (AUC -0.762, OR-14.9), ANC 6510 cells/mm 3 (AUC -0.773, OR-16.8), NLR 5.13(AUC -0.678, OR-6) and dNLR 3.25(AUC -0.685, OR-4.7) respectively., Conclusions: In severe COVID-19 patients irrespective of diabetes, a simple, applicable total leucocyte count cut-off, 8950 cells/mm 3 , together with easily derived cut-offs for ANC, NLR, dNLR may serve as cost-effective prognosticators of clinical outcome. A normal TLC may be misleading in the intensive care and the above applicable cut-off for TLC serves as an early warning tool for high-risk identification and better in-hospital management. Even with similar or lower cut-offs, diabetics had a higher mortality., (Copyright © 2021 Diabetes India. Published by Elsevier Ltd. All rights reserved.)

Background: To mitigate the effects of COVID-19, a vaccine is urgently needed. BBV152 is a whole-virion inactivated SARS-CoV-2 vaccine formulated with a toll-like receptor 7/8 agonist molecule adsorbed to alum (Algel-IMDG) or alum (Algel)., Methods: We did a double-blind, multicentre, randomised, controlled phase 1 trial to assess the safety and immunogenicity of BBV152 at 11 hospitals across India. Healthy adults aged 18-55 years who were deemed healthy by the investigator were eligible. Individuals with positive SARS-CoV-2 nucleic acid and/or serology tests were excluded. Participants were randomly assigned to receive either one of three vaccine formulations (3 μg with Algel-IMDG, 6 μg with Algel-IMDG, or 6 μg with Algel) or an Algel only control vaccine group. Block randomisation was done with a web response platform. Participants and investigators were masked to treatment group allocation. Two intramuscular doses of vaccines were administered on day 0 (the day of randomisation) and day 14. Primary outcomes were solicited local and systemic reactogenicity events at 2 h and 7 days after vaccination and throughout the full study duration, including serious adverse events. Secondary outcome was seroconversion (at least four-fold increase from baseline) based on wild-type virus neutralisation. Cell-mediated responses were evaluated by intracellular staining and ELISpot. The trial is registered at ClinicalTrials.gov (NCT04471519)., Findings: Between July 13 and 30, 2020, 827 participants were screened, of whom 375 were enrolled. Among the enrolled participants, 100 each were randomly assigned to the three vaccine groups, and 75 were randomly assigned to the control group (Algel only). After both doses, solicited local and systemic adverse reactions were reported by 17 (17%; 95% CI 10·5-26·1) participants in the 3 μg with Algel-IMDG group, 21 (21%; 13·8-30·5) in the 6 μg with Algel-IMDG group, 14 (14%; 8·1-22·7) in the 6 μg with Algel group, and ten (10%; 6·9-23·6) in the Algel-only group. The most common solicited adverse events were injection site pain (17 [5%] of 375 participants), headache (13 [3%]), fatigue (11 [3%]), fever (nine [2%]), and nausea or vomiting (seven [2%]). All solicited adverse events were mild (43 [69%] of 62) or moderate (19 [31%]) and were more frequent after the first dose. One serious adverse event of viral pneumonitis was reported in the 6 μg with Algel group, unrelated to the vaccine. Seroconversion rates (%) were 87·9, 91·9, and 82·8 in the 3 μg with Algel-IMDG, 6 μg with Algel-IMDG, and 6 μg with Algel groups, respectively. CD4 + and CD8 + T-cell responses were detected in a subset of 16 participants from both Algel-IMDG groups., Interpretation: BBV152 led to tolerable safety outcomes and enhanced immune responses. Both Algel-IMDG formulations were selected for phase 2 immunogenicity trials. Further efficacy trials are warranted., Funding: Bharat Biotech International., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Several comorbidities have been shown to be associated with coronavirus disease 2019 (COVID-19) related severity and mortality. However, considerable variation in the prevalence estimates of comorbidities and their effects on COVID-19 morbidity and mortality have been observed in prior studies. This systematic review and meta-analysis aimed to determine geographical, age, and gender related differences in the prevalence of comorbidities and associated severity and mortality rates among COVID-19 patients. We conducted a search using PubMed, Scopus, and EMBASE to include all COVID-19 studies published between January 1st, 2020 to July 24th, 2020 reporting comorbidities with severity or mortality. We included studies reporting the confirmed diagnosis of COVID-19 on human patients that also provided information on comorbidities or disease outcomes. We used DerSimonian and Laird random effects method for calculating estimates. Of 120 studies with 125,446 patients, the most prevalent comorbidity was hypertension (32%), obesity (25%), diabetes (18%), and cardiovascular disease (16%) while chronic kidney or other renal diseases (51%, 44%), cerebrovascular accident (43%, 44%), and cardiovascular disease (44%, 40%) patients had more COVID-19 severity and mortality respectively. Considerable variation in the prevalence of comorbidities and associated disease severity and mortality in different geographic regions was observed. The highest mortality was observed in studies with Latin American and European patients with any medical condition, mostly older adults (≥ 65 years), and predominantly male patients. Although the US studies observed the highest prevalence of comorbidities in COVID-19 patients, the severity of COVID-19 among each comorbid condition was highest in Asian studies whereas the mortality was highest in the European and Latin American countries. Risk stratification and effective control strategies for the COVID-19 should be done according to comorbidities, age, and gender differences specific to geographical location.

Background: Coronavirus disease (COVID-19) has been associated with adverse pregnancy outcomes. Due to the lack of effective treatments for COVID-19, it becomes imperative to assess the geographical differences and trends in the current clinical care and outcomes of COVID-19 in pregnant women., Methods: A PubMed search was performed to screen articles reporting therapeutics and outcomes of confirmed COVID-19 in pregnant women prior to August 27, 2020. We performed searches, quality assessments of eligible studies, extracted and reported data according to PRISMA guidelines. Meta-analyses and cumulative meta-analyses of proportions were performed for estimating each outcome and their pattern over time respectively., Results: One thousand two hundred thirty nine pregnant women with COVID-19 from 66 studies were analyzed. In case series analysis reflecting average-risk patients, the proportion of oxygen support, antibiotics, antivirals, and plasma therapy administration except for hydroxychloroquine was substantially higher in Asian studies (55, 78, 80, 6, and 0%) compared to the US (7, 1, 12, 0, and 7%) or European (33, 12, 14, 1, and 26%) studies, respectively. The highest preterm birth and the average length of hospital stay (35%, 11.9 days) were estimated in Asian studies compared to the US studies (13%, 9.4 days) and European studies (29%, 7.3 days), respectively. Even in case reports reflecting severe cases, the use of antivirals and antibiotics was higher in Asian studies compared to the US, Latin American, and European studies. A significant decline in the use of most therapeutics along with adverse outcomes of COVID-19 in pregnant women was observed., Conclusions: Geographical differences in therapeutic practice of COVID-19 were observed with differential rates of maternal and clinical outcomes. Minimizing the use of some therapeutics particularly antibiotics, antivirals, oxygen therapy, immunosuppressants, and hydroxychloroquine by risk stratification and careful consideration may further improve maternal and clinical outcomes.

The severe acute respiratory coronavirus-2 (SARS-CoV-2) is the cause of the global outbreak of COVID-19. Evidence suggests that the virus is evolving to allow efficient spread through the human population, including vaccinated individuals. Here, we report a study of viral variants from surveillance of the Delaware Valley, including the city of Philadelphia, and variants infecting vaccinated subjects. We sequenced and analyzed complete viral genomes from 2621 surveillance samples from March 2020 to September 2021 and compared them to genome sequences from 159 vaccine breakthroughs. In the early spring of 2020, all detected variants were of the B.1 and closely related lineages. A mixture of lineages followed, notably including B.1.243 followed by B.1.1.7 (alpha), with other lineages present at lower levels. Later isolations were dominated by B.1.617.2 (delta) and other delta lineages; delta was the exclusive variant present by the last time sampled. To investigate whether any variants appeared preferentially in vaccine breakthroughs, we devised a model based on Bayesian autoregressive moving average logistic multinomial regression to allow rigorous comparison. This revealed that B.1.617.2 (delta) showed 3-fold enrichment in vaccine breakthrough cases (odds ratio of 3; 95% credible interval 0.89-11). Viral point substitutions could also be associated with vaccine breakthroughs, notably the N501Y substitution found in the alpha, beta and gamma variants (odds ratio 2.04; 95% credible interval of1.25-3.18). This study thus overviews viral evolution and vaccine breakthroughs in the Delaware Valley and introduces a rigorous statistical approach to interrogating enrichment of breakthrough variants against a changing background. IMPORTANCE SARS-CoV-2 vaccination is highly effective at reducing viral infection, hospitalization and death. However, vaccine breakthrough infections have been widely observed, raising the question of whether particular viral variants or viral mutations are associated with breakthrough. Here, we report analysis of 2621 surveillance isolates from people diagnosed with COVID-19 in the Delaware Valley in southeastern Pennsylvania, allowing rigorous comparison to 159 vaccine breakthrough case specimens. Our best estimate is a 3-fold enrichment for some lineages of delta among breakthroughs, and enrichment of a notable spike substitution, N501Y. We introduce statistical methods that should be widely useful for evaluating vaccine breakthroughs and other viral phenotypes.

Purpose: To describe the favorable procedural profile of CT colonography (CTC) during the COVID-19 pandemic., Conclusion: Postponement of cancer screening due to COVID-19 has resulted in a backlog of individuals needing to undergo structural examination of the colon. The experience during the initial COVID-19 surge with urgent evaluation of the colon for transplant patients prior to transplant suggests that CTC can be done in a lower risk manner as compared to other structural examinations. The procedural profile of CTC is advantageous during this pandemic as maintaining social distancing and preserving healthcare supplies including PPE are of paramount importance. CTC is an important option to utilize in the screening armamentarium to allow effective screening of average risk asymptomatic individuals in the COVID-19 era.

Purpose: The objective of this study was to identify and validate smartphone-based visual acuity (VA) apps that can be used in a teleophthalmology portal., Methods: The study was conducted in three phases: A survey to investigate if the SmartOptometry App was easy to download, understand and test (phase I), an in-clinic comparison of VA measured in a random testing order with four tools namely COMPlog, Reduced Snellen near vision, Peek Acuity (Distance VA) and SmartOptometry (Near VA) (phase II) and a repeatability study on these 4 tools by measuring VA again (phase III). The study recruited the employees of our institute and adhered to the strict COVID-19 protocols of testing., Results: Phase I Survey (n = 40) showed 90% of participants used android phones, 60% reported that instructions were clear, and all users were able to self-assess their near VA with SmartOptometry App. Phase II (n = 68) revealed that Peek Acuity was comparable to COMPlog VA (P = 0.31), however SmartOptometry was statistically significantly different (within 2 log MAR lines) from Reduced Snellen near vision test, particularly for young (n = 44, P = 0.004) and emmetropic (n = 16, P = 0.04) participants. All the 4 tests were found to be repeatable in phase III (n = 10) with a coefficient of repeatability ≤0.14., Conclusion: Smartphone-based apps were easy to download and can be used for checking patient's distance and near visual acuity. An effect of age and refractive error should be considered when interpreting the results. Further studies with real-time patients are required to identify potential benefits and challenges to solve., Competing Interests: None

The severe acute respiratory coronavirus 2 (SARS-CoV-2) is the cause of the global outbreak of COVID-19. The epidemic accelerated in Philadelphia, PA, in the spring of 2020, with the city experiencing a first peak of infections on 15 April, followed by a decline through midsummer. Here, we investigate spread of the epidemic in the first wave in Philadelphia using full-genome sequencing of 52 SARS-CoV-2 samples obtained from 27 hospitalized patients collected between 30 March and 17 July 2020. Sequences most commonly resembled lineages circulating at earlier times in New York, suggesting transmission primarily from this location, though a minority of Philadelphia genomes matched sequences from other sites, suggesting additional introductions. Multiple genomes showed even closer matches to other Philadelphia isolates, suggestive of ongoing transmission within Philadelphia. We found that all of our isolates contained the D614G substitution in the viral spike and belong to lineages variously designated B.1, Nextstrain clade 20A or 20C, and GISAID clade G or GH. There were no viral sequence polymorphisms detectably associated with disease outcome. For some patients, genome sequences were determined longitudinally or concurrently from multiple body sites. In both cases, some comparisons showed reproducible polymorphisms, suggesting initial seeding with multiple variants and/or accumulation of polymorphisms after infection. These results thus provide data on the sources of SARS-CoV-2 infection in Philadelphia and begin to explore the dynamics within hospitalized patients. IMPORTANCE Understanding how SARS-CoV-2 spreads globally and within infected individuals is critical to the development of mitigation strategies. We found that most lineages in Philadelphia had resembled sequences from New York, suggesting infection primarily but not exclusively from this location. Many genomes had even nearer neighbors within Philadelphia, indicating local spread. Multiple genome sequences were available for some subjects and in a subset of cases could be shown to differ between time points and body sites within an individual, indicating heterogeneous viral populations within individuals and raising questions on the mechanisms responsible. There was no evidence that different lineages were associated with different outcomes in patients, emphasizing the importance of individual-specific vulnerability., (Copyright © 2021 Everett et al.)

Introduction: The Bronx is a borough of New York City that has been profoundly affected by the COVID-19 pandemic. Limited reports exist discussing the anaesthetic management of obstetric patients infected with COVID-19. We review a cohort of obstetric patients in the Bronx with COVID-19 and report their delivery data, anaesthetic management, and maternal-fetal outcomes., Material and Methods: We reviewed 92 pregnant patients with laboratory-confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) who delivered between 1 February 2020 and 1 May 2020. Medical records were reviewed for patient characteristics, anaesthetic management, and clinical outcomes. Patients were stratified by mode of delivery and COVID-19 disease severity., Results: Of the 92 deliveries, 49 (53%) were vaginal, 14 (15%) were scheduled caesareans, and 29 (32%) were unscheduled caesareans. 64 patients (70%) were asymptomatic for COVID-19 (mild disease: 18 patients [19%], moderate disease: 7 patients [8%], severe disease: 2 patients [2%], critical disease: 1 patient [1%]). 83 patients (90%) received neuraxial analgesia and/or anaesthesia, with combined spinal-epidural (CSE) and dural puncture epidural (DPE) as the most common techniques. 5 patients (5%) required general anaesthesia (GA) for caesarean delivery, 3 (3%) of whom were intubated for severe or critical COVID-19 disease., Conclusions: Given the risks associated with SARS-CoV-2 aerosol transmission, GA was avoided in all but the most critically ill patients. CSE and DPE were optimal for minimizing catheter failure rates and risk of conversion to GA. SARS-CoV-2 infection in obstetric patients may be associated with an increased risk for adverse outcomes including preeclampsia, preterm delivery, unscheduled caesarean delivery, and mechanical ventilation.

Objective: Telehealth is a timely solution for delivering health care during the coronavirus disease 2019 (COVID-19) pandemic. The practice of endocrinology is suited to provide virtual care to patients with a variety of endocrine disorders. In this survey, we aimed to gauge the adoption of telehealth practices during the COVID-19 pandemic among endocrinologists in the United States (U.S.)., Methods: This was a cross-sectional, online survey-based study. Members of the Facebook group "Endocrinologists" were invited to participate in the survey. Characteristics of respondents and their rates of adoption of telehealth were described and analyzed for statistically significant associations using the Pearson chi-square test., Results: A total of 181 physicians responded to the survey. The majority of respondents were females (75%), younger than or equal to 40 years of age (51%), employed (72%) either by a private group/hospital or by an academic setting, worked in an urban area (88.4%), and were adult endocrinologists (93%). With the COVID-19 outbreak, more than two-fifths (44.2%) of participants switched to completely virtual visits, and an additional 44.2% switched to a majority of virtual visits, with some in-person visits in the outpatient setting. Additionally, there was a significantly higher adoption rate of telehealth among endocrinologists younger than or equal to 40 years of age (P = .02) and among those who practiced in northeastern, midwestern, and the western geographic regions of the U.S. (P = .04)., Conclusion: The majority of the responding endocrinologists from the U.S. appeared to have swiftly adapted by using telehealth within a few weeks of COVID-19 being declared a national emergency., Abbreviations: CMS = Centers for Medicare and Medicaid Services; COVID-19 = coronavirus disease 2019; PPE = personal protective equipment; U.S. = United States., (© 2020 American Association of Clinical Endocrinologists. Published by Elsevier, Inc. All rights reserved.)

Background: The resilience of nursing students has a positive impact on their wellbeing and completion of courses, especially during pandemics like Covid-19. However, research on resilience factors among nursing students is limited to India. Aim: This qualitative study aimed to explore senior nursing students' perceptions of resilience factors in recovery from Covid-19 infection. Methods: The virtual focus group discussions (FGDs) were conducted among final year undergraduate nursing students at a tertiary care center. We used an interview guide with semi-structured questions to collect the data. Results: A narrative content analysis revealed four dominant themes: experiences and concerns while caring for patients with Covid-19 infection (subtheme: lack of adequate knowledge and skills, support by clinical preceptors, inadequate supply of personal protective equipment (PPE) kits, fear of acquiring and spreading of Covid-19 infection to friends and other patients), reactions to Covid-19 infection (subtheme: anxiety, fear of rejection, academic worries, and uncertainty of illness), resilience (subtheme: support by seniors, teachers, friends, family support, positive self-concept, relaxation techniques, and organization support), and willingness to serve patients with Covid-19 infection (subtheme: professional responsibility, personal experiences, role models, and supportive working environment). Conclusions: The findings suggest that it is crucial to prepare nursing students for adversity through resilience training. Further, studies that develop and evaluate effective strategies to promote resilience among nursing students are urgently needed. [ABSTRACT FROM AUTHOR]