Background
Similar to coronavirus disease 2019 (COVID-19), the pathogenesis of inflammatory rheumatic diseases includes cytokines dysregulation and increased expression of pro-inflammatory cytokines. Although current data from international studies suggest that rheumatic diseases are associated with a higher risk of COVID-19 infection and worse outcomes, there is limited literature in Saudi Arabia. This study aims to evaluate the outcomes and length of hospital stay of COVID-19 patients with inflammatory rheumatic diseases in Saudi Arabia.
This was a single-center retrospective cohort study that included 122 patients with inflammatory rheumatic diseases and documented coronavirus disease 2019 (COVID-19) infection from 2019 to 2021. Patients with suspected COVID-19 infection, non-inflammatory diseases, such as osteoarthritis, or inflammatory diseases but without or with weak systemic involvement, such as gout, were excluded.
The vast majority (81.1%) of the patients were females. Rheumatoid arthritis was the most common primary rheumatological diagnosis. The admission rate was 34.5% with an overall mortality rate of 11.5%. Number of episodes of COVID-19 infection, mechanical ventilation, cytokine storm syndrome, secondary bacterial infection, number of comorbidities, rituximab, diabetes mellitus, hypertension, chronic kidney disease, and heart failure were significantly associated with a longer hospital stay. Additionally, hypertension, heart failure, rituximab, mechanical ventilation, cytokine storm syndrome, and secondary bacterial infection were significantly associated with higher mortality. Predictors of longer hospitalization were obesity, numberof episodes of COVID-19 infection, mechanical ventilation, number of comorbidities, and chronic kidney disease, whereas, hypertension was the only predictor of mortality.
Obesity, number of episodes of COVID-19 infection, mechanical ventilation, number of comorbidities, and chronic kidney disease were significantly associated with higher odds of longer hospitalization, whereas, hypertension was significantly associated with higher odds of mortality. We recommend that these patients should be prioritized for the COVID-19 vaccine booster doses, and rituximab should be avoided unless its benefit clearly outweighs its risk.
Since the outbreak of coronavirus disease 2019 (COVID-19), in Wuhan, China, many studies have been conducted to investigate the effect of COVID-19 on the course of multiple diseases. Although it is primarily a respiratory disease that manifests as pneumonia, it could potentially affect other organs and systems including the heart, kidney, gastrointestinal tract, nervous and immune systems, and blood [1].
COVID-19 usually manifests as mild-to-moderate self-limiting respiratory symptoms, such as fever, cough, shortness of breath, and loss of taste and smell. On the other hand, in a severe form of the disease, some patients may require hospitalization and intubation with mechanical ventilation [2,3]. Several factors have been associated with poor outcomes in COVID-19, including old age and preexisting comorbidities, such as diabetes mellitus (DM), hypertension (HTN), and chronic pulmonary diseases [4,5]. Current data suggest that rheumatic diseases impose an additional risk of COVID-19 infection and are associated with poorer outcomes. This risk varies based on the underlying rheumatic disease, comorbidities, and treatments [6].
Autoimmune connective tissue diseases are chronic diseases with female predominance. The most common connective tissue diseases aresystemic lupus erythematosus (SLE), scleroderma, myositis, rheumatoid arthritis (RA), and Sjogrens syndrome [7,8]. The pathogenesis of these conditions is highly complicated, and it includes excessive production of pro-inflammatory cytokines, and therefore, high disease activity could result in flares with severe systemic symptoms and increased inflammatory markers. Similarly, COVID-19 has been associated with cytokine dysregulation and increased expression of pro-inflammatory cytokines, which can cause cytokine storm syndrome (CSS) [9,10]. Furthermore,patients who are already on immunosuppressants are more vulnerable to infection [11,12].
Due to the variability of the results among different studies concerning the outcomes of rheumatic patients with COVID-19, and due to limited literature in Saudi Arabia, we aimed to study the impact of autoimmune connective tissue diseases and immunosuppressants on COVID-19 severity, hospitalization, intensive care unit admission rates, and mortality in Saudi Arabia.
We sought to evaluate the outcomes (as mortality/survival) and length of hospital stay (if hospitalization was needed) of polymerase chain reaction (PCR)-positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) patients with known inflammatory rheumatic diseases.
This was a single-center retrospective cohort study that took place in King Abdulaziz Medical City (KAMC), Ministry of National Guard-Health Affairs (MNG-HA), Riyadh, Kingdom of Saudi Arabia.KAMC is an academic government-funded tertiary hospital that combines clinical care, training, academics with research, and state-of-the-art medical technologies.
All adult patients with systemic inflammatory rheumatic diseases and PCR-proven COVID-19 infection, from 2019 to 2021 were included. Initially, 192 patients were identified, but after applying the inclusion and exclusion criteria, only 122 were eligible. Patients with suspected COVID-19 infection, non-inflammatory diseases, such as osteoarthritis and fibromyalgia, or inflammatory diseases but without or with weak systemic involvement, such as gout, were excluded.
The required data were obtained by screening electronic medical records(via the KAMC electronic system - BestCare; Seoul, South Korea: ezCaretech Co.) of allrheumatology patients who were seen in the clinic or admitted to the hospitalfrom 2019 to 2021. The following data were collected: demographics, comorbidities (such as diabetes mellitus, hypertension, and chronic kidney disease), primary rheumatological diagnosis, symptoms of COVID-19, number of episodes of COVID-19 infection (patients with more than one COVID-19 infection after recovery of the first COVID-19), steroid dose, immunosuppressants, length of admission (in weeks), length of ICU admission, mechanical ventilation, cytokine storm syndrome, secondary bacterial infection, and outcomes (as mortality or survival). To know the number of episodes of COVID-19 infection, reinfection was defined as having a positive PCR test for SARS-CoV-2 after having two negative PCR tests in a previously infected patient. Cytokine storm syndrome was defined as a serum ferritin level of at least 10g/L, and secondary bacterial infection was defined as having a positive, respiratory or blood, bacterial culture after COVID-19 diagnosis.
Statistical Package for the Social Sciences (SPSS) version 22 (Armonk, NY: IBM Corp.) was used for data analysis. Categorical variables were presented as frequencies and percentages, whereas, numerical variables were presented as meanstandard deviation. Due to the small sample size, Fisher's exact test was used instead of chi-square to test the association between categorical variables, and independent sample t-test was used to test the association between numerical variables. Multivariate logistic regression analysis was done to assess the predictors of COVID-19 infection mortality and hospitalization by calculating the adjusted odds ratios, and odds ratios were reported with 95% confidence interval. A test was considered significant if two-sided p-value was <0.05.
The study was approved by the Institutional Review Board of King Abdullah International Medical Research Center, Ministry of National Guard-Health Affairs, Riyadh, Kingdom of Saudi Arabia (#RC20/665/R). Informed consent was waived because of the retrospective nature of this study. Access to the data was restricted to the researchers. The confidentiality of all patients was protected, and no names or medical record numbers were used. Privacy and confidentiality were assured and all the data, both hard and soft copies, were kept in a secure place within the National Guard-Health Affairs premises.
The demographics of the patients are shown in Table 1.There were a total of 192 rheumatology patients with COVID-19, only 122 of whom were eligible for inclusion. The vast majority (n=99, 81.1%) of the patients were females with a mean age of 48.316 years and an average BMI of 30.86.4 kg/m2. RA, SLE, psoriasis, and antineutrophil cytoplasmic antibodies (ANCA)-positive vasculitis were the most common primary rheumatological diagnoses, accounting for 41.8%, 24.6%, 8.2%, and 5.7% cases, respectively (Figure 1).The most notable associated comorbidities were HTN, DM, hypothyroidism, chronic kidney disease (CKD), heart failure (HF), and bronchial asthma, accounting for 32.0%, 27.9%, 11.5%, 10.7%, 6.6%, and 5.7% cases, respectively (Figure 2).
Lower respiratory tract symptoms, such as cough and shortness of breath, were the most prominent COVID-19 symptoms with a percentage of 48.4%. Other common COVID-19 presenting symptoms were upper respiratory tract (45.1%) and gastrointestinal symptoms (10.7%). Only five (4.1%) patients had a history of two COVID-19 infections. The majority (65.6%) of the patients did not require hospitalization. However, 16.4% required admission for 7 days, 11.5% for eight to 30 days, and 6.6% for >30 days.
The overall mortality rate was 11.5%. A small fraction of the patients (n=17) required ICU admission. Of those, 14 required intubation with mechanical ventilation with a mortality rate of 85.7%. Secondary bacterial infection was only identified in eight (6.6%) patients, four of whom have died. None of the patients who developed CSS (n=4) have survived.
On Fisher's exact test, having more than one COVID-19 infection, intubation with mechanical ventilation, CSS, secondary bacterial infection, and having more than one comorbidity were significantly associated with longer hospital stay (p=0.006, <0.001, 0.006, 0.01, and <0.001, respectively) (Table 2).Moreover, patients with DM, HTN, CKD, and HF were significantly more likely to have longer hospital stay (p=0.001, 0.003, 0.003, and 0.011, respectively). However, only HTN and HF were significantly associated with higher mortality (p=0.002 and 0.006, respectively) (Table 3).
As a part of their treatment regimen for an underlying rheumatological disease, 60.7% of the patients were on prednisone, 46.7% were on hydroxychloroquine, 28.7% were on methotrexate, 9.8% were on anti-TNF (infliximab or etanercept), 9.0% were on mycophenolate and azathioprine, and 4.9% were on rituximab and tocilizumab. Of the aforementioned immunosuppressants, only rituximab was significantly associated with longer hospitalization and mortality (p=0.046, 0.001). No significance was found between steroid dose and hospital length of stay (p=0.605) or mortality (p=0.821) (Tables 2, 3).
Females had more favorable survival compared to males (p=0.025). Intubation with mechanical ventilation, CSS, secondary bacterial infection, and hospital length stay were associated with higher mortality rates (p0.001, <0.001, 0.006, and 0.001, respectively). Having a higher number of comorbidities was not associated with higher mortality (p=0.11) (Table 3).
In multivariate regression model, obesity (odds ratio {OR}=60.669, 95% confidence interval {CI} 3.53-1042.413, p=0.005), number of COVID-19 infection (OR=59.08, 95% CI 2.532-1378.362, p=0.011), intubation with mechanical ventilation (OR=23.238, 95% CI 3.15-171.434, p=0.002), number of comorbidities (OR=7.11, 95% CI 1.911-26.454, p=0.003), CKD (OR=6.178, 95% CI 1.706-22.38, p=0.006), and HTN (OR=5.291,95% CI 1.266-22.112, p=0.022) were significantly associated with higher odds of hospitalization (Table 4).The only comorbidity that was significantly associated with higher odds of mortality was HTN (OR=5.291, 95% CI 1.266-22.112, p=0.022) (Table 5).
Autoimmune connective tissue diseases are chronic inflammatory diseases with highly complicated pathogenesis that includes excessive production of pro-inflammatory cytokines. Similarly, COVID-19 has been associated with cytokine dysregulation and increased expression of proinflammatory cytokines [9-11]. Patients who are already on immunosuppressive medications are logically more vulnerable to infections [11,12]. Current data suggest that rheumatic diseases are associated with an additional risk of COVID-19 infection and poorer outcomes [6]. In this study, we explored the impact of autoimmune connective tissue diseases and immunosuppressive medications on COVID-19 severity, hospitalization, intensive care unit admission, and mortality rates in Saudi Arabia.
Our patients had a mean age of 48.316 years with females being predominant (81.1%). This is attributed to the fact that inflammatory autoimmune diseases generally have female predilection [7,8]. This is in accordance with other studies, as DSilva et al. who studied the outcomes of 52 COVID-19-infected patients with rheumatic diseases, also reported female predominance. Compared to previously published studies, our patients had a relatively younger mean age [13,14]. Overall hospital mortality of COVID-19 is generally between 15% and 20% and can reach up to 60% in older patients. However, it highly varies across cohorts, reflecting differences in the completeness of testing and case identification, variable thresholds for hospitalization, and differences in outcomes [15-17]. Hospital mortality ranges from less than 5% in patients younger than 40 years to 35% in 70-79 years and greater than 60% in 80-89 years [18]. In our study, the mortality rate was 11.5%, and the mean age was 48.3 which is in compliance with some of the studies. To clarify, Montero et al. reported a mortality rate of 16% [12]. The two percentages are close, and probably our study would have a higher mortality rate if it was delayed further. In contrast, Sharmeen et al. mentioned a mortality rate of 5.9% [19]. Although both Montero and Sharmeen studies have published their works in August 2020, the mortality rates are utterly different. It is hard to judge whether, for example, patients with low mortality rates have been vaccinated and therefore had a milder form of the disease or specific immunosuppressive regimen could have protected those patients. Another factor that could potentially contribute to the differences in mortality rate is the mean age. In our study, the mean age was 48.3 years, whereas, in Montero and Sharmeen they were 60.9 and 57 years, respectively [12,19]. This could not explain the low mortality rate reported in Sharmeen's study.It is also important to mention that our mortality rate might not reflect the actual percentage due to the small sample size and the following limitations: 1) we do not have a unified database for all patients throughout Saudi Arabia and so we could not include patients from other hospitals. 2) Many patients were non-eligible for follow-up in our institution (MNG-HA, KAMC), and so, they might have died outside our institution. 4) Many patients might have died after we collected the data. 3) Many patients, even if eligible, lives outside Riyadh and so cannot be followed up. In our country,Saudi Arabia, at least 56,707,289 doses of COVID vaccines have been administered so far though the mortality rate in our study is still high [20].
The need for admission of COVID-19 patients in the general population depends mainly on their age and preexisting comorbidities, such as chronic respiratory diseases and DM [21,22]. The likelihood of hospitalization increases with age up to a maximum of 18.4% in patients 80 years old [23].In our study, the admission rate was 35%, which is much higher than the global admission rate of the general population. This high percentage could partially be explained by the fact that we included all rheumatology patients with documented COVID-19 from 2019 to 2021. At the beginning of the pandemic, with the lack of clear guidelines, institutions tended to admit COVID-19 positive patients till their swaps came negative. This is a possible explanation for the high admission rate seen in our study. Previously published studies are in agreement with our high admission rate. To emphasize, Gianfrancesco et al. reported an admission rate of 46% [15]. Similarly, Montero et al. also mentioned a high admission rate that is 68% [12]. In addition to what we mentioned above, another explanation could be disease-specific factors as patients with inflammatory diseases might need more medical attention. This is not only limited to rheumatology patients, it is also seen with other autoimmune diseases. To clarify, Sahraianet al. reported a hospitalization rate of 25% in multiple sclerosis patients infected with COVID-19, which is also much higher than the admission rate of the general population in the age group associated with multiple sclerosis patients [24].
In our study, number of COVID infections, CSS, secondary bacterial infection, number of comorbidities, DM, HTN, CKD, and HF were significantly associated with a longer hospital stay. A lot of these factors are in agreement with other studies. For example, DSilva et al. reported several factors that have been significantly associated with longer hospital stay including older age, number of comorbidities, and DM [14]. Moreover, Stradner et al. also reported the same thing. They found that old age and comorbidities, such as HTN, DM, cardiovascular and pulmonary diseases, and end-stage kidney disease were significantly associated with longer hospitalization [25].
Some reports found that rituximab use is not associated with worse outcomes or course of disease in patients with COVID-19. In our study, the only medication that was significantly associated with longer hospitalization and higher mortality was rituximab. Similarly, Tepasse et al., Stradner et al., and Alpizar-Rodriguez et al., in their studies, concluded that rituximab is associated with a higher risk of severe disease and/or mortality in patients with COVID-19 infection [25-27]. Ideally, immunoglobulin levels should be obtained in all patients prior to rituximab prescription. Unfortunately, to the best of our knowledge, our institution does not mandate immunoglobulin levels prior to rituximab prescription, which could explain the high mortality rate and hospitalization in our study. Though it is crucial to keep in mind that our findings are consistent with the literature [25-27]. Possibly due to the small sample size, we have not found any significance with steroid use nor with other immunosuppressants. However, in Gianfrancesco's study, prednisone 10 mg/day was associated with a higher hospitalization rate. Conversely, it has been found that TNF- inhibitoruse was associated with less hospitalization rate [15].
The susceptibility to and severity of COVID-19 is highly influenced by patients comorbidities, such as hypertension, and dysregulated innate immune response as in patients with inflammatory autoimmune diseases [9,11,12,28,29]. This might be due to enhanced expression of angiotensin-converting enzyme 2 (ACE2) receptors on the surface of several organs and epithelial cells. COVID-19 infects epithelial cells through binding with ACE2 and initiates inflammation, endothelial activation, tissue damage, and disordered cytokine release [29,30]. Although, in our study, all the included patients were known to have inflammatory rheumatologic diseases, according to literature, those patients are more likely to be infected with and to develop severe COVID-19. To emphasize, DSilva et al. reported that in COVID-19 patients, the need for intubation with mechanical ventilation was more common in patients with known rheumatologic diseases compared to the general population. Patients with autoimmune inflammatory diseases already have high cytokines and immune dysregulation [14]. The high levels of cytokines intensify the destructive progression that leads to additional epithelial cells dysfunction and inflammation [29,31,32]. Altogether, these disorders ultimately lead to multi-organ failure and death. Comorbidities and suppressed immunity have been found as primary reasons for the exacerbated rate of infection and mortality of COVID-19 [29,30,33]. This is another explanation for the high mortality rate as a lot of those patients are chronically on immunosuppressants. In COVID-19 patients, cellular immunity fails to provide adequate protection due to the viruss ability to escape the innate immunity and induce a functional decline in T-cell counts [29]. The literature identifies TNF- and IL-6 receptor inhibitors to be effective in treating COVID-19 among patients with rheumatic diseases as during recovery of COVID-19, decreased levels of IL-6 and TNF- increase the total T-cell counts [34,35]. In our study, we have not found any protective role for TNF- and IL-6 receptor inhibitors, probably due to the small sample size.
The studied population should be prioritized for the booster dose of COVID-19 vaccine. Those patients are particularly at increased risk of severe infection, and so they should have more precautions. Rituximab should be avoided unless it is the only option with the benefit clearly outweighing the risk. Prompt seeking medical attention is also recommended to prevent morbidity and mortality.
This study is mainly affected by its single-centered retrospective design and the small sample size. The small sample size limited our statistical analysis as we could not perform Kaplan-Meier survival curve. The results could have been affected by the fact that vaccination-related data were not available and so the effect of vaccination on patients outcomes was neglected in the study. We plan to do a follow-up study to assess the effect of vaccination on the outcomes of inflammatory rheumatic diseases.
Over a third (34.5%) of the patients required hospital admission. Predictors of longer hospitalization were obesity, number of COVID-19 infections, mechanical ventilation, number of comorbidities, HTN, and CKD, whereas, HTN was the only predictor for mortality. Furthermore, rituximab was significantly associated with longer hospitalization and higher mortality. Based on what we found, we recommend that patients with inflammatory rheumatic diseases should be prioritized for the COVID-19 vaccine booster dose, and rituximab should be avoided unless its benefit clearly outweighs its risk.
Read more:
Outcomes of COVID-19 in Inflammatory Rheumatic Diseases: A Retrospective Cohort Study - Cureus
- As 2024 Travel Hits Pre-Covid Levels, Here's When To Go To Europe - Forbes - March 10th, 2024 [March 10th, 2024]
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- China to draw on Covid-19 experience to tackle future pandemics - theSun - March 10th, 2024 [March 10th, 2024]
- Free COVID tests through USPS are ending todayhere's where to get tests online - Reviewed - March 10th, 2024 [March 10th, 2024]
- Concern about COVID reaches record low across political spectrum: Survey - The Hill - March 10th, 2024 [March 10th, 2024]
- He Had 217 Covid Shots Without Side Effects, Study Finds - The New York Times - March 10th, 2024 [March 10th, 2024]
- A Man Got 217 COVID-19 Vaccines. Here's What Happened - TIME - March 10th, 2024 [March 10th, 2024]
- German man vaccinated 217 times against covid with no ill effects - The Washington Post - March 10th, 2024 [March 10th, 2024]
- Andrew Cuomo Faces House Subpoena Over Covid Deaths in Nursing Homes - The New York Times - March 10th, 2024 [March 10th, 2024]
- It's been 4 years since COVID hit Michigan. For Long COVID patients, the pandemic isn't over. Michigan Advance - Michigan Advance - March 10th, 2024 [March 10th, 2024]
- 4th Anniversary of the Covid-19 Pandemic - erienewsnow.com - March 10th, 2024 [March 10th, 2024]
- Reflecting on 4 years of the COVID-19 pandemic and discussing what's to come - WBUR News - March 10th, 2024 [March 10th, 2024]
- CDC shortens 5-day COVID isolation, updates guidance on masks and testing in new 2024 recommendations - CBS News - March 10th, 2024 [March 10th, 2024]
- Father, daughter convicted in fraud related to COVID-19 relief - The Cincinnati Enquirer - February 7th, 2024 [February 7th, 2024]
- Supreme Court to weigh whether Covid misinformation is protected speech - STAT - February 7th, 2024 [February 7th, 2024]
- Oklahoma leads country in long Covid - 2 News Oklahoma KJRH Tulsa - February 7th, 2024 [February 7th, 2024]
- MCFR firefighter dies after battle with COVID-19 - WCJB - February 7th, 2024 [February 7th, 2024]
- Audio-based AI classifiers show no evidence of improved COVID-19 screening over simple symptoms checkers - Nature.com - February 7th, 2024 [February 7th, 2024]
- Hidden death toll of COVID-19 pandemic revealed - Earth.com - February 7th, 2024 [February 7th, 2024]
- Switching arms improves effectiveness of two-dose vaccinations, OHSU study suggests - OHSU News - February 7th, 2024 [February 7th, 2024]
- Tributes paid to Irish health official 'central' to EU Covid-19 response - The Irish Times - February 7th, 2024 [February 7th, 2024]
- Court: Not wearing mask during COVID-19 health emergency isn't protected speech - Honolulu Star-Advertiser - February 7th, 2024 [February 7th, 2024]
- One arm or two? How you get vaccinated may make a difference - The Seattle Times - February 7th, 2024 [February 7th, 2024]
- 70% of kindergarteners didn't pass readiness test in pandemic, study estimates - University of Minnesota Twin Cities - February 7th, 2024 [February 7th, 2024]
- USS Theodore Roosevelt sailors roam free on Guam for first time since COVID-19 outbreak - Stars and Stripes - February 7th, 2024 [February 7th, 2024]
- Pandemic linked to 14% increase in underweight children in India - Medical Xpress - February 7th, 2024 [February 7th, 2024]
- COVID and travel: Should I still wear a mask on the plane? - USA TODAY - February 7th, 2024 [February 7th, 2024]
- Vaccine hesitancy and equity: lessons learned from the past and how they affect the COVID-19 countermeasure in ... - Globalization and Health - February 7th, 2024 [February 7th, 2024]
- Increase in STIs Among Adolescents Witnessed During COVID-19 Pandemic - Drug Topics - February 7th, 2024 [February 7th, 2024]
- VDH: COVID deaths not seeing decline - Vermont Biz - February 7th, 2024 [February 7th, 2024]
- US outpatient care for serious mental health issues declined during COVID-19 - University of Minnesota Twin Cities - February 7th, 2024 [February 7th, 2024]
- COVID-19 Vaccination in a Patient With Gluten Enteropathy: A Case Report - Cureus - February 7th, 2024 [February 7th, 2024]
- COVID-19 cases drop, but still lots of flu, RSV cases in Erie County - GoErie.com - February 7th, 2024 [February 7th, 2024]
- Lives versus livelihoods: The COVID-19 trade-off from an epidemiological-economic perspective - CEPR - February 7th, 2024 [February 7th, 2024]
- Weatherhead's Jonathan Ernest notes economic changes of childcare facilities following COVID-19 pandemic - The Daily | Case Western Reserve University - February 7th, 2024 [February 7th, 2024]
- U.S. adults face distress, unequal mental health care access during the COVID-19 era - News-Medical.Net - February 7th, 2024 [February 7th, 2024]
- Simnotrelvir to reduces the symptoms of mild to moderate COVID-19 - 2 Minute Medicine - February 7th, 2024 [February 7th, 2024]
- Vaccine Effectiveness: Which COVID-19 Shots Offer the Most Protection? - SciTechDaily - February 7th, 2024 [February 7th, 2024]
- New evidence confirms COVID-19 vaccination in pregnancy is safe for babies - Gavi, the Vaccine Alliance - February 7th, 2024 [February 7th, 2024]
- Audit Committee co-chairs, Evers at odds over interest from COVID-19 funds - WisPolitics.com - February 7th, 2024 [February 7th, 2024]
- Evaluation of Olfactory Dysfunction Among COVID-19 Patients in Baghdad, Iraq - Cureus - February 7th, 2024 [February 7th, 2024]
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- Rutgers researchers work on breakthrough COVID-19 treatment | Video - NJ Spotlight News - February 7th, 2024 [February 7th, 2024]
- Curious Iowa: Has the state spent all of its COVID-19 relief funding? - The Gazette - October 16th, 2023 [October 16th, 2023]
- Accelerating into Immunization Agenda 2030 with momentum from ... - Infectious Diseases of Poverty - BioMed Central - October 16th, 2023 [October 16th, 2023]
- Study Uncovers Why Young Children Suffer Less Severe COVID-19 - Technology Networks - October 16th, 2023 [October 16th, 2023]
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- Maternal COVID-19 Vaccination, Infection Boosts Infant Antibody ... - Contagionlive.com - October 16th, 2023 [October 16th, 2023]
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- What Are the Side Effects of the 2023 COVID Vaccine? Experts ... - Good Housekeeping - October 16th, 2023 [October 16th, 2023]
- Covid inquiry: Bereaved families relief as High Court dismisses Cabinet Office JR - openDemocracy - July 6th, 2023 [July 6th, 2023]
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- Healthline: Medical information and health advice you can trust. - January 2nd, 2023 [January 2nd, 2023]
- China can expect repeat Covid infections with new strains on the way: experts - South China Morning Post - January 2nd, 2023 [January 2nd, 2023]
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- Covid-19 surge after Covid-19 surge has made it impossible for US hospitals to plan for the future - Vox.com - January 2nd, 2023 [January 2nd, 2023]
- COVID-19 in China: Demand for a particular fruit rises as people seek natural remedies to fight the virus - WION - December 21st, 2022 [December 21st, 2022]