AHNA COVID-19 Update
Tuesday, March 16, 2021
The American Holistic Nurses Association (AHNA) supports the Center for Disease Control (CDC) and the World Health Organization (WHO) in acknowledging the immediate global public health risk of COVID-19.

Self-Care Sharing: To sustain nurses in the Holistic Core Value of Self-Care AHNA is providing FREE public access to STRESS MANAGEMENT and RESILIENCE materials!

This update is current to time of release. Previous updated information is reduced weekly to keep the report as concise as possible. For a comprehensive appraisal, please review subsequent weekly updates (since Feb 2020) at: https://www.ahna.org/Home/Resources/Coronavirus-COVID-19
The research findings point to vaccination of obese individuals has a high potential to reduce transmission via superspreading.

A critical factor in transmission events is individual physiology and the capacity of airway lining mucus to resist breakup on breathing. Findings from, Edwards DA, Ausiello D, Salzman J, et al. “Exhaled aerosol increases with COVID-19 infection, Age, and Obesity” indicate viral particulate exhalation varies significantly and instance is higher among those in advanced stages of infection, obesity and higher body mass index, and advancing age (i.e., BMI-years).
  • “18% of human subjects (35) accounted for 80% of the exhaled bio aerosol of the group (194), reflecting a super spreader distribution of bio aerosol analogous to a classical 20:80 super spreader of infection distribution.”
These results should promote reassessment of prioritization in vaccination for individuals with higher BMI, and future treatment modalities may benefit from understanding the source and variance of respiratory droplet generation, and stabilizing airway mucosa. Edwards DA, Ausiello D, Salzman J, et al. Exhaled aerosol increases with COVID-19 infection, age, and obesity. Proceedings of the National Academy of Sciences of the United States of America. 2021 Feb; 118 (8). DOI: 10.1073/pnas.2021830118.
Additional consideration: a study awaiting peer review referenced in mainstream media suggested obesity correlated with reduced response in humoral immunity (in a small study of vaccination among healthcare workers). This is consistent with the pathological inflammatory immune response leading to severe infection. Do not interpret this as evidence vaccinating persons with ‘higher’ BMI results in less efficacy long-term. Should peer-review validate the findings it would suggest a need to re-evaluate of the required dosages or doses for obese persons and reiterate the need to consider early vaccine initiatives in this population. Pellini, Venuti, Pimpinelli, et al. Obesity may hamper SARS-CoV-2 Vaccine Immunogenicity

Viral load: Analysis of SARS-CoV-2 transmission among clusters in Catalonia, Spain, distinguished the relationship between viral load and transmission risk. Patient data identified 314 COVID-19 infected persons who met inclusion criteria. 282 had at least 1 contact (753 total) and index patients infected 125 secondary cases, corresponding to a secondary attack rate of 17%. Index patients with the lowest viral loads exhibited a secondary attack rate of 12%. The highest load group was 24%, and in this group, secondary cases developed symptoms of increased viral load as well. Researchers estimate secondary transmission odds increase 30% for every log (10) increase in viral load. Implications: the index patient’s viral load could be a major driver of secondary transmission risk and potentially disease severity in secondary cases. Isolation of symptomatic persons remains necessary.

In-Flight Transmission: Citizens and permanent residents returning to New Zealand are required to participate in managed isolation and quarantine (MIQ) for 14 days followed by SARS-CoV-2 testing. The mandate was issued in March 2020. Conclusion of a review of follow up data shows despite pre-departure testing, multiple instances of in-flight SARS-CoV-2 transmission were likely before entrance to the country prior to October. These results confirm the efficacy of the countries strict enforcement of quarantine, and the limited spread after return into country; of 62,698 arrivals, testing of persons in MIQ identified 215 cases of SARS-CoV-2. A flight from Dubai, United Arab Emirates, noted of 86 passengers from five different countries of origin, 7 persons in MIQ tested positive. Five were negative in pre-departure tests. Analysis of points of infection included legs of travel and viral genomic data. All seven genomes were identical except for a single mutation in one sample indicating in-air transmission was likely. Swadi, T., Geoghegan, J. L., Devine, T., McElnay, C., Sherwood, J., et al. (2021). Genomic Evidence of In-Flight Transmission of SARS-CoV-2 Despite Predeparture TestingEmerging infectious diseases27(3), 687–693. https://doi.org/10.3201/eid2703.204714

Origin: Coronaviruses of bats and pangolins have been implicated in the origin and evolution of the pandemic SARS-CoV-2. Nature Communications published Structure and Binding Properties of Pangolin-CoV Spike Glycoprotein Inform the Evolution of SARS-CoV-2 noting spikes from Guangdong Pangolin-CoVs, are closely related to SARS-CoV-2 and bind strongly to human and pangolin ACE2 receptors. However, the cryo-EM structure of a Pangolin-CoV spike protein, aside from the Receptor-Binding Domain (RBD), resembled the spike of a bat coronavirus RaTG13 more closely than that of SARS-CoV-2.

Fitness Centers: Twenty-one cases have been linked to a fitness instructor in Hawaii between June and July 2020. The individual taught classes <1 day, 1 to <2 days, and ≥2 days before symptom onset; aggregate attack rates were 95%, 13%, and 0%, respectively. Despite vaccine initiatives, it is recommended that to reduce asymptomatic transmission, facilities improve ventilation and humidification, and continue public mask-wearing mandates, physical distancing and screening for ill patrons. Outdoor and virtual exercise remains preferable. (Hawaii Department of Health, 3/21)

Outdoor Transmission: “Worldwide, scientists have not documented any instances of outdoor transmission unless people were in close conversation of extended duration, or settings where people mixed indoors alongside an outdoor setting.” Dr. Muge Cevik, University of St. Andrews, Scotland, Department of Infectious Diseases. The new variants are more virulent, but there is no evidence to suggest they will be more infectious outdoors.
Variants of Concern (VOC’s): The CDC is utilizing multiple surveillance systems and networks to gather genomic data from positive SARS-CoV-2 tests, including the SARS-CoV-2 Sequencing for Public Health Emergency Response, Epidemiology, and Surveillance (SPHERES) consortium and the National SARS-CoV-2 Strain Surveillance (NS3) system. The following are an underestimation of the total impact- currently only a small portion of specimens are undergoing genomic analysis. The best-performing state in the U.S.A., Wyoming, has only sequenced 3.5% of its positive specimens, and more than half of all US states have sequenced fewer than 0.5%.

  1.      https://www.biorxiv.org/content/10.1101/2021.01.25.428137v2
  2.         https://cov-lineages.org/global_report_B.1.351.html
  3.        https://cov-lineages.org/global_report_P.1.html
  4. https://apnews.com/article/health-mogadishu-coronavirus-pandemic-somalia-aa81aa83d77d387f444c1f6ff405e85a
Variant Specificity: Vaccine efficacy against emerging SARS-CoV-2 variants is a growing concern. Manufacturers report they are designing boosters for concerning VOC’s:
  • Pfizer and BioNTech- initiating clinical trials for a second booster dose (i.e., a third dose) of their vaccine with the rationale that three doses producing higher antibody titers. The company is also developing an adapted (updated) version including targeting of variants.
  • Moderna is conducting clinical trials for an updated vaccine targeting the B.1.351 variant and has shipped the variant-specific vaccine to the US NIH to evaluate 3 approaches: a single-variant booster dose, a multivalent booster dose, and a second booster dose (i.e., third total dose) of the original vaccine.
  • US FDA described how EUAs will be evaluated for SARS-CoV-2 vaccines that target emerging variants. Most notably, accepting data from smaller clinical trials, similar to those conducted for seasonal influenza. This could accelerate the review process for modified versions of vaccines that have already demonstrated acceptable safety and efficacy profiles.

Blood Clotting          Multiple countries in Europe—including Germany, Italy, France, Spain, the Netherlands, Norway, Iceland, Ireland, Denmark, Bulgaria, Sweden, and Latvia—have temporarily suspended use of the AstraZeneca-Oxford SARS-CoV-2 vaccine due to reports of blood clots as side effects. The suspensions are creating additional challenges for vaccination campaigns across Europe, as the region faces a third surge. AstraZeneca has reported 15 events of deep vein thrombosis and 22 events of pulmonary embolism in vaccinated individuals as of March 8.

Infant Trials: Janssen Biotech, the Johnson & Johnson subsidiary, confirmed that the company will extend clinical trials to children. Trials in pregnancy, infants, and newborns as well as those with compromised immune systems, are in planning stages. Unlike Moderna & Pfizer, this vaccine is not mRNA technology. It is more similar to ‘traditional’ vaccines from engineered vectors and based upon a weakened adenovirus 26 (of the common cold).

Pregnancy: The WHO updated Moderna SARS-CoV-2 vaccine recommendations to include pregnant women on January 26, 2021. The CDC posted on March 11th, “No safety concerns were demonstrated in rats that received Moderna COVID-19 vaccine before or during pregnancy; studies of the Pfizer-BioNTech vaccine are ongoing.” Both vaccine manufacturers are monitoring people in the clinical trials who became pregnant and have planned studies to include pregnant women.

Single Dose Immunity: Data regarding immunological responses to single-dose BNT162b2 are limited as well as vaccine responses following previous natural infection. The UK Government adopted the strategy of delaying second vaccination to 12 weeks in attempt to control rapid acceleration of cases and to maximize public health impact of limited initial quantities. This policy generated controversy. Prendecki, Clarke, Brown, Cox, Gleeson, et al., Effect of Previous SARS-CoV-2 Infection on Humoral and T-Cell Responses to Single-Dose BNT162b2 Vaccine, Lancet 2021 Feb 25; [EPub Ahead of Print] Respiratory Medicine, investigated the efficacy of single dose vaccination using a combination of serology, live virus neutralization, and T-cell enzyme-linked immunospot (ELISpot) assays. Specimens from 72 HCWs from Imperial College Healthcare NHS Trust vaccinated between Dec 23 and Dec 31, 2020, tested for antibodies to SARS-CoV-2 nucleocapsid and spike (anti-S) proteins using the Abbott Architect SARS-CoV-2 IgG and IgG Quant II, respectively.
  • “21 (29%) participants had evidence of previous SARS-CoV-2 infection: 16 with positive baseline serology, and five further with strong T-cell responses to non-spike antigens post-vaccination (>100 spot forming units [SFU] per 106 peripheral blood mononuclear cells [PBMC])”

Implications: individuals with previous SARS-CoV-2 infection generate strong humoral and cellular responses to one dose of BNT162b2 vaccine. These results indicates a ‘single dose’ regimen of the Pfizer vaccine offered effective initial protection for persons recovered COVID-19, and, provides improved utilization of limited resources. This is not surprising given evidence of declining humoral immunity over time, but there is also confirmation of continued T-Cell immunity worth considering. (Cell) published research investigating the role of SARS-CoV-2-specific T cell immunity, its protective relationship to antibodies and pre-existing immunity against endemic coronaviruses (huCoV). 82 healthy donors (HDs), 204 recovered (RCs), and 92 active COVID-19 patients (ACs) participated. Results showed ACs had high amounts of anti-SARS-CoV-2 nucleocapsid, spike IgG but lymphopenia, and overall reduced antiviral T cell responses due to the inflammation and expression of inhibitory molecules in T Cells. SARS-CoV-2-specific T cell immunity (conferred by polyfunctional, mainly interferon-γ-secreting CD4+ T cells) remained stable throughout convalescence, whereas humoral responses declined. Future research should determine if T-cell immunity sufficient to decrease the necessity of vaccination in the COVID-19 recovered population.

“In contrast, most individuals who are infection-naive generate both weak T-cell responses and low titers of neutralising antibodies” Prendecki, Clarke, Brown, Cox, Gleeson, et al. suggesting that in the absence of previous SARS-CoV-2 infection, two vaccine doses spaced appropriately as directed, remains best practice. doi.org/10.1016/S0140-6736(21)00502-X

Public Vaccine Finder: vaccinefinder.org allows users to enter an address or ZIP code and select a search area and view listings of providers, availability, contact information, eligibility criteria, and where possible, link to a vaccine scheduler.

Full Vaccination: The issuance of CDC revised guidelines for post-vaccinated individuals reflects a reduction of risk of disease for the vaccinated person(s) but does not show an elimination of harm in all vulnerable populations. Changes in ‘normal’ for those who are vaccinated:
  • Individuals, who received two doses of Moderna or Pfizer, or a single dose of Johnson & Johnson, may gather indoors with fully vaccinated people without wearing a mask.
  • Vaccinated persons may gather indoors without masks with unvaccinated people from one other household (i.e. relatives who all live together) unless any of those people or anyone they live with is among a vulnerable population.
  • If exposed to COVID-19 after full vaccination individuals should isolate and be tested if symptoms present. Exception: group settings (correctional / detention facilities / dormitories) should isolate for 14 days, and be tested even without symptoms.
Certain precautions are still necessary after vaccination:
  • Mask wearing in public.
  • Mask wearing when gathering with unvaccinated and/or, those in contact with vulnerable persons.
  • Continuance of 6 feet spacing.
  • Avoidance of medium – large crowds and poorly ventilated spaces.
  • Delay domestic and international travel in high-spread areas, and monitor for symptoms if evidence of exposure. Isolate and test if symptoms are noted.

Herd Immunity: Questions regarding what ‘herd immunity’ will be required to overcome the pandemic are heavily debated. Resource: a thorough discussion of native infection immunity vs. vaccine immunity from Dr. Paul Auwaerter and dkbmed.
NSF International and Novateur Ventures screened over 1,100 independently assessed, point-of-care COVID-19 tests and identified 5 direct (antigen/RNA) tests for detection of acute infection and 6 indirect (antibody) tests for detection of prior infection. Each meet the recently published World Health Organization (WHO) “desirable” Target Product Profile (TPP) criteria. The study, COVID-19 Point-of-Care Diagnostics That Satisfy Global Target Product Profiles, appears in the January 2021 issue of The Journal of Diagnostics, an international peer-reviewed, open-access journal published monthly by the Multidisciplinary Publishing Institute.

Resource: The Center for Health Security developed a “Testing Toolkit” for professional reference.
Pneumonia: Nature, Grant et al directly compares bronchoalveolar lavage fluid samples from 88 patients with SARS-CoV-2-induced respiratory failure and 211 patients with known or suspected pneumonia from other pathogens. Distinct clinical features observed using flow cytometry and bulk transcriptomic profiling showed “in the majority of patients with SARS-CoV-2 infection, the alveolar space was persistently enriched in T cells and monocytes.” Bulk and single-cell transcriptomic profiling suggests SARS-CoV-2 “infects alveolar macrophages, which respond with T cell chemoattractants. T cells produce interferon-γ to induce inflammatory cytokine release from alveolar macrophages and further promote T cell activation”. Authors state that collectively our results suggest SARS-CoV-2 results in “a slowly unfolding, spatially limited alveolitis in which alveolar macrophages containing SARS-CoV-2 and T cells form a positive feedback loop that drives persistent alveolar inflammation”. Limitations: authors admit observational study provides minimal quantitative data. Bronchial lavage samples are inconsistent and patients meeting study criteria were quite ill; multiple interventions were in progress. The results should lead to hypothesis and further investigation. Grant, R.A., Morales-Nebreda, L., Markov, N.S. et al. Circuits between infected macrophages and T cells in SARS-CoV-2 pneumonia. Nature 590, 635–641 (2021).

Mechanical Ventilation (MV) / VICE and DICE Scores: The taxed infrastructure and disaster response demands faced by healthcare workers during the pandemic necessitated development of tools to evaluate severe infection risk stratification, resource utilization requirements, and outcomes of MV. Multivariable logistic regression analyses were used to construct and validate the Ventilation in COVID Estimator (VICE) and Death in COVID Estimator (DICE) risk scores. The scores (which performed with C-statistics of 0.84 and 0.91 respectively) were devised using factors found independently predictive. The MV requirement reviewed history of diabetes mellitus, SpO2:FiO2 ratio, C-reactive protein, and lactate dehydrogenase. DICE risk is estimated with ten noted predictors of in-hospital mortality (age, male sex, coronary artery disease, diabetes mellitus, chronic statin use, SpO2:FiO2 ratio, body mass index, neutrophil to lymphocyte ratio, platelet count, and procalcitonin). Nicholson, Wooster, Sigurslid, Li, Jiang, Tian, et al. Estimating risk of mechanical ventilation and in-hospital mortality among adult COVID-19 patients admitted to Mass General Brigham: The VICE and DICE scores, EClinicalMedicine, Vol. 33, 2021, 100765, ISSN 2589-5370, https://doi.org/10.1016/j.eclinm.2021.100765.
Glomerular Disease    Acute Kidney Infection (AKI) is reported to occur in 20% of all hospitalized patients and in 30% of critically ill COVID-19 patients and is accompanied by high-grade proteinuria. Previous research demonstrates an association between high-risk gene variants in the APOL1 gene. The gene, which encodes the APOL1 protein, results in collapsing glomerulopathy in patients with HIV.

Shetty, Tawhari, Safar-Boueri, Seif, Alahmadi, et al. Journal of the American Society of Nephrology Jan 2021, 32 (1) 33-40completed genetic testing in three of six severe SARS-CoV-2 patients, confirming each demonstrated high-risk APOL1 genotypes. Selection criteria were recent African ancestry and development of COVID-19–associated AKI with podocytopathy, collapsing glomerulopathy, or both. Respiratory symptoms among these patients were generally mild, and none required ventilator support. Collapsing glomerulopathy occurred in one with an engrafted kidney, which was transplanted from a donor who carried an APOL1 low-risk genotype, a finding inconsistent with current models of APOL1-mediated kidney injury and suggests that “intrinsic renal expression of APOL1 may not be the driver of nephrotoxicity and specifically, of podocyte injury”.
Clinical Management
Monoclonal Antibodies: The NIH and IDSA recommend monoclonal antibodies (mAbs) for people with COVID-19 who are at high risk of progressing to severe disease or hospitalization, but these antibody treatments must be given within days of diagnosis. We can improve patient outcomes and reduce burden on hospitals and health care facilities by quickly identifying eligible patients and getting them to infusion centers. Join us for a live webinar covering what you should know about mAbs and how to quickly facilitate treatment for eligible patients”.

Date: Thursday, April 1, 2021
Time: 12:00-12:30 PM EDT

Dexamethasone: A New England Journal of Medicine published RCT open-label trial compared outcomes of hospitalized COVID-19 patients, distinguishing between 2,104 patients receiving oral or intravenous dexamethasone (up to 10 days) from 4,321 control subjects receiving ‘standard’ care.
  • 482 patients (22.9%) in the dexamethasone group and 1110 patients (25.7%) in the usual care group died within 28 days after randomization (age-adjusted rate ratio, 0.83; 95% confidence interval [CI], 0.75 to 0.93; P<0.001).

The proportional and absolute between-group differences in mortality varied considerably according to the level of respiratory support that the patients were receiving at the time of randomization. Results: 28 day mortality was lower in the dexamethasone groups than that in the usual care group among patients receiving invasive mechanical ventilation (29.3% vs. 41.4%; rate ratio, 0.64; 95% CI, 0.51 to 0.81). Those receiving dexamethasone and oxygen without invasive mechanical ventilation (23.3% vs. 26.2%; rate ratio, 0.82; 95% CI, 0.72 to 0.94) had lower fatality rates. Patients receiving no respiratory support at randomization did not show statistically significant improvement with dexamethasone. (17.8% vs. 14.0%; rate ratio, 1.19; 95% CI, 0.92 to 1.55)

Visual Resource: Dexamethasone and COVID-19
RECOVERY Collaborative Group, Horby, P., Lim, W. S., Emberson, J. R., Mafham, M., Bell, J. L., Linsell, L., Staplin, N., Brightling, C., Ustianowski, A., Elmahi, E., Prudon, B., Green, C., Felton, T., Chadwick, D., Rege, K., Fegan, C., Chappell, L. C., Faust, S. N., Jaki, T., … Landray, M. J. (2021). Dexamethasone in Hospitalized Patients with Covid-19The New England Journal of Medicine384(8), 693–704. DOI: 10.1056/NEJMoa2021436

Long-COVID: Newly announced, the Long COVID Alliance is a network of patient-advocates, scientists, disease experts, and drug developers leveraging their collective knowledge and resources to educate policy makers, accelerate research, and transform our understanding of post-viral illness. 
Specialty Specific Care
Frontline Treatments Webinar: A multi-specialty webinar presents updated rationales and evidence for standard frontline treatments. The on-demand program is available after creating a user profile and sign in.

Neurology Database: The body’s response to COVID-19 infection on the brain, spinal cord, nerves and muscle can be particularly devastating. COVID-19 Neuro Databank/Biobank (NeuroCOVID) database will collect information from clinicians about COVID-19-related neurological symptoms, complications, and outcomes as well as COVID-19 effects on pre-existing neurological conditions. Created and maintained by NYU Langone Health, New York City, the database will be a resource of clinical information as well as bio specimens from people of all ages who have experienced neurological problems associated with SARS-CoV-2 infection. Researchers and clinicians can request access to the database via the NeuroCOVID website.

Pediatrics & MIS-C: Pediatrics account for roughly 13% of the total SARS-CoV-2 cases in the United States. In-person school openings are likely to inflate this statistic until a vaccine is approved for children under 12. The most serious pediatric response, multisystem inflammatory syndrome in children (MIS-C), has been reported in at least 2,060 children across the US and contributed to 33 deaths (through March 1, 2021). Black and Hispanic/Latino children are disproportionately affected, representing 66% of the reported cases. The Journal of the American Medical Association (JAMA) published a case series including 539 patients with MIS-C and 577 patients with severe COVID-19. MIS-C patient demographics reflected similar disparities to the adult populations. “Children with MIS-C were more often 6 to 12 years old, non-Hispanic Black, and displayed severe cardiovascular or mucocutaneous involvement with extreme inflammation.” These findings suggest patterns of clinical presentation and organ involvement distinguishing MIS-C from severe acute SARS-CoV-2 infection. Feldstein LR, Tenforde MW, Friedman KG, et al. Characteristics and Outcomes of US Children and Adolescents With Multisystem Inflammatory Syndrome in Children (MIS-C) Compared With Severe Acute COVID-19. JAMA. Published online February 24, 2021. doi:10.1001/jama.2021.2091

Pediatrics & PASC: The occurrence of Post-acute sequelae of SARS-CoV-2 infection (PASC)—commonly referred to as “long COVID-19” is enigmatic, more so in pediatric patients. Several facilities—including the University Hospitals Rainbow Babies & Children’s Hospital in Cleveland, Ohio—established dedicated clinics to treat these patients and gather data. Disparities in US health coverage pose concern, potentially leading to large out-of-pocket costs for specialized testing and treatment.
The National Institutes of Health has launched multiple research efforts to understand how SARS-CoV-2 affects children.

Research conducted through CARING for Children with COVID is partially funded by the Coronavirus Aid, Relief, and Economic Security (CARES) Act.

Eliquis: apixaban 2.5 mg anticoagulant, donated by Bristol Myers Squibb/Pfizer, is under investigation as a convalescent therapeutic in those discharged following moderate-to-severe COVID-19. The ACTIV-4 Convalescent trial is the third of the ACTIV-4 Antithrombotics master protocol for adaptive trials and is a collaborative effort of Duke University, Durham, North Carolina, University of Pittsburgh; University of Illinois at Chicago; Brigham and Women’s Hospital, Medical College of Wisconsin, University of California, University of Ottawa and the Ottawa Hospital Research Institute.

Tocilizumab: Used to treat rheumatoid arthritis and other autoimmune diseases, tocilizumab is a monoclonal antibody that blocks the protein that serves as receptor for interleukin-6 (IL-6), a signaling molecule in the immune system. That dampens the immune response. Compared to control subjects, the anti-inflammatory drug tocilizumab decreased the need for mechanical ventilation, decreased mortality rates by 4%, and expedited recovery. A pre-print describing results of the United Kingdom’s Recovery Trial noted “between 23 April 2020 and 24 January 2021, 4116 adults were included in the assessment of tocilizumab, including 562 (14%) patients receiving invasive mechanical ventilation, 1686 (41%) receiving non-invasive respiratory support, and 1868 (45%) receiving no respiratory support other than oxygen. Median CRP was 143 [IQR 107-204] mg/L and 3385 (82%) patients were receiving systemic corticosteroids at randomization. Overall, 596 (29%) of the 2022 patients allocated tocilizumab and 694 (33%) of the 2094 patients allocated to usual care died within 28 days (rate ratio 0·86; 95% confidence interval [CI] 0·77-0·96; p=0·007). Consistent results were seen in all pre-specified subgroups of patients”. It is important to note this document is awaiting peer review. If accepted for publication results could offer a new standard of care, however, due to its expensive price the medication may be cost prohibitive in underserved areas.

CRISPR          The breakthrough technology could target viral RNA instead of human DNA. Researchers are investigating using CRISPR as an inhaled anti-viral therapeutic preprogrammed to treat influenza and other respiratory viruses, including SARS-CoV-2. Treatment of influenza and SARS-CoV-2 infections via mRNA-encoded Cas13a in rodents. Blanchard EL, Vanover D, Bawage SS, Tiwari PM, Rotolo L, Santangelo PJ. Et al. Nat Biotechnology. 2021 Feb 3. [Published online ahead of print.]
Complementary Therapies
Pyridoxamine (vitamin B6): Research discussed in Frontiers in Nutrition suggests vitamin B6 has the potential reduce the onset and severity of cytokine storm associated with COVID-19. Associate Professor Thanutchaporn Kumrungsee of Hiroshima University’s Graduate School of Integrated Sciences for Life, investigated the protective effects of B6. “In addition to washing your hands, food and nutrition are among the first lines of defense against Covid-19 virus infection. Food is our first medicine and the kitchen is our first pharmacy,” Kumrungsee. Thanutchaporn, Zhang, Chartkul, Yanaka and Kato, (2020), “Potential Role of Vitamin B6 in Ameliorating the Severity of COVID-19 and Its Complications”, Frontiers in Nutrition.

Vitamin B6 is a water-soluble vitamin. There are six isoforms of B6 vitamers, among these; pyridoxal 5′-phosphate (PLP) is the most active form that acts as a coenzyme in various enzymatic reactions. B6 deficiency is associated with lower immune function and higher susceptibility to viral infection. Its known effects validate this as B6 is an anti-inflammatory, to include lung capillary endothelial cells as seen in COVID-19. Reducing neutrophil infiltration and inflammasomes, oxidative stress, and carbonyl stress, decreases adverse cardiac effects and endocrine / adrenal fatigue an especially important consideration for persons with diabetes. “Vitamin B6 deficiency is associated with insulin-glucagon dysregulation, glucose tolerance, and β-cell degeneration, and B6 has previously shown benefit to vascular endothelial function in diabetic patients.” MacKenzie, K. E., Wiltshire, E. J., Gent, R., Hirte, C., Piotto, L., & Couper, J. J. (2006). Folate and vitamin B6 rapidly normalize endothelial dysfunction in children with type 1 diabetes mellitusPediatrics118(1), 242–253. https://doi.org/10.1542/peds.2005-2143, and, Jain S. K. (2007). Vitamin B6 (Pyridoxamine) supplementation and complications of diabetes. Metabolism: clinical and experimental56(2), 168–171., and Voziyan, P. A., & Hudson, B. G. (2005). Pyridoxamine as a multifunctional pharmaceutical: targeting pathogenic glycation and oxidative damageCellular and molecular life Sciences: CMLS62 (15), 1671–1681. https://doi.org/10.1007/s00018-005-5082-7

Severe COVID-19 is often evidenced by increases in both CRP and IL-6 and a decrease in lymphocytes. Chen, N., Zhou, M., Dong, X., Qu, J., Gong, F., Han, Y et al. (2020). Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. The Lancet395(10223), 507-513. A hyper-thrombotic state is characteristic and can induce complications resulting in higher rates of mortality. Pre-pandemic research of Pyridoxamine revealed anti-thrombotic effects, and among the functional medicine community, this is an accepted correlation accredited to a reduction in inflammation. Shen, J., Lai, C. Q., Mattei, J., Ordovas, J. M., & Tucker, K. L. (2010). Association of vitamin B-6 status with inflammation, oxidative stress, and chronic inflammatory conditions: the Boston Puerto Rican Health StudyThe American Journal of Clinical Nutrition91(2), 337–342. https://doi.org/10.3945/ajcn.2009.28571 Evidence that supplementation with vitamin B6 suppresses IL-6 and increased total lymphocytes in patients with chronic conditions supports this. Friso, S., Jacques, P. F., Wilson, P. W., Rosenberg, I. H., & Selhub, J. (2001) Circulation103 (23), 2788-2791, noted “low circulating vitamin B6 was associated with elevation of C-reactive protein independent of plasma homocysteine levels.” Implications: the anticoagulant and anti-inflammatory properties of B6 should merit extensive investigation into the prophylaxis role, and plausible intervention of Vitamin B6 on SARS-CoV-2.

Global Health

Data Platform for Global Health      An international team of epidemiologists launched a website to provide anonymized data on COVID-19 patients worldwide. The new site, Global.Health, was developed with support from Google and the Rockefeller Foundation and includes patient demographics to travel history records for more than 5 million COVID-19 patients across 160 countries. This is critical to conducting epidemiological analysis and on-going pandemic intervention.

Stewardship   Health systems need to be redesigned for the resilience of global communities per the Lancet Global Health, guidance and discussion, Redesigning Health Systems for Global Health Security. This requires reserve funding for rapid disaster response, epidemic preparedness, international health security, and protection of vulnerable populations. Building adequate and committed investment in public health through sustainable health financing should be priority as we emerge from the COVID-19 pandemic. Concurrent outbreaks of cholera, Ebola virus disease, yellow fever, and chikungunya in the African continent, may offer a roadmap, including processes for financial accountability of emergency funding.
Global Situation Report

CASES: 120,320,804     
FATALITIES:   2,662,878
as of 3/16/21

Noteworthy Changes     Case fatality ratios (CFRs) in most countries are reaching equilibrium after peaking at 7.2% in late April/early May 2020. They are settling around 2.2%. The exception is Brazil, where high contagion variants have increased public hospital occupancy. Twenty-six states are at or near capacity with mortality rates reaching record highs over 1,210 per day.

International Immunization Campaigns
The WHO reported 325.6 million vaccine doses administered globally, including 190.7 million individuals with at least 1 dose. The dashboard does not yet include daily or weekly vaccinations. Our World in Data reports 381.3 million vaccine doses administered globally, a 22% increase compared to this time last week. The daily average is approaching 10 million doses per day. The current average of 9.7 million doses per day is a 37% increase compared to a week ago. At least 133 countries and territories are reporting national vaccination data.

  • 2.54 million vaccines are administered daily
  • The E.U. is considering a Digital Green Pass for vaccinated travelers.
  • Ghana received an initial distribution of 600,000 doses of the AstraZeneca-Oxford SARS-CoV-2 vaccine via COVAX. Another 504,000 doses were delivered to Cote d’Ivoire later in the week and shipments will continue to other countries eligible under COVAX.
  • Honduras has requested priority vaccine distribution from the WHO in the wake of hurricanes Eta and Iota. The country faces estimated $1.9 billion in damages (United Nations Economic Commission).
  • The Philippines began broad inoculation safety awareness to overcome hesitancy of foreign-made vaccines. The country has one of the highest fatality rates among Southeast Asia.
  • The health minister of Tanzania announced it “has no plans in place to accept COVID-19 vaccines”. President John Magufuli stated the health ministry will accept and adopt inoculation plans after they are certified by independent Tanzania experts.
  • March 12, the WHO issued an emergency use listing for the J&J SARS-CoV-2 vaccine. The WHO made the designation only one day after the European Commission authorized the vaccine, with WHO and outside evaluators using an “abbreviated assessment” based on the review by the European Medicines Agency (EMA).

Indigenous Losses     The centuries-old Juma tribe in the Amazon lost its last member to COVID-19 in February 2021. Apid, an independent indigenous organization, maintains the mortality rate among tribal communities is over 970. These societies grieve extensively, as many fatalities were elders who shared precious oral histories and knowledge.
United States of America
Fatalities: 543,523
The US surpassed 500,000 cumulative deaths on February 23, less than 1 year from the first reported fatality but daily mortality has decreased substantially over the past several weeks.

Cases: 29,935,349      
Progress may be short-lived. Friday March 12th the US saw 13 million air travelers: more than any other day in the past year. Spring-break travel led to an uptick averaging 50,000 new cases per day. CDC Director Rochelle Walensky reminds citizens to continue masking and distancing. 

Variant Transmission: The British variant, B.1.1.7, is doubling in the United States every ten days Cal.2.0C the variant is found in over 50% of new samples tested in Los Angeles. It replicates and spreads more quickly by producing twice as many viral particles.

VACCINATIONS:          First Dose: 74,216,064,306        Second Dose: 39,618,556

Safety Monitoring Breakdowns:  Thus far, authorized vaccines appear quite safe. There are few severe allergic reactions, including anaphylaxis, but they are treatable and considered rare. Bruising and bleeding caused by lowered platelet counts are reported but unsubstantiated if these effects are linked to the vaccines, or coincidental. 9,000 adverse events were reported with 979 serious and the rest classified as non-serious, according to the most recent CDC report. The reported ‘breakdown’ is not in the current vaccinations, but in the database.

In 2017 The Biologics Evaluation Safety Initiative (BEST), was designed to improve FDA tracking of new blood products and vaccines, and it was trialed in preliminary studies used in evaluating the safety of shingles and influenza vaccines. It is an “active” surveillance system as clinical data can be collected and consistently access over 100 million individual medical records, and search and detect safety problems, determining if they are valid. (Rather than reliant upon reporting of individuals without medical validation, the concern is vaccine related). Set to debut as an improvement in the current Vaccine Adverse Event Reporting System (VAERS) passive monitoring system, per previous FDA and CDC officials, the upgrade to BEST is delayed “due to funding shortages, turf wars and bureaucratic hurdles in 2020”. These public health experts are discouraged as the outdated system cannot sustain the large scale monitoring and data collection required to monitor the COVID vaccine initiative. 

Safety Data     Current results cite the rate at which anaphylaxis has occurred— 4.7 cases in every million doses of the vaccine by Pfizer and BioNTech, and 2.5 cases per million for the vaccine by Moderna — are in line with other widely used vaccines. Dr. Daniel Salmon, Director Institute for Vaccine Safety at Johns Hopkins University, and former federal vaccine official.

Mutation S: E484K  Researchers in Oregon identified a mutation of the variant originating in Great Britain. It is unknown if this mutation decreases vaccine efficacy but genetic analysis suggests community acquisition. This is indicative of greater transmission.

School Outbreak       Investigation of SARS-CoV-2 transmission in a Georgia school district during December 1, 2020–January 22, 2021, identified nine clusters of COVID-19 cases involving 13 educators and 32 students at six elementary schools. Two clusters involved probable educator-to-educator transmission that was followed by educator-to-student transmission in classrooms and resulted in approximately one half (15 of 31) of school-associated cases. (CDC MMWR, 2/26/21)

Re-Infection   Five residents of a skilled nursing facility received positive SARS-CoV-2 nucleic acid test results in two separate COVID-19 outbreaks separated by 3 months. Residents received at least four negative test results between the two outbreaks, suggesting the possibility of reinfection. Severity of disease in the five residents during the second outbreak was worse than that during the first outbreak and included one death. (CDC MMWR, 2/26/21)
Shortages & Solutions
Oxygen The WHO, recognizing the central importance of sustainable oxygen supply, alongside therapeutic products such as dexamethasone for the treatment of COVID-19, generated the Access to COVID Tools Accelerator Therapeutics (co-led by Unitaid and Wellcome). The accelerator is taking a new role to coordinate and advocate for increased supply of oxygen via an Emergency Taskforce. Current estimates cite more than half a million people in LMICs need 1.1 million cylinders of oxygen per day, with 25 countries reporting surges, the majority in Africa. Supply was constrained prior to COVID-19 but is exacerbated by pandemic demands. Oxygen Shortage, WHO
Vulnerable Populations
Racial and ethnic disparities COVID-19 incidence among persons aged <25 years in 16 US jurisdictions raised dramatically January–April 2020 and “generally decreased during May–December, largely because of a greater increase in incidence among White persons, rather than a decline among racial and ethnic minority groups” CDC 3/10/2021. The largest persistent disparities are among Native Hawaiian and Pacific Islander, American Indian or Alaska Native, and Hispanic persons. Racial and Ethnic Disparities in COVID-19 Incidence by Age, Sex, and Period Among Persons Aged <25 Years — 16 U.S. Jurisdictions, January 1–December 31, 2020

Vaccine Equity        Inequality in vaccination rates between richest and poorest communities is growing. Connecticut, for example has a difference of 65% (STAT analysis of local-level vaccine data in 10 states of widest wealth disparity). California, Florida, New Jersey, and Mississippi have each vaccinated a significantly higher proportion of people in the wealthiest 10% of counties. Public health departments state these statistics are influenced by vaccine hesitancy and the correlation of poverty and ethnicity. This is a contributing factor, but it is dismissive of the barriers poverty places in obtaining vaccination. 

For example, in Topeka, the capitol of the State of Kansas, the known diversity index is 58 and the median income is $45,000. The wealth index is 65. (Wealth Index is based upon indicators of affluence including average household income, average net worth, and material possessions and resources relative to the national level. Values below 100 represent below-average wealth compared to the national level.) Owner occupied housing has decreased over the past decade (another indicator of wealth redistribution). In Shawnee County, where the capitol lies, if an individual would like to be vaccinated they must enroll in one of three optional waiting lists. These each require internet service to register. There is no follow up until a time is available. A person wishing to check for an appointment by phone is redirected to the online submission form. Notification of appointment occurs via email. This ‘system’ eliminates availability for anyone who does not have reliable daily internet access.

The external pharmacy options discussed in the national vaccine plan are also limited to online registration with ‘no staff availability for phone scheduling’. The only alternative is a single phone appointment line to an FQHC offering one clinic destination for immunizations. This is limited to appointment availability. Given the current economic conditions, this increases the likelihood of barriers due to location, transportation, employment, childcare… There are no mass vaccination walk-in sites. No immunization drives within low income communities for persons unable to ‘work from home’ as is common in white-collar society. It is not difficult to surmise why the state is in the lowest for vaccination rates, but this description is not unique. Other states, such as Tennessee, have developed vaccine prioritization algorithms based on the CDC Social Vulnerability Index. These index factors allow for priority access to vaccination, which is a start, but priority access means very little when “access” in itself is unavailable.

A public health initiative taking the vaccines into congested workplaces, community centers, churches, and schools is required to reduce systemic barriers of inequality and reduce transmission among the most vulnerable. 
President Biden announced an additional 700 HRSA-supported health centers will be invited to join the Health Center COVID-19 Vaccine Program. These health centers will have the opportunity to join the program over the next six weeks, increasing the total number of invited health center participants to 950 as part of the commitment to ensure underserved communities have access to vaccination. (3/16/21 HRSA). Biden Administration to Expand COVID-19 Vaccine Program to 950 Community Health Centers
Self-Care Resources

Meet the newest addition to our Resilience series:

“At the heart of each one of us exists a silent pulse of perfect rhythm,” Mary Burmeister.

Persistent high levels of occupation stress are proven to contribute to high blood pressure,
headaches, anxiety and depression, and chronic illness’. These physical effects, coupled with moral injury, contribute to Burn-out, result in increased absences, and lower staff retention. AHNA has joined the National Academies of Medicine Collaborative against Clinician Burn-out, and continues our long history of advocating for self-care for nurses.

Our newest resource, **Jin Shin Jyutsu (JSJ) for Resilience, builds on our series of FREE
quick-care, stress management tools for healthcare workers and their families.

International reviews of literature have proven that acupressure, including self-administered acupressure, as a complementary medical intervention, improves emotional vitality. With regular practice, the cumulative benefits of JSJ support sustained mental wellbeing. Nurses in an RCT crossover design study, were surveyed to evaluate the effects of JSJ on stress and caring efficacy. Participants demonstrated significant changes in measures of emotional vitality and buoyancy after JSJ education, Millspaugh, J., Errico, C., Mortimer, S., Kowalski, M. O., Chui, S., & Reifsnyder, C. (2020). Jin Shin Jyutsu® Self-Help Reduces Nurse Stress: A Randomized Controlled Study. Journal of Holistic Nursing.

JSJ acupressure techniques can be a complementary therapy for managing symptoms of:
  • anxiety and depression
  • self-regulation and awareness
  • sleep and digestion
  • tension and pain

Research confirms practice of JSJ Self-Help is an effective non-pharmacological stress management technique. Menard, M. (2018). Research: Is Acupressure an Effective Form of Self-Care?

**AHNA graciously thanks Julia Millspaugh, RN, HNB-BC for her JSJ expertise in this publication.
Self-Care Strategies for Stress Management from AHNA were among the first publications specific to nurses during the COVID-19 response.
The Primal Scream Line” is a forum to yell, laugh, cry or vent, for a solid minute. 

Coronavirus Aid, Relief and Economic Security (CARES) Act, pandemic unemployment assistance is available to workers who are normally ineligible- including self-employed workers and those who have quit a job as a direct result of COVID-19.

Mental Health Conditions covered by ADA access to paid time off or accommodations such as a reduced workload per the Americans With Disabilities Act https://adata.org/factsheet/health

National Suicide Prevention Lifeline 1-800-273-8255 (TALK) or https://www.speakingofsuicide.com/resources

National Parent Helpline 855-427-2736 or  https://www.nationalparenthelpline.org/ Emotional support

Postpartum Support International specific programs for diverse groups; NICU parents, Spanish-speaking moms, LGBTQ+

https://askjan.org/soar.cfm a searchable database of various accommodation options

United Way operates a 24-hour help line that connects callers to local food programs, housing assistance, health care resources and mental health support. Dial 211 from your phone.

Mutual Aid Hub offers a nationwide listing of food pantries and community refrigerators and freezers.

National Women’s Law Center List (download) List of state and local laws dictating where and when workers have the legal right to request flexible work hours without retaliation.
Legal Network for Gender Equity: Free consultations, 202-319-3053 https://nwlc.org/about/nwlc-legal-network/

Center for WorkLife Law, University of California Hastings College of Law advocacy group for working parents. Attorneys and law students operating free legal advice on job protection, 415-851-3308 or email COVID19Helpline@worklifelaw.org

A Better Balance a nonprofit legal advocacy group, operates a confidential help line to assist callers with understanding their workplace rights. Call 833-633-3222.

Hospital Usage: Patients Hospitalized / CCU Beds Available
Restrictions: What is open and closed in each state
Cities & Metro Areas:  Where it is getting better and worse
Nursing Homes: The hardest hit states & facilities
Colleges and Universities: Cases at more than 1,800 schools

Happy App "warm line" offers 24/7 access to a trained Support Giver.

MoodFit App enables nurses to set goals using best-practice methods such as mindfulness meditation, breathing exercises, lifestyle tracking (sleeping and nutrition) and set up custom reminders. Download through Google Play or the Apple App Store. In account registration, enter program code ANF30 for customized nurse-focused messaging.
Compassionate Listening Circles offered several times a week for 60 minutes. The Compassionate Circles are virtual Listening offering and are not a replacement or substitute for medical, psychological or mental health crisis care. Participants are requested to let all facilitators know of their need to access such supports and agree to provide their phone number to the facilitator. Participation in the circles is fully voluntary. Facilitators are present to compassionately listen and are not serving as a crisis or mental health support team.

Regis College: 5 Stress Management Techniques for Nurse Leaders Created for nursing professionals and healthcare communities who are interested in sharing information about stress symptoms and ways to reduce stress among nurses.

Holliblu- Connect with other nurses and find self-care resources for before, during, and after your shift!

Professional Resources

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Topeka, KS 66611-1980
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