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Answering Patient Questions About COVID-19, Part 1

AUTHORS

C.S. Solomon, BSPharm, RPh, CTTS, NCTTP, Clinical Associate Professor, Department of Internal Medicine and Neurology, Wright State University Boonshoft School
of Medicine, Dayton, OH

Glen D. Solomon, MD, MACP, FRCP (London), Chairman, Department of Internal Medicine and Neurology, Wright State University Boonshoft School
of Medicine, Dayton, OH

WSU-BSOM COVID-19 Education Task Force Members, Wright State University Boonshoft School of Medicine, Dayton, OH

PEER REVIEWER

Sary Beidas, MD, MBI, FACP, Associate Professor of Medicine, Florida State University, Sarasota, FL

EXECUTIVE SUMMARY

During the COVID-19 pandemic, one medical school initiated a task force to bring together answers to common questions by clinicians and the public regarding the pandemic. This issue summarizes the results of that effort and is presented in a different format, with references included for each section.

For more than two years, we have been struggling with finding the right answers to a host of issues that are changing constantly in complexity and applicability.

  • What should primary care physicians do if a patient tests positive?
  • Why is it so difficult to interpret the medical literature in the face of often contradictory and politically charged theater?
  • Where are the trusted sources of information?
  • How should we respond to new, mutated viral strains? How do we decide on appropriate therapy for individual patients, and how do we prepare for the apparently inevitable next wave of infection?

Introduction

To disseminate accurate information effectively in our local community, a task force was formed inside Wright State University Boonshoft School of Medicine to educate clinicians and answer community members’ questions, first about vaccines, and second about all things COVID-19. More than 25 members, from faculty experts to medical students, have spent two and a half years providing community outreach, setting up at farmers’ markets, and hosting symposia for regional clinicians needing timely information about new vaccines. Through many phases of the COVID-19 pandemic, clinicians have needed to stay current with concepts of the virus, its variants, the changing methods of management and treatment, and best practices for patient benefit. Following are examples of some of our current questions.

What do I do if I test positive for COVID-19?

If a COVID-19 test (either a home test or a polymerase chain reaction [PCR] test) shows a positive result, the patient should isolate at home in a room separate from others, if possible, for at least five days. The first day of symptoms is day 0 (if asymptomatic, the day of the positive test is day 0). An N95 mask is the most suitable should the patient need to leave home or need to share bathrooms or other home areas. If the patient is a child, one adult should be assigned to care for the child. Day 5 is not the “definitive” day for no longer being contagious, according to the Centers for Disease Control and Prevention (CDC). With testing used as an important tool here, if the patient is antigen-positive, they may be infectious. Isolation can end if the patient is fever-free for 24 hours without the use of a fever-reducing medication and other symptoms are improving. Loss of taste and smell may persist longer and need not delay the end of isolation. The individual should continue to wear a well-fitted mask around others at home and in public for an additional five days after ending the isolation period.1

Why isn’t COVID-19 going away?

The extremely contagious nature of the currently most dominant coronavirus strains, the Omicron subvariants BA.4 and BA.5, which make up a combined 70% of coronavirus variants in the Unites States as of July 2, 2022, forces us to reexamine all we are doing as we try to live our daily lives.2 Since viruses have a goal of reproducing, variants are created with two purposes: to effectively infect the host (humans) and to evade the immune system. Because these subvariants are better able to evade the immune system, people may need to rethink the level of protection they choose. The benefits of being up to date with CDC vaccination recommendations is critical, meaning that the primary vaccination series is given and all available recommended boosters have been administered based on age and vulnerability. Updated COVID-19 boosters with Omicron adaptations or others, when available, may be more helpful than just additional doses of current COVID-19 vaccines. The Food and Drug Administration (FDA) now recommends that COVID-19 vaccine producers include components tailored to combat BA.4 and BA.5 for fall 2022 boosters. Properly fitted masks, although not mandated, should be employed as a precaution when one is in a vulnerable situation, whether it be at a grocery store or in a large group situation, along with social distancing and hand hygiene.3 Fitness centers, bars, offices, and long-term care facilities all are vulnerable places for people to be exposed to the virus.

Why is it so difficult to interpret the COVID-19 medical literature?

As a novel disease with global reach, there were more than a quarter-million medical research papers on COVID-19 published in the last two years. To expedite the sharing of information, some of these papers were released prior to peer review (“pre-print”). Additionally, because of the multiple waves of variants, the changing scope of vaccinations, and the differing populations and medical standards in other countries, it is challenging to compare studies. In reviewing the medical literature, it is critical to know when patients were enrolled (and which variant was predominant), their vaccination status (which vaccine and how many doses), and their demographics (years of age and underlying conditions).

Are there terms that will help me better interpret and explain information about COVID-19?

See Table 1 for terminology relating to COVID-19. This table provides the scientific definition for each term, a more colloquial interpretation, and an example providing context for the terminology. The interpretations were provided by members of the Wright State University Boonshoft School of Medicine COVID-19 Education Task Force.

Table 1. Common Epidemiologic Terms

Term

Definition

COVID-19 Colloquial Interpretation

Example

Prevalence

Proportion of persons who have a condition at or during a particular time period

Number of people who currently have COVID-19

“The prevalence of COVID-19 is dropping; now, we have only 3,000 active cases across the state.”

Incidence

Proportion or rate of persons who develop a condition during a particular time period

New COVID-19 cases in a given time

“The incidence of COVID-19 increased to 1,000 new cases per day.”

Sensitivity

A test’s ability to correctly detect ill patients who have the condition

If you have COVID-19, this is the accuracy of a COVID-19 test to confirm you have COVID-19

“The PCR test has a sensitivity of 98%; if it says you are COVID-19-positive, you probably are.”

Specificity

A test’s ability to correctly reject healthy patients without a condition

If you do not have COVID-19, this is the accuracy of a COVID-19 test to confirm you do not have COVID-19

“Using a saliva COVID-19 test is 98% specific; if it says you do not have COVID-19, you can trust it is probably right.”

R0 (R-naught)

Expected number of secondary cases produced by a single infection in a completely susceptible population

If you have COVID-19, the number of people you will infect

“The Delta variant of COVID-19 had an R0 of about 5, so if you got COVID-19, you would probably give it to five people.”

Case Fatality Rate

Proportion of people who die from a specified disease among all individuals diagnosed with the disease over a certain period of time

If someone gets COVID-19, how likely they are to die from it

“The case fatality rate for the Delta variant was 5%, which means if you get this variant of COVID-19, you are more likely to die from it than from the original COVID-19.”

Sources: Infectious Diseases Society of America. IDSA guidelines on the diagnosis of COVID-19: Molecular diagnostic testing. Last updated Dec. 23, 2020. https://www.idsociety.org/practice-guideline/covid-19-guideline-diagnostics/

Warsi I, Khurshid Z, Shazam H, et al. Saliva exhibits high sensitivity and specificity for the detection of SARS-COV-2. Diseases 2021;9:38.

Liu Y, Rocklöv J. The reproductive number of the Delta variant of SARS-CoV-2 is far higher compared to the ancestral SARS-CoV-2 virus. J Travel Med 2021;28:taab124.

Murata GH, Murata AE, Perkins DJ, et al. Sustained beneficial effects of vaccination on the case fatality rate for COVID-19 infections. medRxiv 2022; Mar 14. doi: https://doi.org/10.1101/2022.01.22.22269689. [Preprint].

What are some of the most helpful resources when searching for COVID-19 information?

Part of the charge of the task force has been to develop a reliable toolkit of references and resources for physicians and other clinicians to use in answering patient questions about COVID-19.

Easily referenced resources on COVID-19 are essential for healthcare professionals in speaking with patients. Easy-to-navigate, dependable, up-to-date sources of information help serve patients requiring specific and timely answers to questions. Having a “go-to” list of resources can reduce confusion about COVID-19, making vaccination updates and other conversations more productive. Reliability can be determined by checking the source, author, and content.

Reliable sources include governmental agencies and reputable medical institutions. Medical organizations also can be effective resources:

Recommended for ease of use: The Public Health Communications Collaborative (https://publichealthcollaborative.org) is a resource initiated in August 2020 as a result of rapidly changing information concerning COVID-19.4 The platform was founded by the CDC and others to combine and organize answers to questions commonly asked by patients of providers. The format of this platform allows for easy access to commonly asked questions, along with shareable graphics and webinars that can be accessed by all.

A unique and up-to-date resource: We Can Do This (https://wecandothis.hhs.gov), a platform created by the U.S. Department of Health and Human Services, provides more than 600 resources to answer specific questions for different patient populations.5 Increasing community confidence and COVID-19 education, this platform covers topics ranging from vaccination during pregnancy to booster recommendations in those 50 years of age and older.

A dependable source: Boosting COVID-19 Vaccine Confidence (https://primeinc.org/online/boosting-covid-19-vaccine-confidence-educational-toolkit-providers) is an educational toolkit for providers, created by PRIME.6 This interactive educational format allows providers to gain confidence in speaking with patients about the benefits and risks of vaccination. By including a full description of what COVID-19 is and how the vaccines work, this platform breaks down the pandemic in an easy-to-explain manner. This patient-friendly toolkit and training session allows for both providers and patients to better understand why vaccines are important.

Recommended for accuracy: COVID-19 Toolkits (https://www.cdc.gov/coronavirus/2019-ncov/communication/toolkits/index.html) is a resource provided by the CDC that offers accurate and relevant information on COVID-19 vaccines, boosters, masks, and indications for different populations.7 This source allows providers to access the latest guidelines and recommendations concerning COVID-19. Additionally, it also includes contact tracing recommendations, which can be especially helpful in school and long-term care facility populations, through the health department.

Since COVID-19 constantly is shaping healthcare in new ways, the task force thought it imperative to formulate an educational toolkit for both community members and healthcare providers.8 By consistently updating the toolkit with the latest resources and guidelines, misinformation and anxiety related to COVID-19 can be reduced within the community. Resources that allow healthcare providers to gain confidence in their knowledge and understanding of COVID-19 are included. During a pandemic, it is important for providers to have the latest information available to aid patients in making the best decisions for themselves. By using toolkits that are updated continually, healthcare providers have organized, reliable resources.

References

  1. Centers for Disease Control and Prevention. Quarantine and isolation. Updated March 30, 2022. https://www.cdc.gov/coronavirus/2019-ncov/your-health/quarantine-isolation.html
  2. Centers for Disease Control and Prevention. Variant proportions. https://covid.cdc.gov/covid-data-tracker/#variant-proportions
  3. Centers for Disease Control and Prevention. How to protect yourself & others. Updated Feb. 25, 2022. https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/prevention.html
  4. Public Health Communications Collaborative. Communications resources for public health officials. Published March 7, 2022. https://publichealthcollaborative.org
  5. We Can Do This. COVID-19 public education campaign. Published April 4, 2022. https://wecandothis.hhs.gov
  6. PRIME. Recommended free CME and other online educational activities. Published Sept. 15, 2021. https://primeinc.org/online
  7. Centers for Disease Control and Prevention. COVID-19 toolkits. Updated April 11, 2022. https://www.cdc.gov/coronavirus/2019-ncov/communication/toolkits/index.html
  8. Wright State University Boonshoft School of Medicine. COVID-19 vaccine resources. Published March 8, 2021. https://medicine.wright.edu/about/news-and-events/article/covid-19-vaccine-resources


Symptoms of COVID-19

What are the presenting symptoms of COVID-19, and which patients are at high risk for a poor outcome?

Symptoms of COVID-19 are cough, fever, chills, difficulty breathing, body aches, sore throat, loss of taste or smell, diarrhea, headache, fatigue, nausea/vomiting, and/or congestion/runny nose.1 Patients who are concerned they may have COVID-19 should reach out to their provider as soon as possible. See Table 2 for common conditions associated with poor outcomes and more severe COVID-19, including hospitalization, intensive care, ventilator use, and death.

Table 2. Common Conditions Associated with Poor Outcomes and More Severe COVID-192-13

  • Cancer
  • Chronic kidney/liver/lung disease
  • Cystic fibrosis
  • Dementia/neurologic conditions
  • Diabetes
  • Heart conditions
  • Human immunodeficiency virus
  • Immunocompromised health
  • Mental health conditions
  • Physical inactivity
  • Pregnancy
  • Sickle cell/thalassemia
  • Smoking history/substance use disorder
  • Overweight
    (body mass index > 25)
  • Older than 65 years of age
  • Transplant recipient
  • Cerebrovascular disease
  • Tuberculosis

Many COVID-19 precautions are being lifted, causing one to ask, “Is being out in the community safe? Am I at risk of developing severe symptoms? Am I part of the high-risk population?” Higher risk patients, including racial and ethnic minorities, should be advised to use properly fitted masks, social distance, avoid poorly ventilated areas and large gatherings, and stay up to date with all CDC recommended vaccinations.14,15 COVID.gov is a patient-friendly website, and test to treat locations can be found at 1-800-232-0233 (TTY: 1-888-720-7489).16

References

  1. Johns Hopkins Medicine. COVID-19 vs. the flu. Updated Feb. 23, 2022. https://www.hopkinsmedicine.org/health/conditions-and-diseases/coronavirus/coronavirus-disease-2019-vs-the-flu
  2. Centers for Disease Control and Prevention. People with certain medical conditions. Updated May 2, 2022. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html#obesity
  3. Robilotti EV, Babady NE, Mead PA, et al. Determinants of COVID-19 disease severity in patients with cancer. Nat Med 2020;26:1218-1223.
  4. Mayo Clinic. COVID-19: Who’s at higher risk of serious symptoms? https://www.mayoclinic.org/diseases-conditions/coronavirus/in-depth/coronavirus-who-is-at-risk/art-20483301
  5. National Institutes of Health COVID-19 Treatment Guidelines. Special
    considerations in people with HIV. Updated May 2, 2022. https://www.covid19treatmentguidelines.nih.gov/special-populations/hiv/
  6. National Institutes of Health COVID-19 Treatment Guidelines. Special considerations in pregnancy. Updated July 8, 2021. https://www.covid19treatmentguidelines.nih.gov/special-populations/pregnancy/
  7. Johns Hopkins Medicine. Who is at higher risk for severe coronavirus disease? Updated Dec. 8, 2021. https://www.hopkinsmedicine.org/health/conditions-and-diseases/coronavirus/coronavirus-and-covid19-who-is-at-higher-risk
  8. Gupta R, Ghosh A, Singh AK, Misra A. Clinical considerations for patients with diabetes in times of COVID-19 epidemic. Diabetes Metab Syndr 2020;14:211-212.
  9. Panepinto JA, Brandow A, Mucalo L, et al. Coronavirus disease among persons with sickle cell disease, United States, March 20-May 21, 2020. Emerg Infect Dis 2020;26:2473-2476.
  10. Dard R, Janel N, Vialard F. COVID-19 and Down’s syndrome: Are we heading for a disaster? Eur J Hum Genet 2020;28:1477-1478.
  11. Gao C, Cai Y, Zhang K, et al. Association of hypertension and antihypertensive treatment with COVID-19 mortality: A retrospective observational study. Eur Heart J 2020;41:2058-2066.
  12. Frydrych LM, Bian G, O’Lone DE, et al. Obesity and type 2 diabetes mellitus drive immune dysfunction, infection development, and sepsis mortality. J Leukoc Biol 2018;104:525-534.
  13. Muniyappa R, Gubbi S. COVID-19 pandemic, coronaviruses, and diabetes mellitus. Am J Physiol Endocrinol Metab 2020;318:E736-E741.
  14. Centers for Disease Control and Prevention. Obesity, Race/Ethnicity, and COVID-19. Last reviewed May 20, 2022. https://www.cdc.gov/obesity/data/obesity-and-covid-19.html
  15. Centers for Disease Control and Prevention. How to protect yourself & others. Updated Feb. 25, 2022. https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/prevention.html
  16. Office of the Assistant Secretary for Preparedness and Response. Test to Treat. https://aspr.hhs.gov/TestToTreat/Pages/default.aspx

Public Health Challenges

What are some of the public health challenges related to COVID-19?

In 2020, the COVID-19 pandemic radically changed our approach to public health. Before the COVID-19 pandemic, most people would have assumed that young, healthy, immunocompetent individuals would be resistant to all but the most severe infectious diseases; meanwhile, only older individuals or those with preexisting conditions would be considered at risk of severe negative outcomes from less virulent endemic diseases, such as influenza. Unlike expectations from previous experience, young, healthy people; asymptomatic people; and people not considered high-risk may be affected negatively by COVID-19.

The goal of increasing access and education related to COVID-19 vaccines was discussed as part of a recent Journal of the American Medical Association (JAMA) Network Health Agencies Update. An administrator stated that investments in community-based funding help reduce disparities in underserved communities disproportionately affected by the pandemic.

The high infectivity of COVID-19, combined with its potential for severe disease, has ignited a new focus on the relationship between immunology and pathologic processes. Research suggests that various biopsychosocial factors and health behaviors can predispose people to COVID-19.1

During this pandemic, social distancing has remained a prime approach to preventing infection with COVID-19. However, conflicting perspectives around the severity of COVID-19 have caused discussions regarding prevention to become more political than public health-focused. Current research has identified specific barriers, such as socioeconomic status, occupation, and housing density as major obstacles to proper social distancing.2,3 Essential workers, unhoused individuals, and minority populations are groups of interest when thinking about disparities in COVID-19 infection.4

Eradication of COVID-19 is unlikely, since its causative viral agent continues to mutate, which is common for all ribonucleic acid (RNA) viruses. Geographic separation of exposures tends to result in genetically distinct variants.5 Although social distancing is an effective method for preventing the spread of COVID-19, it is most effective as part of a larger prevention strategy that includes good sanitation practices, mask wearing, and vaccine adherence.6 Historically, vaccines have been an excellent tool in the control and eradication of disease. Although many people were thrilled to have such an option for COVID-19, others noted significant concerns about the speed of vaccine development, inconsistency in messaging from public health officials, and the potential for adverse outcomes.7

There are considerable differences in COVID-19 vaccine uptake among different populations, ranging from distrust of the medical establishment to reduced access to vaccines. Healthcare inequities, personal opinions valuing or devaluing vaccine access, and misinformation contribute to achieving public health goals. Initially, people of color had lower vaccination rates. Data from the Centers for Disease Control and Prevention (CDC), in the April 2022 Kaiser Family Foundation Report, show that 77% of the total U.S. population had received at least one dose of a COVID-19 vaccine. With unvaccinated people at increased risk of infection, severe illness, and death, white people accounted for two-thirds (64%) of people who remain unvaccinated.8 With booster shot eligibility now expanding to many of the pediatric groups, ensuring equity in uptake of boosters and primary vaccinations among children will continue to be a top priority.

References

  1. Gonzales A, Lee EC, Grigorescu V, et al. Overview of barriers and facilitators in COVID-19 vaccine outreach. Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services. Published Sept. 13, 2021. https://aspe.hhs.gov/reports/covid-19-vaccine-outreach
  2. Garnier R, Benetka JR, Kraemer J, Bansal S. Socio-economic disparities in social distancing during the COVID-19 pandemic in the United States. medRxiv 2020; Nov 9. doi.org/10.1101/2020.11.07.20201335. [Preprint].
  3. Bibbins-Domingo K. This time must be different: Disparities during the COVID-19 pandemic. Ann Intern Med 2020;173:233-234.
  4. Centers for Disease Control and Prevention. Risk of exposure to COVID-19. Updated Dec. 10, 2020. https://www.cdc.gov/coronavirus/2019-ncov/community/health-equity/racial-ethnic-disparities/increased-risk-exposure.html#ref10
  5. Bollinger R, Ray S, Maragakis L. COVID variants: What you should know. Johns Hopkins Medicine. Updated April 8, 2022. https://www.hopkinsmedicine.org/health/conditions-and-diseases/coronavirus/a-new-strain-of-coronavirus-what-you-should-know#:~:text=Alpha%2C%20beta%2C%20gamma%2C%20delta,2%20variants%20of%20high%20consequence
  6. Su Z, Wen J, McDonnell D, et al. Vaccines are not yet a silver bullet: The imperative of continued communication about the importance of COVID-19 safety measures. Brain Behav Immun Health 2021;12:100204.
  7. Troiano G, Nardi A. Vaccine hesitancy in the era of COVID-19. Public Health 2021;194:245-251.
  8. Centers for Disease Control and Prevention. COVID Data Tracker. https://covid.cdc.gov/covid-data-tracker

Prevention of COVID-19

What can my family do to prevent getting COVID-19?

Our understanding of COVID-19 has grown rapidly since the start of the pandemic and, in turn, our management of the disease has become more effective and standardized. Despite these advances, COVID-19 still is a potentially deadly virus. Prevention, rather than treatment, is the goal. Here, we discuss views on physical mitigation and vaccines as preventive measures.

COVID-19 is a respiratory virus that spreads when an infected person breathes out droplets and very small particles that contain the virus via airborne transmission, such as breathing or speaking. Some of these droplets are large and fall to the ground rather quickly, while others are smaller particles or aerosols (less than 10 microns in diameter) and can linger in the air.1 These droplets and particles can be breathed in by other people or land in their eyes, nose, or mouth.2 Masking acts as a barrier, helping to block droplets and even some aerosols.1,3 The ability to filtrate particles and droplets varies based on characteristics, such as the type of material, the number of layers of material, and the fit. However, even simple cloth masks can block some droplets and aerosols. Numerous studies have shown that masks are effective in helping to reduce the spread of infection.1,3

Patients should be encouraged to wear masks when out in public, both to reduce their risk of contracting SARS-CoV-2 as well as to reduce their risk of potentially spreading an asymptomatic or pre-symptomatic infection.

Practicing social distancing, using telecommunication instead of in-person contact, physical distancing at social events, staying at least six feet from others, or staying away from large gatherings helps prevent the spread of COVID-19.2 Proactive use of testing to detect either SARS-CoV-2 or biomarkers of SARS-CoV-2, or antibodies made after getting COVID-19, prior to such activities can help refine and reduce superspreader opportunities in schools and elsewhere.

Vaccines are another important tool in the fight against COVID-19. In resource-rich countries, such as the United States, COVID-19 has become a vaccine-preventable disease. This term does not reflect that a vaccine will eradicate all diseases for which there is a vaccine, but instead represents that the disease can be rendered less deadly and less severe through vaccination. Vaccine-preventable diseases can cause long-term illness, hospitalization, and death.4

Despite increasing numbers of vaccinated individuals becoming infected with the extremely contagious Omicron variant, vaccines have remained highly effective at preventing hospitalizations and death.5 Studies also have shown that keeping vaccinations up to date helps enhance the patient’s immune response and improve protection against COVID-19.5 All eligible patients should be up to date with all CDC-recommended vaccinations to maximize prevention of infection, hospitalization, and death. (For current vaccine information for specific patients, see toolkit references.)

Although life in many areas of the United States is regaining elements of pre-COVID normalcy, it is important that we use information and resources to prevent further morbidity and mortality.6,7

References

  1. Brooks JT, Butler JC. Effectiveness of mask wearing to control community spread of SARS-CoV-2. JAMA 2021;325:998-999.
  2. Centers for Disease Control and Prevention. How COVID-19 spreads. Updated July 14, 2021. https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/how-covid-spreads.html
  3. Centers for Disease Control and Prevention. Science Brief: Community use of masks to control the spread of SARS-CoV-2. Updated Dec. 6, 2021. https://www.cdc.gov/coronavirus/2019-ncov/science/science-briefs/masking-science-sars-cov2.html
  4. Centers for Disease Control and Prevention. Vaccines and preventable diseases. Last reviewed Nov. 22, 2016. www.cdc.gov/vaccines/vpd/index.html
  5. Centers for Disease Control and Prevention. Science Brief: Omicron (B.1.1.529) variant. Updated Dec. 2, 2021. https://www.cdc.gov/coronavirus/2019-ncov/science/science-briefs/scientific-brief-omicron-variant.html
  6. Centers for Disease Control and Prevention. COVID Data Tracker. April 2022. https://covid.cdc.gov/covid-data-tracker/#datatracker-home
  7. World Health Organization. WHO Coronavirus (COVID 19) Dashboard. April 2022. https://covid19.who.int/

Pregnancy and COVID-19

Does COVID-19 vaccination or COVID-19 infection affect pregnancy?

Pregnancy or recent pregnancy is associated with a higher risk for severe COVID-19.1 COVID-19 also is associated with a higher risk of numerous prenatal and perinatal complications, including preeclampsia, maternal mortality, and preterm birth.2,3 Pregnant people with additional comorbidities, such as advanced maternal age, high body mass index (BMI), preexisting diabetes, or chronic hypertension, also are associated with a higher risk for intensive care unit (ICU) admission or forced ventilation.2,3 Despite the increased risk associated with pregnancy and COVID-19 infections, vaccination coverage and uptake among pregnant people remains low.4,5 The pregnant population provides opportunity for better education and promotion of both the vaccines and COVID-19 prevention strategies.

Two additional questions related to pregnancy are whether the vaccine is safe for both mother and fetus and whether vaccination during pregnancy is safe and beneficial to the newborn.6,7 Studies of pregnant persons have shown no increased pregnancy-related adverse effects from COVID-19 vaccination, nor increased risk of miscarriage.6,8,9 A helpful counseling point for patients considering vaccination is that immunization likely will help protect their child against COVID-19 by the passing of anti-spike protein immunoglobulin G (IgG) antibodies through the placenta. It has been found, in mothers who were vaccinated between 20 and 32 weeks of gestation, that detectable levels of anti-spike IgG antibodies were found in 98% of their infants at two months, with that number dropping to 57% at six months (compared to only 8% of infants with detectable IgG whose mothers were infected with COVID-19 during the same time period).7

The American College of Obstetricians and Gynecologists (ACOG) and the CDC guidelines recommend vaccination any time before or during pregnancy, including for those planning to become pregnant, those who are pregnant, or those who are breastfeeding to provide some immunity to their babies.10

Education on vaccine safety and efficacy, along with proper COVID-19 prevention strategies, such as masking and social distancing, are a critical responsibility of primary care physicians. A poll of 12,887 people indicated that primary care providers were the most trusted source of information about the COVID-19 vaccine and the most preferred place to get vaccinated.11 The low levels of vaccination in pregnant populations, the increased risk of complications during pregnancy from COVID-19, and the additional benefits to the fetus from maternal vaccination highlight an opportunity to effect a positive change through proper education and health promotion with pregnant patients.

References

  1. Centers for Disease Control and Prevention. Science Brief: Evidence used to update the list of underlying medical conditions associated with higher risk for severe COVID-19. Updated Feb. 15, 2022. https://www.cdc.gov/coronavirus/2019-ncov/science/science-briefs/underlying-evidence-table.html
  2. Allotey J, Stallings E, Bonet M, et al. Clinical manifestations, risk factors, and maternal and perinatal outcomes of coronavirus disease 2019 in pregnancy: Living systematic review and meta-analysis. BMJ 2020;370:m3320.
  3. Villar J, Ariff S, Gunier RB, et al. Maternal and neonatal morbidity and mortality among pregnant women with and without COVID-19 infection: The INTERCOVID Multinational Cohort Study. JAMA Pediatr 2021;175:817-826.
  4. Blakeway H, Prasad S, Kalafat E, et al. COVID-19 vaccination during pregnancy: Coverage and safety. Am J Obstet Gynecol 2022;226:236.e1-236.e14.
  5. Stock SJ, Carruthers J, Calvert C, et al. SARS-CoV-2 infection and COVID-19 vaccination rates in pregnant women in Scotland. Nat Med 2022;28:504-512.
  6. Shimabukuro TT, Kim SY, Myers TR, et al. Preliminary findings of mRNA Covid-19 vaccine safety in pregnant persons. N Engl J Med 2021;384:2273-2282.
  7. Shook LL, Atyeo CG, Yonker LM, et al. Durability of anti-spike antibodies in infants after maternal COVID-19 vaccination or natural infection. JAMA 2022;327:1087-1089.
  8. Magnus MC, Gjessing HK, Eide HN, et al. Covid-19 vaccination during pregnancy and first-trimester miscarriage. N Engl J Med 2021;385:2008-2010.
  9. Kharbanda EO, Haapala J, Desilva M, et al. Spontaneous abortion following COVID-19 vaccination during pregnancy. JAMA 2021;326:1629-1631.
  10. Centers for Disease Control and Prevention. COVID-19 vaccines while pregnant or breastfeeding. Updated June 13, 2022. https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations/pregnancy.html
  11. African American Research Collaborative. American COVID-19 Vaccine Poll. https://covidvaccinepoll.com

Fertility and COVID-19

Does COVID-19 vaccination or COVID-19 infection affect infertility?

Various viral infections are associated with impaired male fertility and decreased semen quality.1 The most well-known of these viruses is mumps, but also includes hepatitis B and C, as well as human papillomavirus (HPV).1 Most recently there is evidence that infection with SARS-CoV-2, especially moderate to severe infection, has been linked with impairments to male fertility.1

SARS-CoV-2 has been found to infect cells by binding to the angiotensin-converting enzyme 2 (ACE-2) receptor on the cell surface.1-3 The receptor can be found on up to 72 different types of tissue in the human body, including the heart, lung, brain, and testis.2 After gaining entry into the cell, viral replication begins to occur, leading to cellular dysfunction. This triggers an inflammatory cascade of events involving multiple cytokines to prevent continued viral replication and infection of other cells that can end up damaging the body in the process.

It has been postulated that male fertility is affected by SARS-CoV-2 infection through multiple different mechanisms, including direct damage to cells, with indirect damage from inflammation.2 In terms of direct effects, viral infection via ACE-2 receptors on the testis can lead to inflammatory changes in male reproductive interstitial tissue and infertility. Reduction of Sertoli and Leydig cells can lead to less testosterone, lack of nourishment of sperm, and, ultimately, impaired fertility.2 Indirectly, increased inflammation and cytokine storm following COVID-19 infection may induce a higher temperature of the testes with increased blood flow, leading to germ cell damage, ultimately jeopardizing the blood-testis barrier.3 This adversely affects spermatogenesis and hormone production within the testes.3 In addition, drugs, such as glucocorticoids and interferons used to treat SARS-CoV-2 infections, may be gonadotoxic, adversely affecting the male reproductive system.3

Concerning female infertility, results have been less conclusive regarding the long-term effects of SARS-CoV-2 infection. It has been noted that ACE-2 also is highly expressed in female reproductive tissues, including those of the ovaries, vagina, and uterus.4 Although there have been changes noted to the female menstrual cycle associated with COVID-19, it appears that this is a temporary response, possibly associated with the increased physiologic stress related to infection.4 Ovarian reserve did not seem to be significantly altered by COVID-19 infection, except in a few instances of noted severe infection.4

There is no current evidence that suggests COVID-19 vaccines affect fertility; rather, they should be considered as a possible modality to prevent infertility.

References

  1. Adamyan L, Elagin V, Vechorko V, et al. A review of recent studies on the effects of SARS-CoV-2 infection and SARS-CoV-2 vaccines on male reproductive health. Med Sci Monit 2022;28:e935879.
  2. Seymen CM. The other side of COVID-19 pandemic: Effects on male fertility J Med Virol 2021;93:1396-1402.
  3. Tian Y, Zhou LQ. Evaluating the impact of COVID-19 on male reproduction. Reproduction 2021;161:R37-R44.
  4. Carp-Veliscu A, Mehedintu C, Frincu F, et al. The effects of SARS-CoV-2 infection on female fertility: A review of the literature. Int J Environ Res Public Health 2022;19:984.

Continued in Part 2.