Early signs of COVID-19 in Pakistan

'Background: 'The outbreak of novel coronavirus (COVID-19) has turned into a public health emergency of international concern. With no antiviral drugs nor vaccine, presence of carriers without obvious symptoms and varied clinical characteristics, the traditional public health measures are certainly less effective. The early signs of COVID-19 and epidemiological data are essential to strengthen the overwhelmed healthcare systems. 'Aim:' To detect, assess and analyse the early signs of COVID-19 in Pakistan before the official reporting of cases in the country. 'Methods:' The study uses the EpiWATCH observatory to extract data from 1 November 2019 to 1 April 2020. The trend of pneumonia of unknown origin cases in Pakistan was observed to assess if cases of COVID-19 could have been detected before the first official case was reported. A descriptive analysis of the obtained data was achieved on the basis of geographic and demographic features. 'Results:' A total of 151 entries were included in the study. Before the identification of the first official case of COVID-19 in Pakistan, 54 reports of cases of pneumonia of unknown origin were recorded. After the first case of COVID-19 was reported, 97 reports of cases of COVID-19 were recorded. The study findings suggest that there were early signs of COVID-19 in Pakistan since the second week of January 2020, a month and a half prior to the first case being reported in the country

The impact of COVID-19 and COVID vaccination on cardiovascular outcomes

COVID-19 is an independent risk factor for cardiovascular disease. COVID-19 vaccination may prevent this, but in some cases, COVID-19 vaccination may cause myocarditis or pericarditis. Patients with COVID-19 may present with non-specific symptoms that have a cardiac origin. This review examines the cardiovascular complications of COVID-19 infection and the impact of COVID-19 vaccination. COVID-19 cardiovascular complications include myocardial injury, pericarditis, coagulopathy, myocardial infarction, heart failure, arrhythmias, and persistent post-acute risk of adverse cardiovascular outcomes. Diagnostic and referral pathways for non-specific symptoms, such as dyspnoea and fatigue, remain unclear. COVID-19 vaccination is cardioprotective overall but is associated with myopericarditis in young males, though at a lower rate than following SARS-CoV-2 infection. Increased awareness among primary care physicians of potential cardiovascular causes of non-specific post-COVID-19 symptoms, including in younger adults, such as fatigue, dyspnoea, and chest pain, is essential. We recommend full vaccination with scheduled booster doses, optimal management of cardiovascular risk factors, rapid treatment of COVID-19, and clear diagnostic, referral, and management pathways for patients presenting with non-specific symptoms to rule out cardiac complications

The epidemiology of influenza B - evidence to inform the use of quadrivalent influenza vaccines and predict seasonal severity

While seasonal influenza B poses a smaller burden than influenza A and is less severe, the burden of influenza B may be under-estimated. Quadrivalent influenza vaccine (QIV) containing 2 A strains and 2 B lineages, was introduced in Australia in 2015. The benefits of QIV over the trivalent vaccine (TIV) should be evaluated to inform vaccination programs. The aims of the research were: to determine the epidemiology of B, to estimate age- and type-specific influenza morbidity, to evaluate the role of QIV, and to develop a risk-assessment tool to predict the severity of an emerging influenza season before the epidemic.A literature review was conducted using global surveillance studies. Laboratory-confirmed influenza notifications were analysed. For disease burden, hospitalisations attributable to influenza (2001-2013) were estimated for four principle diagnoses, using a statistical model. A meta-analysis of randomised controlled trials was conducted for summary estimate of vaccine efficacy and safety of QIV in adults. Using surveillance and epidemiologic data for calibration, a real-time forecasting tool was developed.Globally, the proportion of influenza B was 19.6% across 49 countries over multiple seasons. The proportion of influenza B in Australia over 10 years was 17%, and on average, B/Victoria was more common than B/Yamagata. Influenza B was highest in children aged 5-19 years, and B lineage mismatch with TIV occurred about one third of the time. The estimated overall influenza morbidity burden was highest in the elderly. QIV showed superior efficacy with higher seroprotection rate of 12-14% to the non-TIV B lineage. In a risk-analysis model, severity of an emerging influenza season could be predicted by May each year. This tool, Flucast, has been developed as a web-based real-time tool calibrated against 10 years of retrospective influenza epidemiologic data in Australia.This research was commenced to inform policy makers for the effective use of QIV, prior to introduction of QIV in Australia. The debate about QIV versus TIV has re-emerged with the introduction of new high dose TIV vaccines for people aged ≥65 years in 2018. The thesis provides data to inform risk analysis for seasonal influenza and choices between vaccine options for Australia

Decrease in breast cancer incidence following a rapid fall in use of hormone replacement therapy in Australia.

Objective: To determine if the recent rapid fall in use of hormone replacement therapy (HRT) in Australia has been followed by a reduction in breast cancer incidence among women aged 50 years or older, but not among younger women. Design and setting: Analysis of trends in annual prescribing of HRT, using Pharmaceutical Benefits Scheme data, and in annual age-standardised breast cancer incidence rates in Australian women for the period 1996-2003. Results: In Australia, prescribing of HRT increased from 1996 to 2001, but dropped by 40% from 2001 to 2003. Age-standardised breast cancer incidence rates in women aged ≥ 50 years also increased to 2001 but declined thereafter. The incidence rates in this age group were lower by 6.7% (95% CI, 3.9%-9.3%; P < 0.001) in 2003 compared with 2001, equivalent to 600 (95% CI, 350-830) fewer breast cancers (out of about 9000 incident breast cancers annually for women this age). There was no significant change in breast cancer incidence for women aged < 50 years. Conclusions: While other factors may have contributed to a recent reduction in breast cancer incidence among Australian women aged ≥ 50 years, the available evidence suggests that much of the decrease is due to the recent fall in use of HRT. This is consistent with other evidence that the HRT-associated increase in risk of breast cancer is reversible after ceasing use of HRT

Systematic review of influenza vaccine effectiveness against laboratory-confirmed influenza among older adults living in aged care facilities

ABSTRACTWe estimated the effectiveness of influenza vaccines in preventing laboratory-confirmed influenza among older adults in aged care. Electronic database searches were conducted using search terms, and studies were selected as per the selection criteria. Fourteen studies were included for final review. The studies exhibited considerable variation in reported vaccine effectiveness (VE) across different seasons. Among the observational studies, VE ranged from 7.2% to 89.8% against laboratory-confirmed influenza across different vaccines. Randomized clinical trials demonstrated a 17% reduction in infection rates with the adjuvanted trivalent vaccine. The limitations include the small number of included studies conducted in different countries or regions, varied seasons, variations in diagnostic testing methods, a focus on the A/H3N2 strain, and few studies available on the effectiveness of enhanced influenza vaccines in aged care settings. Despite challenges associated with achieving optimal protection, the studies showed the benefits of influenza vaccination in the elderly residents

Using Laboratory Data to Aid Early Warning in Prospective Influenza Mortality Surveillance

Many countries prospectively monitor influenza-attributable mortality using a variation of the Serfling seasonal time series model. Our aim is to demonstrate use of routine laboratory-confirmed influenza surveillance data to forecast predicted influenza-attributable deaths during the current influenza season. The two models provided a reasonable forecast for 2012. The model forecasts of weekly deaths during 2012 were compared against observed deaths using root mean squared error (RMSE). The results shown that the model including influenza type A and B provided a better fit. Here, we demonstrated a time series model for influenza-attributable mortality surveillance based on laboratory surveillance information

Using Laboratory Data to Aid Early Warning in Prospective Influenza Mortality Surveillance

Many countries prospectively monitor influenza-attributable mortality using a variation of the Serfling seasonal time series model. Our aim is to demonstrate use of routine laboratory-confirmed influenza surveillance data to forecast predicted influenza-attributable deaths during the current influenza season. The two models provided a reasonable forecast for 2012. The model forecasts of weekly deaths during 2012 were compared against observed deaths using root mean squared error (RMSE). The results shown that the model including influenza type A and B provided a better fit. Here, we demonstrated a time series model for influenza-attributable mortality surveillance based on laboratory surveillance information

Estimated hospitalisations attributable to seasonal and pandemic influenza in Australia: 2001- 2013.

BACKGROUND:Influenza continues to cause seasonal epidemics and pandemics in humans. The burden of influenza is underestimated by traditional laboratory-based surveillance, and modelled estimates are required for influenza-attributable morbidity and mortality. We aimed to estimate the influenza-attributable hospitalisation in Australia, by influenza type. METHODS:A generalised-additive regression model was used to estimate type- and age-specific influenza-attributable hospitalisation rates per 100,000 population by principal diagnosis in Australia, from 2001 through 2013. Weekly counts of laboratory-confirmed influenza notifications and by type, influenza A and B were used as covariates in the model. Main principal diagnosis categories of interest were influenza and pneumonia and respiratory admissions. A smoothing spline was used to control for unmeasured time varying factors. Results for 2009, in which the pandemic influenza A(H1N1)pdm09 virus circulated, were not included in annual averages and are reported separately. RESULTS:During the study period, the estimated annual average, all-age, annual respiratory hospitalisation rates attributable to seasonal influenza type A, B and total influenza were 45.4 (95% CI: 34.9, 55.9), 32.6 (95% CI: 22.8, 42.4), and 76.9 (95% CI: 73.6, 80.2) per 100,000 population, respectively. During 2009, the estimated total pandemic influenza-attributable, all-age, respiratory hospitalisation rate was 56.1 (95% CI: 47.4, 64.9) per 100,000. Older adults (≥85 years of age) experienced the highest influenza-attributable hospitalisation rates for both seasonal and 2009 pandemic influenza. Collinearity between influenza A and B time series in some years limited the ability of the model to resolve differences in influenza attribution between the two virus types. CONCLUSION:Both seasonal and pandemic influenza caused considerable morbidity in Australia during the years studied, particularly among older adults. The pandemic hospitalisation rate in 2009 was lower than the average overall annual rate for seasonal influenza, but young to middle aged adults experience a hospitalisation rate similar to that of severe seasonal influenza

Normal endometrial cells in cervical cytology: systematic review of prevalence and relation to significant endometrial pathology.

Objectives: To estimate the prevalence of normal endometrial cells (NECs) and the proportion of NECs associated with significant endometrial pathology in conventional and liquid-based cytology (LBC) cervical smears; and to assess the association between NECs and clinical symptoms in women with endometrial hyperplasia or carcinoma. Methods: Systematic review of the literature and meta-analysis of prevalence and proportion data. The review was confined to studies reporting on NECs in smears from postmenopausal women or women aged 40+. Results: A total of 22 relevant primary studies were identified from 1970 to 2007. The overall summary estimate for the prevalence of NECs in smears from postmenopausal women or women aged 40+ in all screening smears was 0.4% (95% CI 0.2-0.7%); this was 0.3% (95% CI 0.1-0.5%) and 0.9% (95% CI 0.5-1.4%) for conventional and LBC smears, respectively; P = 0.003 for difference. The overall estimate for the proportion of NECs associated with significant endometrial pathology was 7% (95% CI 4-10%); this was 11% (95% CI 8-14%) and 2% (95% CI 1-2%) for conventional and LBC smears, respectively; P < 0.001 for difference. In women with significant endometrial pathology, the presence of NECs in followed-up women was associated with abnormal uterine bleeding in 79% (95% CI 68-87%) of cases. Conclusion: Compared with conventional cytology, LBC may be associated with a higher prevalence of NECs but these are less likely to be associated with endometrial pathology. This finding might be explained by more consistent use of sampling instruments for LBC with better access to the endocervical canal or alternatively by changes over time, broadly coincident with the introduction of LBC, in the population in which NECs are reported. In followed-up women with NECs, most endometrial pathology is accompanied by symptoms, implying that a relatively smaller number of additional cases are identified through follow-up of asymptomatic women