The COVID-19 pandemic has impacted all spheres of society including medical education and healthcare systems. In response to the pandemic, there has been a transition in medical education practice from traditional forms of teaching to online instruction delivery and virtual learning. Effective clinical microbiology education involves a combination of 'hands-on' practical learning and instructional delivery of scientific knowledge. Microbiology practical laboratories are critical learning environments offering 'hands-on' learning experiences that cannot be replicated through online learning. We conducted a mixed-methods study to understand the perception of online and face-to-face microbiology laboratory sessions among the medical students and microbiology faculty at Arabian Gulf University (AGU).The study participants were third and fourth-year undergraduate medical students and faculty involved in delivering microbiology labs at AGU. The questionnaire consisted of questions ranging from perceived learning style to attitude towards online delivery of microbiology curriculum. After the questionnaire administration (google form), focus group discussion (FGD) was conducted for students and microbiology faculty separately.Among 168 students, 50.6% preferred face-to-face lab sessions as compared to 30.4% who preferred online labs, and 51.8% considered online labs to be an essential addition to face-to-face labs. Among the faculty, 85.7% preferred the face-to-face mode of teaching. All the faculty (100%) disagreed that all the microbiology labs teaching should be online. 57.2% considered online labs to be an essential addition to traditional face-to-face labs. Both faculty and students hold that a blended mode of instructional delivery is vital and indispensable for the transfer of skills and knowledge for microbiology students.The blended mode of delivering microbiology laboratory sessions in medical school is successful and well-received by both students and faculty. Students take the responsibility for furthering their own learning and understanding of concepts. Instructors have also noticed that blending learning strategies also successfully enhances the development of cognitive skills and problem-solving abilities in students. A review of the microbiology lab curriculum is necessary to identify content areas that can be delivered effectively through online, face-to-face lab sessions, or both, supported with appropriate tools and infrastructure.The online version contains supplementary material available at 10.1186/s12909-022-03346-2. Bahrain suspended all academic institutions to curb the spread of COVID-19 infection on 25ary 2020 . It is fary 2020 . MedicalMany unknowns, from student-driven to staff-driven factors, may determine whether an online learning program succeeds or fails . ClinicaFace to-face labs provide students with the opportunity to work and learn alongside peers and instructors . It can Several studies have reported satisfaction with online laboratory sessions on the basis of cost-effectiveness and convenience . ResearcBlended learning combines online and in-person learning; this approach to learning factors in financial and faculty constraints as well as students’ learning priorities or prerequisites . AssigniThere remains a paucity of published studies on the preferred mode of learning and teaching for microbiology laboratory sessions in medical schools. Hence, we aimed to conduct a mixed-methods study which might help to delineate microbiology learning needs and how well they are being met and help improve student learning outcomes. This article discusses the perception of microbiology laboratory sessions among the medical students and microbiology faculty at the Arabian Gulf University (AGU).The study was approved by the Research and Ethics Committee, CMMS, Arabian Gulf University (E049-PI-4/21). The participants were third and fourth-year undergraduate medical students, and faculty involved in delivering microbiology labs to undergraduate medical students at AGU. We selected third and fourth-year undergraduate medical students as they had the opportunity to experience both, face to face and online (ZOOM platform) mode of learning microbiology lab sessions. According to the approved protocol, a questionnaire was prepared for the students which was adapted from Salter and Gardner . The facAt AGU, we follow Problem Based Learning (PBL) curriculum. There are a total of 9 units (3 units each year) with 93 problems in Phase II . The problems are designed in accordance with regional and global clinical scenarios. The microbiology laboratory sessions (MLS) are designed to correspond to the learning outcomes of PBL sessions. The MLS focuses on the student’s ability to demonstrate pre-specified microbiology laboratory skills, identify, and differentiate common pathogens based on microscopical examination , culture , serological and molecular methods, evaluate and interpret the laboratory results and relate these laboratory test results with the clinical scenarios. The MLS are divided into wet labs and dry labs. The students are divided into groups of 20-25 each and the sessions lasts about 2-3 hours. All the students are given the opportunity to execute a specific lab skill under supervision.th, 2020, when all the educational institutions were officially closed in Bahrain and online teaching was initiated.For this questionnaire-based study, lab sessions were assessed in two formats: 1) face-to-face lab sessions before the closure of the institution and 2) online lab sessions after the closure of the institution on February 26The questionnaire was divided into three parts  microbiology lab sessions to which the students and faculty responded using Likert scale.Part 3 related to their preferences for, and perceptions of, face to face lab sessions, online lab sessions or a blended form.The questionnaire contained four items for face-to-face perception and eight items for online perception. Students and faculty selected their responses from a five-point Likert scale from “strongly agree” through “strongly disagree” options. Students were asked about the effectiveness of the current pandemic-induced format for lab delivery and their preferences in regard to online and face-to-face lab sessions. They were also asked about the quality of interactions and strategies to enhance learning under the new educational environment. The questionnaire was administered through google form and the link was shared through emails, and WhatsApp.After the questionnaire administration, separate focus group discussion (FCD) sessions were conducted for students and microbiology faculty. The semi-structured interview guide for FCD was validated by content and education experts. There were three focus groups: 1) Faculty group 2) Year 3 students’ group and 3) Year 4 students’ group. The FCDs were conducted through ZOOM platform. All the sessions were recorded with the knowledge and consent of the participants. Informed consent was obtained from the study participants before the FCDs. The discussions were transcribed into word document verbatim.The sample size for the study was:n= 170), responders Number of students in year 3 (n= 184), responders Number of students in year 4 (n=10), participants Number of faculty (n=168) and Faculty (n=7)Total responders 175: Students . Variables were presented as counts and percentages or as means and standard deviations where applicable. The validity and reliability of the questionnaire was tested using appropriate statistical methods . A cluster bar graph was plotted to represent the distribution of the two qualitative variables. Independent sample t test was used to compare the mean of quantitative variables between groups, and the Chi-Square test was used to compare the proportions between categorical variables. A The data collected from the focus group discussions were transcribed and analyzed using thematic analysis. The approach adopted for the analysis was the inductive approach in which codes obtained from the data were directed by the content of the data and were not based on any preexisting coding frame or preconceptions. Both coding and theme development were done using Microsoft Excel. Raw data was logged into an Excel spreadsheet and sections of text and ideas that appeared repetitively in the data color coded. Such codes were revisited and labeled as they relate to a theme. In order to strengthen accuracy in the analytic process, themes were rechecked against codes and raw data set, creating a map that linked raw data, codes, and the themes that emerged from the data.For the 168 student respondents, the mean age was 21.35±2.16 years, mostly females (72.6%).n=7) females were 28.5% (n=2). Mean age for male faculty was 53.8 and for female was 51.5.The mean age for year 3 students was 20.93 . The mean age for Year 4 students was 21.78 . Among faculty responders . Among the faculty, 57.1% (n=4) spent 30-60 minutes and 42.9% (n=3) spent 60-90 minutes on each online practical teaching.The rates for attendance at online practical sessions was highest for year 3 (57%) compared to year 4 students 56.1%). Majority of the respondents attend online practical sessions for 60-90 minutes (56.5%) compared to attendance for 30-60 minutes (38.7%) and attendance for less than 30 minutes (4.8%). The results of the chi-square test showed  attend online lab sessions off-campus 79.2%) compared to attendance for a combination of both on-campus and off-campus (18.5%) and attendance on campus (2.4%)  were conducting online lab sessions on campus.All the faculty  preferred face-to-face mode of teaching with the same percentage and majority  believing that face-to-face sessions enhanced students understanding of the course. They all agreed that not all lab sessions should be entirely online; though; over half (57.2%) considered online labs to be an essential addition to traditional face-to-face labs . All the faculty  preferred a blended mode of teaching microbiology lab sessions.Blended lab sessions using both modes of delivery were preferred by year 3 (62.8%) and year 4 (70.7%) students Fig. . The resIn the pre-COVID period, microbiological lab sessions at AGU were conducted face to face. However, during the COVID-19 pandemic, lab sessions were held via the ZOOM platform. We compared the AGU lab curriculum to the internationally recognized ASM curriculum recommendations for undergraduate microbiology education. According to the ASM microbiology lab skills criteria, the AGU microbiology lab objectives were met Table . At AGU,The analysis yielded six main learning/teaching themes and sub-themes as shown in Table The six main themes that emerged from the study are as follows:The advantages of online lab sessions are: easy access to sessions from any location; use of tools such as PowerPoints, images, case studies, clinical cases, and videos that facilitate effective delivery of theoretical content; sessions can be recorded allowing students to revisit the session and deepen learning; instructors can also review recorded sessions for evaluative or other purposes as needed; elimination of lab management challenges related to large groups; and better time management .The drawbacks to online lab sessions are that both teaching and learning are less adaptable for wet labs compared to dry labs; challenges with evaluating student learning; deficits with regard to acquisition of cognitive skills since students cannot engage in hands-on lab activities or learn how to use actual lab equipment; poor feedback compared to face-to-face sessions where there is direct communication, including emotional cues; and technological glitches that may impede teaching and learning. Inconsistency in level of student engagement in online sessions was also identified as a drawback by both faculty and students. As observed by a Year 3 student “So, there is no problem with gaining information, but the problem is for staying focused I think, during the session”.The pedagogical strategies used in face-to-face lab sessions are already well-established; instructors are skilled in these practices leading to efficient teaching and assessment; students are able to gain practical and cognitive skills through hands-on participation; socially and mentally beneficial physical interaction takes place in face-to-face lab settings; effective bi-directional feedback; and higher retention of information by students. This mode of delivery of lab sessions is also effective for both wet and dry labs.The drawbacks to face-to-face microbiology lab sessions are indirect rather than direct: less flexibility in the teaching and learning process such that the student and teachers must be in the physical location for the lab session; time constraints such as travel time to lab location; some waste of material resources; and tendency to repeat rather than innovate with technical methodologies.Online laboratory sessions are effective for delivering dry labs which are theory-based microbiology lab sessions in which concepts are explored and conceptual knowledge acquired. Assessment of students’ learning regarding such theoretical aspects can also be done online.Online lab sessions do not support the delivery of wet lab which are lab sessions that require and involve demonstration of some experimentation to students and sessions that require students to learn how to use lab tools such as the microscope for slide preparation and examinations or diagnostic procedures from cultures to immunodiagnostics. For such wet lab sessions, face-to-face sessions are required. Evaluation of students’ practical skills and their learning is also done during such face-to-face sessions.Blended learning, which is strategic combination of both online lab sessions and face-to-face lab sessions in the delivery of the microbiology lab curriculum, emerged as the most efficient way to deliver this course. Certain procedures can be effectively learned using a combination of online and face-to-face instructions; some activities can be effectively conducted in the online mode eliminating the need for physical presence, and others can only be conducted only in a physical environment. For instance, sample handling requires physical presence for the processing activities, but reporting may be done online. As stated by one of the participants, “Sample processing... it's not going to get theoretical. It must be done face to face. They have to handle the specimen”. A blended learning curriculum takes into consideration the possibility, benefits, and advantages of teaching and learning processes in either the online, face-to-face mode, or both as appropriate.Thus, the emergence of blended learning as a critical strategy for the delivery of microbiology lab is based on both the requirements for microbiology education and the pre-COVID-19 trend toward technology integration. The adoption of online learning in response to the pandemic reinforced this phenomenon. Post-COVID-19, if the virus is controlled, technological adoptions made during the pandemic will not only remain but will likely accelerate as more technological innovations are developed and society continues to exploit the benefits of remote education. This scenario creates the need for a curriculum review to determine a blended learning curriculum that is most effective for microbiology education and a best fit for the institution.The institution is growing and evolving in its use of online lab sessions during the COVID-19 pandemic. Constant review of the teaching strategies, student outcomes, and formulating of test curricula has helped optimize transfer of knowledge during the pandemic, bringing cost benefits for the department and institution. Infrastructural challenges exist for effective delivery of blended learning. Tools such as videos and images must be further developed. A core of IT technical support team with specialized training must be developed, and training workshops implemented for both faculty and students on all relevant aspects.This study investigates student and faculty perception of the different modes of learning and teaching microbiology laboratory sessions at AGU. Previous research has mainly focused on the impact of online and in-person labs, with little emphasis on student  and facuIn our findings, traditional delivery of microbiology lab sessions has been based on the face-to-face model. Both faculty and students hold that this mode of delivery continues to remain vital and indispensable for the transfer of skills and knowledge for students. Certain aspects of laboratory training can only be done effectively using face-to-face lab sessions, specifically, wet labs. These lab sessions are associated with gain in cognitive and practical skills, increased retention of information, and quality interaction between faculty and students. This was consistent with Brockman et al. who found that 90% of the students, preferred face-to-face lab sessions . SimilarDespite the overwhelming number of students opting for face-to-face lab sessions, our data indicate a minimal trend in which students (30.4%) prefer online learning as the ideal format for microbiology labs. Among the faculty, none opted for online microbiology labs except for delivering theory-based knowledge and case discussions. There are also barriers to online teaching and learning, particularly in large-enrollment courses, although such barriers also present opportunities to innovate and improve align our curricula with the current educational environment .The major focus among microbiology educators remains the provision of tried and tested face-to-face microbiology practical sessions. Because the acquisition of core "hands-on" skills is crucial in many science and fine arts courses, finding appropriate instructional strategies during the pandemic has been an urgent task . Hands-oBlended learning is a teaching method that combines online self-learning with classroom instruction. When well-designed, blended learning courses in medicine can improve students self-learning, insight, and problem-solving skills, ultimately increasing the quality of learning . BlendedThe limitations of this study may provide a basis for future research on laboratory perceptions in medical schools. Our study included year 3 and year 4 medical students (phase II) in a six-year medical undergraduate programme, and the response rate was only 50%. The faculty sample size was also small. One of the drawbacks of FGD is that study participants may not express their honest and personal opinions about the subject at hand. They may be reluctant to voice their opinions especially if their opinions differ from those of another participant. Future research addressing these limitations may be important for providing additional insight into perceptions regarding microbiology lab sessions under the current educational environment.In conclusion, blended mode of delivering microbiology laboratory sessions in medical school are successful and well-received by both students and faculty. Students take the responsibility of self-learning which improves their abilities to think critically while acquiring a deeper understanding of concepts. Instructors noted that these innovative sessions successfully enhance the development of cognition and problem-solving abilities in students. Instructors also became more effective in the delivery of knowledge when students engage in self-directed learning rather than passing theoretical knowledge. Review of microbiology lab curriculum is necessary to identify content areas that can be delivered effectively through online modalities, face-to-face lab sessions, and blended formats. Appropriate tools and infrastructure aligned with the microbiology lab curriculum must be developed in support of online formats including videos, images, specialized training tools, and case studies since this is still an emerging pedagogical format.Additional file 1.Additional file 2.Additional file 3.Additional file 4.Additional file 5.Additional file 6.Additional file 7.


While basically all countries have been hit by the COVID-19 pandemic, the impact has varied in large degrees among countries. In the present study, national differences in six COVID-19 indicators  were studied in relation to socio-economic and Hofstede's cultural dimensions by using the latest data available. The results differed to some degree from the studies conducted in the earlier stage of the pandemic. COVID-19 deaths per capita were predicted by Uncertainty Avoidance (UA) and Indulgence (IVR); excess mortality by UA; the impact of pandemics by Power Distance (PDI), Long-term Orientation (LTOWS) and IVR; change in GDP per capita by PDI; vaccination rate by Individualism and UA; and Stringency Index by LTOWS. In addition to further clarifying the role of cultural dimensions in the pandemic, three conclusions can be drawn. First, the pandemic reached different countries at different times, which is reflected in the results. The conclusion about the role of socio-economic and cultural factors can be drawn only after the pandemic. Second, cultural dimensions were related to COVID-19 measures only when socio-economic indicators were not considered but lost their significance when socio-economic variables were entered into the models. Cultural dimensions influence the outcome variables via socio-economic factors. Third, earlier studies have focused mainly on COVID-19 deaths. The impact of the COVID-19 pandemic is a complex phenomenon and cannot be reduced to the death rate. Up to date (23 July 2021), the COVID-19 pandemic has claimed 4,136,518 lives globally. The highest number of deaths has been reported in the USA , followed by Brazil  and India  [Several studies have investigated possible socio-economic or population factors which could explain the regional differences in COVID-19 outcomes. The most investigated economic factors seem to be GPD per capita, income inequality measured with the Gini index, and health care expenses per capita. In several studies, the GDP per capita has been positively related to higher COVID-19 death rates –9 while Such population factors as high median age, obesity and population density can be expected to be related to higher COVID-19 mortality because COVID-19 infection seems to be especially risky for elderly patients and patients with obesity or chronic illnesses such as Type 2 diabetes mellitus, hypertension, and other metabolic comorbidities , 19. TheA pandemic is a crisis that requires effective crisis management to mitigate the damage and secure the functioning of society. For example, countries have to decide about policies related to facial masks, social distancing, screening travellers, guaranteeing symptomatic patients, contact tracing and vaccination priorities. Curfews, closedown of businesses and obligatory distance learning at schools are all harsh measures in which the authorities must balance health risks and harm done to societal life. The effectiveness of countries' response to the COVID-19 pandemic might reflect the general quality of governance in general. In some studies, good governance has been found to be related to fewer COVID-19 deaths –30, whilWhile socio-economic factors, population characteristics and governance quality certainly are important factors influencing, it should be noted that many of these factors reflect national cultural values. For example, policies for reducing income equality, investment in the public health care sector and, finally, restrictions on citizens' activities or business are all political decisions that are based on specific values. Therefore, it is not surprising that some social scientists have investigated the role of cultural values using such theories as Schwartz’s Basic Human Values , 33, 34 Culture can be called “the collective programming of the mind that distinguishes the members of one group or category of people from another” . The cenAlmost all the studies use fatalities per capita, infections per capita, or fatalities per detected infections as a criterion (dependent or predicted variable) in analyses. These measures are, however, challenging in many ways. First, the reported numbers of cases and deaths can be strongly affected by testing capacity and reporting policy, resulting in significant underreporting . This unThe present study aimed to investigate how socio-economic and cultural factors are related to six national COVID-19 pandemic outcomes and performance measures.The data were downloaded from various online sources. The data included six COVID-19 related dependent variables , which shows that excess mortality is due to COVID-19 deaths to a great degree. However, the COVID-19 deaths do not account for the variance of the excess mortality of more than 41.0%, which means that excess mortality also captures those deaths which might be indirectly related to SARS-CoV-2 infection, e.g., fatalities caused by the conditions related to pandemic .Correlations between COVID-19 measures and socio-economic and cultural dimensions can be seen in Table Comparison of correlations between COVID-19 deaths and socio-cultural variables with excess mortality per 100,000 inhabitants and socio-cultural variables show that COVID-19 deaths correlated significantly with most of the socio-cultural variables, whereas excess mortality correlated statistically significantly only with WGI, obesity, physicians per 10,000 people, Power Distance, Uncertainty Avoidance, and Indulgence. Interestingly, the only cultural dimensions which COVID-19 deaths correlated significantly with was Uncertainty Avoidance.r = 0.28) with COVID-19 deaths per capita. Bearing in mind that a high total score means a high (negative) impact of the pandemic, in this model, COVID-19 deaths seemed to be only one aspect in the total view of how the pandemic has impacted a country. Unlike the death rate having a negative correlation to GDP per capita before the pandemic, the total score correlated positively with GDP. The strongest correlations among the total impact score and socio-cultural variables were between the total score and GDP per capita 2019 (r = − 0.51), WGI (r = − 0.51), Power Distance (r = 0.64), and Individualism (r = − 0.50). These correlations indicate that high-income individualistic countries with high-quality governance but low Power Distance have been less impacted by the pandemic than the other countries. It should be noted that the COVID-19 deaths per capita have a positive correlation to GDP and WGI but non-significant correlations to Individualism and Power Distance while correlating positively with Uncertainty Avoidance.The overall score of COVID-19 impact composed of change in GDP, excess mortality, vaccination percentage and stringency index correlated relatively weakly but significantly  and then to socio-economic variables (Block 2). Hofstede's cultural dimensions accounted for 18% of the variance. In Block 1, Uncertainty Avoidance and Indulgence were positively related to COVID-19 deaths. The socio-economic variables accounted for an added share of 15% of the variance, but none of the individual variables had a significant effect on the deaths per 100,000 people.In the second analysis, the overall impact of the COVID-19 pandemic was regressed to cultural dimensions (Block 1) and then to socio-economic variables (Block 2). In Block 1 (58% of the variance accounted for), Power Distance was positively, and Uncertainty Avoidance and Long-Term Orientation were negatively related to the overall COVID-19 impact score. Since a low overall score means a low (negative) impact of the pandemic, we can conclude that countries with high Power Distance and low Uncertainty Avoidance and low Short-Term Orientation were more harmed by the pandemic. The socio-economic variables accounted for an added share of 16% of the variance, but none of the individual variables had a significant effect on the overall score.In the third analysis, the change in GDP per capita during the COVID-19 pandemic was regressed to cultural dimensions (Block 1) and then to socio-economic variables (Block 2). In Block 1 (23% of the variance accounted for), only Power Distance was related to the change in GDP per capita. In GDP change, a positive number means an increase in GDP and a negative number a decrease in GDP per capita, so the COVID-19 pandemic seemed to have a larger (negative) effect on the economy (measured with GDP) when a country scored high in Power Distance. However, it should be noted that only Iran and Taiwan showed an increase in GDP per capita during the pandemic while all the GDP of the other countries shrank to smaller or larger degrees. The socio-economic variables accounted for an added share of 28% of the variance, but none of the individual variables had a significant effect on the change in GDP.In the fourth analysis, excess mortality was regressed to cultural dimensions (Block 1) and then to socio-economic variables (Block 2). In Block 1 (28% of the variance accounted for), only Uncertainty Avoidance had a statistically significant relationship to excess mortality. Countries with higher Uncertainty Avoidance scores had higher excess mortality during 2020. The socio-economic variables accounted for an added share of 32% of the variance. Among the socio-economic variables, the obesity rate was positively related to excess mortality.In the fifth analysis, the percentage of vaccinated (at least one vaccination) was regressed to cultural dimensions (Block 1) and then to socio-economic variables (Block 2). In Block 1 (63% of the variance accounted for), Individualism and Uncertainty Avoidance had a statistically significant relationship to vaccination rate. Countries with higher Uncertainty Avoidance and Individualism score had higher vaccination rates. The socio-economic variables accounted for an added share of 16% of the variance. Among the socio-economic variables, WGI, years of schooling and obesity rate were positively related to the proportion of the population vaccinated against the SARS-CoV-2 virus.In the last regression analysis, the stringency index was regressed to cultural dimensions (Block 1) and then to socio-economic variables (Block 2). In Block 1 (37% of the variance accounted for), only Long-Term Orientation had a statistically significant relationship to vaccination rate. Countries with a higher score in Long-Term Orientation applied less stringent COVID-19 policies. The socio-economic variables accounted for an added share of 20% of the variance. Among the socio-economic variables, life expectancy was positively, and the median age was negatively related to stringent policies.Since the beginning, the COVID-19 pandemic has cost more than four million lives. While being the most painful outcome of the pandemic, COVID-19 deaths are just one of the many adverse outcomes of the pandemic. Even SARS-CoV-2 infection with mild or unnoticeable symptoms may lead to "long COVID" characterized by long-lasting fatigue, cough, chest tightness, headaches, breathlessness, palpitations, myalgia and difficulty to focus . It has r = 0.05) with COVID-19 deaths per capita, and the excess mortality rate correlated negatively (r = − 0.17) with COVID-19 mortality per capita. These findings do not support the claim by Grüss and Tusaon (2021) that «Individualism…can kill». In fact, Individualism correlated negatively with the overall COVID-19 impact score, indicating that individualistic countries have been less impacted by the COVID-19 pandemic than collectivistic countries. Vaccination percentage, for example, had a strong correlation (r = 0.58) with Individualism and Stringency Index negative  correlation with Individualism. The explanation for the difference between the findings of the current and earlier studies might be straightforward: earlier studies naturally applied data from the earlier stages of the pandemic, while the present study is based on the most recent data. The COVID-19 pandemic has spread to different countries at a different speed, Europe having been impacted heavily in a very early stage of the pandemic. Besides, wealthy individualistic countries are leading in the current vaccination percentage, which naturally is reflected in COVID-19 mortality. Hence, the results of the earlier studies and the present study do not conflict: they reflect the different phases of the pandemic .Countries differ in a large degree in terms of their "resilience" to the effects of the COVID-19 pandemic. Research has indicated that certain socio-cultural and economic factors make countries more or less impacted by the COVID-19 pandemic. In addition to economic, political, and population-related factors, several studies have investigated the role of cultural values in the effects of the COVID-19 pandemic. One of the most robust findings is that Individualism  is positively related to COVID-19 deaths , 38, 57.r = 0.39) and excess mortality (r = 42) as well as with the higher impact of the pandemic (r = 0.21). The positive relationship between Uncertainty Avoidance correlated with COVID-19 deaths and excess mortality was also found in regression analyses. Interestingly, Uncertainty Avoidance also predicted the higher vaccination percentage indicating that people scoring high in Uncertainty Avoidance are more worried about the severe consequences of SARS-CoV-2 infection and rely on the vaccine than people scoring low in Uncertainty Avoidance. This is understandable because being vaccinated reduces the likelihood of adverse effects and, thus, reduces uncertainty. However, it is difficult to explain the positive correlation between Uncertainty Avoidance correlated with COVID-19 deaths and excess mortality since people with high Uncertainty Avoidance should welcome all measures  to reduce the likelihood of SARS-CoV-2 infection. Uncertainty Avoidance, however, had almost a zero correlation (r = − 0.02) with the Stringency Index.In addition to Individualism, also Uncertainty Avoidance has appeared to be an important factor in relation to COVID-19 deaths, although the findings have been somewhat conflicting. Reman and Medeiros (2021) found a positive relationship between Uncertainty Avoidance and COVID-19 deaths and infection rate. In Oey & Rahardjo (2021), Uncertainty Avoidance was negatively related to COVID-19 deaths. Hunyh (2020) reported that Uncertainty Avoidance predicted the lower proportion of people gathering in public such as retail and recreation, grocery and pharmacy, parks, transit stations, and workplaces. In our study, Uncertainty Avoidance correlated with COVID-19 deaths per 100,000 people  claim that the "combination of high individualism and indulgence leads the United States to selfishness and lack of concern for others' well-being" did not get support from the present study if we take the US as an example of high indulgence and Individualism since neither Individualism nor indulgence was positively related to COVID-19 mortality.The findings of the current study based on the pandemic situation in July 2021 differed drastically from the earlier studies based on 2020 data. This underlines the nature of the COVID-19 pandemic and maybe of all pandemics in the past (Spanish flu in 1918) and in future. Meng studied the spread of the COVID-19 pandemic in G20 countries and found that the cases and deaths related to the COVID-19 pandemic had a nonlinear nature and convergence . This meAnother important question is how the underlying socio-economic, cultural, and population-related factors can be considered in battling against future pandemics. While the socio-economic and cultural factors might not be directly linked to pandemic mortality or infection rates, they can give important information for planning campaigns and interventions for changing attitudes. Since many of the countermeasures such as obligatory face mask use, social distancing and lockdowns, and vaccination intake are based on people’s readiness to accept and apply measures introduced by the health authorities, information campaigns should be designed according to the target population. In countries scoring high on individualism, for example, the messages should focus on individuals’ own vulnerabilities and benefits, while in collectivistic countries, the focus should be on an individual’s responsibility for others, i.e., family and the local community. Similarly, cultures scoring high on Uncertainty Avoidance may be more prone to conspiracy theories and less likely to trust governmental information. In this case, health campaigns could mainly focus on the trustworthiness of the information provided . These are just a few examples of how the present study's findings and future studies about culture and socio-economic factors in health behaviour can be used in future pandemics.The present study results somewhat differed from the earlier findings: Individualism was not related to COVID-19 deaths but instead was related to the low impact of the pandemic. Uncertainty Avoidance correlated with COVID-19 deaths, whereas Uncertainty Avoidance and Power Distance correlated significantly with excess mortality. In addition, countries with Long-Term Orientation were less impacted by the pandemic. In addition to these results about cultural dimensions and COVID-19 indexes, this study has other even more important messages. First, the COVID-19 pandemic reached different countries and regions at different times, which is clearly reflected in the results. The final conclusion about the role of socio-economic and cultural factors in managing the COVID-19 pandemic can be drawn only after the pandemic, not during the pandemic. Second, cultural dimensions were related to COVID-19 measures only when socio-economic indicators were not considered but lost their significance when socio-economic variables were entered into the models. This can mean that cultural dimensions influence the outcome variables via socio-economic and political factors. Further studies are needed to describe how the effects of the socio-economic and population factors mediate the effects of cultural values on the outcomes of the pandemic. Third, earlier studies have focused mainly on COVID-19 deaths. The present study shows that the impact of the COVID-19 pandemic is a complex phenomenon and cannot be reduced to the death rate. Other outcome variables such as excess mortality as well as the impact on the economy and citizens' freedom should be taken into account.


Childhood undernutrition is a major public health concern that needs special attention to achieve 2025 global nutrition targets. Moderate acute malnutrition (MAM), manifest as wasting (low weight-for-height), affects 33 million children under 5, yet there are currently no global guidelines for its treatment. We recently performed a randomized-controlled clinical study of a microbiota-directed complementary food formulation (MDCF-2) in 12-18-month-old Bangladeshi children with MAM. The results revealed that MDCF-2, freshly prepared each day, produced a significantly greater improvement in ponderal growth than a standard ready-to-use supplementary food (RUSF), an effect that is associated with repair of the disrupted gut microbial community development that occurs in children with MAM. To test the generalizability of these results in acutely malnourished children at other sites, there is a pressing need for a packaged, shelf-stable, organoleptically-acceptable formulation that is bioequivalent to MDCF-2. This report describes the protocol for a clinical study to evaluate candidate formulations designed to meet these criteria.A randomized single-blind study will be conducted in 8-12-month-old Bangladeshi children with MAM to compare the efficacy of alternative shelf-stable MDCF prototypes versus the current MDCF-2 formulation that is produced fresh each day. V4-16S rDNA amplicon and shotgun sequencing datasets will be generated from faecal DNA samples collected from each child enrolled in each group prior to, during, and after treatment to determine the abundances of MDCF-2-responsive bacterial taxa. Efficacy will be assessed by quantifying the change in representation of MDCF-2-responsive gut bacterial taxa after 4-weeks of treatment with freshly prepared MDCF-2 compared to their changes in abundance after treatment with the prototype MDCFs. Equivalence will be defined as the absence of a statistically significant difference, after 4-weeks of treatment, in the representation of faecal bacterial taxa associated with the response to MDCF-2 in participants receiving a test MDCF.This trial aims to establish acceptability and equivalence with respect to microbiota repair, of scalable, shelf-stable formulations of MDCF-2 in 8-12-month-old Bangladeshi children with moderate acute malnutrition.ClinicalTrials.gov (NCT05094024). The trial has been registered before starting enrolment on 23 October 2021. Worldwide, 47 million children under 5-years-of-age are acutely malnourished (wasted), while 149 million are short for their age (stunted) . In BangOur recent work in undernourished Bangladeshi children has focused on the contribution of the gut microbiota to their nutritional status. Using culture-independent methods to analyze serially collected faecal samples collected from healthy children and from those with MAM, we found that MAM is associated with impaired microbiota development (microbiota ‘immaturity’) , 8. We sWe subsequently performed a larger, longer proof-of-concept (POC) study to compare the effects of MDCF-2 and RUSF on the growth of 12-18-month old children with MAM. Despite its lower caloric density , children who received MDCF-2 exhibited a significantly faster rate of weight gain during the 3-month period of intervention compared to those consuming RUSF. This improvement was associated with an increase in the abundance of the underrepresented bacterial taxa that MDCF-2 was designed to promote .Both the pre-POC and POC studies described above used a formulation of MDCF-2 that was prepared fresh each day at icddr,b facilities. The objective of the current study is to test industrially manufactured, packaged, shelf-stable formulations of MDCF that would greatly facilitate the expansion of tests of its efficacy to other sites/populations. These studies require development of a uniform formulation that satisfies the following criteria: (i) biological activity equivalent to the current freshly prepared formulation of MDCF-2; (ii) shelf-stable, free of microbial contamination, with satisfactory organoleptic properties; (iii) conforms to existing WHO/UNICEF specifications for a nutritional intervention for treating MAM; (iv) can be produced at scale using ingredients from sustainable sources at an affordable price with the potential for distribution across national boundaries. Here, we present the research protocol for a pre-POC study of candidate shelf-stable MDCF prototypes in Mirpur area of Dhaka city, Bangladesh.The primary goal of the trial is to compare the efficacy of a shelf-stable formulation of MDCF-2 with that of freshly prepared MDCF-2 and assess its organoleptic acceptability. We will also test the extent to which alternative MDCF formulations are able to repair the gut microbiota of children with MAM compared to the repair produced by the current MDCF-2 formulation.Figure It will be conducted in three phases. The first 2 weeks after enrolment are a ‘run-in’ phase where children are followed on their normal diets, without nutritional intervention. During this phase, collection of fecal samples will allow the baseline configuration of their microbiota to be characterized prior to treatment. Subsequently, participants will be randomized to receive one of the food prototypes, administered under supervision, twice daily for 4 weeks. Fecal samples collected at the end of the intervention phase will be used to assess the extent of microbiota repair produced by each treatment. After completion of the intervention, each child will be followed for another 2 weeks. Fecal samples collected during this phase will be used to assess the durability of the microbiota repair. Blood samples will be collected at baseline and at the end of the treatment phase to quantify levels of plasma protein biomarkers/effectors of healthy growth .Eligible participants are 8-12-month-old Bangladeshi children with MAM. The study will be conducted among members of the slum population in Baoniabad of Mirpur, one of the 21 administrative units of the nation’s capital, Dhaka. Mirpur was selected because it is inhabited by poor and lower middle-class families, and because residential and sanitary conditions are typical of congested urban settlements. Additionally, the investigators have established several field sites in this area and have ongoing research activities in the community.A trained Field Research Assistant (FRA) will explain the study design and methodology in detail, describe potential risks and benefits, answer any questions from the parent(s), and invite the parent(s) to enroll their child in the study. If the parent(s) are interested, they will proceed to screening and consenting. Eligibility will be determined based on the inclusion and exclusion criteria listed in Table If a subject is eligible to participate, the consent process will consist of a thorough review of the written consent form in a manner appropriate for the parents’ literacy level. Prior to parental signing of the consent form, the child will undergo thorough clinical examination by study physician. In addition, there may be a recommendation that a child undergo laboratory tests to exclude any organic diseases or any other causes of secondary malnutrition. During this period, parents of the participants will have an opportunity to ask any questions about the study. If the FRA determines that participants have demonstrated adequate comprehension of the study, the consent form will be signed by the FRA and the child’s parent(s). If the parent(s) are not sufficiently literate to read and/or sign the consent form, consenting and a thumbprint signature will be obtained in the presence of a witness who is not associated with the study. The child’s parent(s) will be provided with a copy of the signed consent form.At the beginning of the study, information will be collected on the demographic characteristics of the participants . FRAs will collect anthropometry data by recording the child's weight using a digital scale with 2g precision , length (Seca model 416 infantometer), and mid-upper arm circumference (MUAC) to the nearest millimeter (using a non-stretch tape). Z scores will be calculated using the new child growth standards of the World Health Organization . CollectArm 1 - Reference control: kitchen-prepared MDCF-2Arm 2 - Individually packaged, pre-measured sachets of MDCF-2 ingredients, combined and reconstituted in the home setting prior to consumptionArm 3 - MDCF-2 shelf-stable foil pouch formulation with green banana powderArm 4 - MDCF shelf-stable foil pouch formulation with sweet potato instead of green bananaArm 5 - Ready-to-use supplementary food (RUSF)The trial will have 5-arms designed to compare the efficacy of alternative MDCF formulations in repairing the gut microbiota of children with MAM compared to the repair produced by the current kitchen prepared MDCF-2 formulation. All the formulations are fortified with equal amount of vitamins and minerals. Children will be randomly assigned to one of the interventions after enrolment.Table Formulations in arm 1 and arm 2 will be prepared in a kitchen setting. For the rest of the arms, test products will be manufactured in an industrial setting. Each child will receive 250 kcal per day of their assigned formulation. Due to differences in caloric density of the prototypes, the weight per serving of each formulation will be adjusted to ensure equivalent energy provision , neopterin , calprotectin , lipocalin-2 , dual oxidase 2 ] and protein losing enteropathy [alpha-1-antitrypsin ]. These proteins will be measured using commercially available ELISA according to the kit manuals. Changes in oxidation-reduction potential and pH of fecal samples will be quantified using a redox meter  and pH meter , respectively. In addition, changes in the abundances of 7000 circulating plasma proteins that include biomarkers and mediators of various facets of host physiology will be quantified using the SomaScan-aptamer-based proteomics platform .11 In that study, we identified 209 bacterial Amplicon Sequence Variants (ASVs) that were present above 5 counts in at least 5% of the 939 faecal samples analyzed from 118 participants. We calculated 95% confidence intervals  for the change (delta) in abundance of each of the 209 ASVs between day 0 (pre-intervention) and 4 weeks of intervention for the 59 children in the MDCF-2 treatment group of the POC study. Using a bootstrapping approach with ASV data from 5000 subsets of 20 children from the MDCF-2 group and 5000 subsets of 20 children from the RUSF group, we identified 121 ASVs whose mean changes in abundance for the MDCF-2 subsets fell within the 95% CI of the mean changes for the 59 MDCF-2 participants, but not in children who had received RUSF, with 80% power (“MDCF-2-responsive ASVs”). Therefore, each arm will include a minimum of 20 children who complete the study. Considering potential drop-outs (15%), 23 children will be recruited per arm.The sample size was informed by the faecal 16S rRNA gene amplicon datasets generated for the proof-of-concept study of 12 to 18-month-old Bangladeshi children with MAM.All biological samples (blood and faeces) will be collected according to the standard operating procedures (SOPs) described in our previous publications . Five mioC freezer prior to analysis. No additives, preservatives or media will be added to the faecal samples.Faecal samples will be collected weekly during the run-in, treatment and wash-out phases of the study. At the site of collection, samples will be aliquoted into sterile, pre-labelled 2 mL cryovials and immediately placed into pre-charged liquid nitrogen dry cryo-shippers  for transport back to the laboratory. At the laboratory, vials will be placed on dry ice while they are organized and subsequently transferred to 9x9 freezer boxes. These boxes will be maintained in a -80To assess the comparability of microbiota repair elicited by shelf-stable test formulations of MDCF-2 and the reference kitchen prepared formulation, we will sequence PCR amplicons generated from variable region 4 of bacterial 16S rRNA genes present in DNA isolated from faecal samples collected from participants in the different study arms immediately prior to intervention (day 0) and at the end of intervention (day 28). ASV data will be processed using DADA2  and filtExploratory outcomes will include the effects of the test formulations on features of the plasma and faecal proteomes, including MDCF-2-responsive proteins that are associated with various facets of healthy growth using approaches described in the MDCF-2 POC study .Enrolment for the study began on 31 October 2021. We are currently recruiting study participants. The enrolment is expected to be completed by 31 December 2022.Privacy, anonymity and confidentiality of data will be strictly maintained. All trial related information will be kept confidential and stored securely at the central office in icddr,b. Codes will be used to depersonalise the data. The linking code, electronic data files and paper forms are stored in a separate location under password protections or lock and key. Access to the data will be restricted to the investigators.The current version of MDCF-2 is freshly prepared in local kitchens on a daily basis and distributed locally on the same day without sterilization. Given the need to identify a bioequivalent formulation that can be produced at scale and distributed to other geographic locales, we have designed this study of children with MAM to test alternative shelf-stable prototypes of MDCF-2 that each provide ~250 kcal/day, plus 70% RDA of key micronutrients. Outcomes will include the organoleptic acceptability of the prototypes and their effects on microbiota repair over 4-weeks of intervention. Our goal is to identify a packaged, shelf-stable formulation for advancing into larger, longer proof-of-concept studies that evaluate efficacy using clinically-relevant growth outcomes. One weakness of this study is that it is not possible to attain full blinding since the test prototypes are not packaged in a similar manner.In conclusion, this study aims to establish the acceptability of a scalable, shelf-stable formulation that is bioequivalent to MDCF-2 with respect to microbiota repair in 8-12-month-old Bangladeshi children with moderate acute malnutrition. The results of this study will inform the selection of a shelf-stable formulation of its efficacy for treating of moderate acute malnutrition.


Diabetes management requires ongoing monitoring of diabetes care from primary care, specialist care and laboratory testing. COVID-19 led to changes in access to in-person care. The purpose of this research was to assess changes in the management of diabetes during the COVID-19 pandemic using population-linked datasets and population segmentation.We identified over 1.4 Million Ontarians with diabetes (approximately 10% of the population) with valid health insurance as of April 1, 2019 and April 1, 2020. We measured 11 indicators of diabetes management including laboratory testing for HbA1c and LDL (highlighted in this abstract). With screening indicators, we examined changes in the proportion of the population up-to-date with screening at the end of each fiscal year  overall and according to population segments created using linked health data from primary care, home care, long term care and hospitals.Overall screening rates that required laboratory testing for HbA1c and LDL fell substantially from 54% to 40% and 68% to 59% overall. Comparing across population segments, residents in Long Term Care facilities had the smallest changes in screening rates; individuals with low, medium and high complexity chronic conditions and end-of-life conditions had the largest changes; maternity, cancer, mental health and frail populations were in the middle. Differences according the primary care enrolment models (capitation vs fee-for-service) were relatively minor but patients who were not rostered to a primary care physician had the largest reductions in laboratory screening. Results for all 11 indicators will be shared in the presentation.COVID-19 was associated with substantial reductions in laboratory-based diabetes screening. Poor diabetes management is one of the strongest risk-factors for adverse outcomes in COVID-19. Rates of diabetes management declined most for at risk patient populations amplifying the need to differentially connect with patients to ensure ongoing care during the pandemic.


The rapid spread of the SARS-Cov-2 virus, the increase in the number of patients with severe COVID-19, and the high mortality rate created the basis for the production of safe and effective vaccines. Studies have confirmed the increased risk of severe Covid-19 disease and mortality in cancer patients. It is logical that cancer patients should be the first to receive the primary vaccination and the booster vaccine for Covid-19. Since studies related to cancer patients and the effectiveness of existing Covid-19 vaccines have not been widely conducted, there are significant uncertainties about the effectiveness of the vaccine and the level of humoral and cellular immune responses in these patients. As a result, the possible risks and side effects of existing vaccines are not clear for patients with different cancers who are undergoing special treatments. In this study, we will discuss the effectiveness and safety of existing vaccines on cancer patients. In addition, we highlight factors that could affect the effectiveness of vaccines in these patients and finally discuss opportunities and challenges related to vaccination in cancer patients. Coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) . Cancer Among all cancer patients, patients who have received stem cells, patients with blood-related malignancies, and patients with lung cancer are at higher risk –12. OverCancer patients must go to medical centers to follow the treatment process, and they are more exposed to SARS-CoV-2 infection, so they are susceptible to contracting COVID-19. Also other treatments, such as gene therapy, radiotherapy, and chemotherapy used to treat cancer patients , often sPatients with hematologic malignancies are susceptible to COVID-19 due to dysfunction of the humoral and cellular immune systems, cytotoxic chemotherapy, and old age , 15. StuThe type of cancer, the time of diagnosis, the stage of cancer, and the type of treatment are factors that play an important role in increasing the risk of severe COVID-19 in patients with blood malignancies. The most common malignancies were acute myeloid leukemia (AML), (33%), non-Hodgkin’s lymphoma 27%), and myeloma or amyloidosis (16%) . There w%, and myOn the other hand, the fear of contracting Covid-19 can reduce the number of cancer patients who go to the relevant centers for treatment and cause irreparable damage to the patients . AdminisIn patients with Covid-19 without cancer, the symptoms subside within 7-14 days. But for patients with solid tumors (one month), hematologic malignancies (about 2 months), and patients with hematologic malignancies who have had stem cell transplants, it takes more than 60 days for recovery , 39. ThiThe immune status of solid tumor cancer patients after primary vaccination is dynamic and not all of them show an adequate immune response. Therefore a third booster dose seems necessary for insufficient responders . A thirdThe importance of the risk of severe COVID-19 in cancer patients should not be underestimated. However, some cancer patients have mild symptoms of COVID-19, so worrying and stressing in these patients does not seem like a good idea. A married couple with symptoms of Covid-19 was admitted to the emergency room at the same time. The woman recently underwent fulvestrant and abemaciclib chemotherapy for recurrent breast cancer. The husband was healthy but had a history of high blood pressure. Both Covid-19 patients received similar treatment. The woman left the hospital on the sixth day despite suffering from a benign immunodeficiency. In contrast, her husband recovered slowly and needed intensive care . Based oHumoral and cellular immunity protects the host body against viral infections . In humoLive vaccines are made using a weak form of a virus or a virus that has lost its ability to reproduce. The safety created by live vaccines is usually long-lasting, and only one dose can cause strong immunity. However, they are associated with a higher risk of developing symptomatic disease, especially in immunocompromised individuals , 52.Use physical or chemical methods to inactivate viruses in inactivated vaccines. Although inactivated vaccines do not cause infection, they do not induce severe cellular immunity, resulting in shorter immunity in the person using it . In addiThe SARS-CoV-2 passive vaccine, BBIBP-CorV, was administered in two doses two weeks apart and was well tolerated. Production of neutralizing antibodies to prevent covid-19 disease was induced after six weeks in vaccine recipients. In phase I/II trials, it did not cause any serious side effects, but had lower levels of neutralizing antibodies than recovering patients and low T cell responses . Zhang eViral carrier vaccines consist of a transmissible virus  with selected antigens from the target pathogen that are obtained by recombinant engineering. After inoculation, the engineered virus infects the host cells and leads to the expression of the virus antigen. These vaccines are very effective in promoting both humoral and cellular immunity, but their effectiveness can vary from person to person. Because most humans already have neutralizing antibodies against viral vectors, these antibodies can bind to the vectors and reduce the effectiveness of the vaccine, depending on the degree of binding. In addition, viral vectors can induce tumorigenesis in the user .ChAdOx1 nCoV-19 (AZD1222) is a recombinant chimpanzee adenovirus vector vaccine containing the SARS-CoV-2 protein. Random analysis of randomized and controlled trials was performed for this vaccine. The results showed in participants who received two standard doses, vaccine efficacy was 62.1% in the ChAdOx1 nCoV-19 group, and in participants who received a low dose followed by a standard dose, efficacy was 90.0%. In the vaccinated group, spike-specific T cell responses peaked on day 14. Anti-spike IgG responses increased until day 28, and increased after the second dose. Age and dose received were two factors that changed the effectiveness of the vaccine from 62% to 90%. Side effects were somewhat balanced among the study groups. Only one case of transverse myelitis was observed following vaccination with AZD1222 , 58.Ad26.COV2.S is a recombinant vector vaccine that encodes the SARS-CoV-2 spike (s) protein. Single-dose inoculation is sufficient to treat severe disease . The traThe best way to deal with emerging diseases such as SARS-CoV-2, which affects the world, is to expand vaccination. However, the vaccine must be produced in large quantities and more rapidly and be effective against the epidemic. Nucleic acid-based vaccines fall into two categories: DNA and RNA vaccines are a more promising choice because mRNA vaccines have the potential for rapid development with high efficacy and low cost . The firBNT162b2 and mRNA-1273 are two important COVID-19 mRNA vaccines that have been approved. The BNT162b2 vaccine is an mRNA-based vaccine that uses the entire SARS-CoV-2 spike protein. It is produced by Pfizer-BioNTech against COVID-19 . The resmRNA-1273 is an mRNA vaccine against Covid-19 developed by Moderna. This vaccine is protected by nanoparticles and produces neutralizing antibodies by producing a part of the SARS-CoV-2 protein. The vaccine was studied in animal models of non-human mammals. The results showed that the vaccine enhances the responses of Th1 helper T cells (type 1). However, T cell responses were undetectable . The firIn these vaccines, certain parts of the studied pathogen are used, such as proteins, sugars, and capsids in order to create a strong immune response. For SARS-CoV-2, the spike (s) protein, which is the major outer surface protein, may receive more attention because it plays a pivotal role in infiltrating host cells and can induce T-cells and antibodies . BecauseNVX-CoV2373 was evaluated for preclinical evaluation in mice and baboons. The results showed that in mice, low-dose NVX-CoV2373, combined with a saponin-based matrix-M adjuvant, produced antibodies that bound to the hACE2 receptor and blocked these receptors, protecting against SARS-CoV-2. It also produces T cells (CD4+ and CD8+), and B cells in the spleen. In baboons, low-dose levels of NVX-CoV2373 with Matrix-M were also highly immunogenic, and anti-S antibodies blocked the receptors. As a result, SARS-CoV-2 cannot penetrate host cells . The vacImmune system disorders and the use of immunosuppressive drugs are factors that weaken the immune system. These people are more susceptible to infectious diseases, especially COVID-19. They will have more severe consequences than COVID-19, including hospitalization and death. Even a reduction in the appropriate immune response to COVID-19 vaccination is to be expected in immunocompromised individuals compared with immunocompromised individuals.In some diseases with COVID-19, such as high blood pressure and diabetes, severe disease outcomes and mortality increase . In typeMultiple sclerosis (MS) is a chronic disease of the central nervous system (CNS) that causes the destruction of nerve cells by autoimmune reactions in CNS tissues . VariousDMTs used to treat MS patients affect immune responses. However, the effect of DMT on COVID-19 in patients with MS is not well understood. The results of the studies are contradictory. One study found that the use of DMT in MS patients did not increase the risk of COVID-19 . In anotImmunosuppression and the use of systemic therapy to treat cancer can have severe consequences for COVID-19 in cancer patients. Although extensive vaccination programs have been considered to reduce the severe symptoms of SARS-CoV-2 infection, concerns about the use of current vaccines in cancer patients are evident. These concerns are more pronounced in patients with blood malignancies than in those with solid cancers due to specific conditions. For patients diagnosed with hematologic malignancy in the last 5 years, an increased risk of death of at least 2.5-fold and for other cancers at least 1.2-fold has been observed . TherefoCytotoxic chemotherapies seal the cell cycle by interfering with DNA synthesis. Lymphocytes proliferate more rapidly in the presence of antigens, so these treatments suppress their proliferation . HoweverTreatment with Immune checkpoint inhibitors increases the number of active CD8+ T cells that have the antiviral ability . ActivatCheckpoint inhibitors pose a risk of safety-related side effects (IRAEs) depending on the type of treatment . TherefoA 52-year-old woman was receiving immunotherapy 10 days after receiving the first dose of the Pfizer-BioNTech COVID-19 vaccine and was HBV positive. Because both immune checkpoint inhibitors and Covid-19 vaccines stimulate an immune response, an increased incidence of a wide range of complications can occur . CytokinSo et al. Studies were performed on cancer patients undergoing anti-cancer treatment during vaccination. Of the total patients, 94.9% had solid malignancy and 88.5% were receiving anti-cancer treatment during vaccination. Three patients undergoing immunotherapy showed new side effects, including worsening of pre-existing grade 1 pruritus, grade 2 transaminitis, and grade 2 hypocortisolism. Patients receiving immunotherapy within 6 months of vaccination appear to be at a lower risk of developing any vaccine-related adverse events as well . Negative independent predictors of developing vaccine-related systemic adverse events include receiving chemotherapy within 28 days of vaccination  . InteresDuring the COVID-19 pandemic, limitations, including hospital beds, delayed non-urgent  surgeries. However, surgical strategies for cancer patients, including lung cancer, did not change. However, the challenge of assessing the risks and benefits of surgical delay based on the severity of the Covid-19 epidemic was evident. These interventions to determine the time of surgery after Quid-19 are associated with a mortality rate above 10% to 24% for all surgeries , 110. InCOVID-19 vaccines have shown very promising results. BNT162b2 and mRNA-1273 mRNA vaccines are safe and very effective. However, delaying general vaccination and waiting for them to be scheduled for vaccination may reduce a person’s motivation to get vaccinated. One of the obstacles to a successful vaccination program is public reluctance to vaccinate due to misconceptions and various concerns about vaccine safety and efficacy. Vaccines intended for general vaccination must be able to induce an adequate response to infection even in immunocompromised individuals. A very important point to note is that once a drug has shown its appropriate effects in the general population, should also the safety and efficacy of the drug in susceptible populations be investigated. These vulnerable populations can include patients with chronic diseases or patients with weakened immune systems. Finite data have been obtained from trials on the safety and efficacy of existing vaccines for critically ill cancer patients undergoing treatment. Because cancer patients who were treated with immunosuppressive drugs during the previous 25 weeks were excluded from the study, and this study limitation has made many information unavailable.Although the covid-19 vaccines cannot produce proper effects in patients with malignancies, the results are much more effective after receiving a booster dose. There are very few studies that determine the effectiveness and safety of existing vaccines in cancer patients. Additionally, there are no data in active cancer patients or patients receiving active treatment. Determining the time interval to receive the vaccine requires consideration of the type of treatment for cancer, the risk of progressive cancer, the risk of COVID-19, the state of the disease and co-morbidities –114. HowExtensive global efforts to produce Covid-19 vaccines have been able to reduce Covid-19 mortality. The protective nature of the available vaccines is the production of neutralizing antibodies that make the vaccinated person immune to the SARS-CoV-2 virus, however, the production of neutralizing antibodies in cancer patients is lower than in healthy individuals. It is gratifying that a high percentage of patients with solid tumors developed humoral and cellular immunity after vaccination. However, factors such as chemotherapy can suppress immune responses. But choosing the best possible time to vaccinate cancer patients who are undergoing treatment can reduce this limitation. Although Covid-19 vaccines are not significantly effective in patients with malignancies due to limited immune responses (the nature of the disease and the use of treatments that reduce B cells), beneficial results were looked in some of these patients after booster doses. Therefore extensive studies with a large statistical population in cancer patients, especially leukemia patients, can shed light on many unknowns.ATJ and ZHA contributed to conception and design of the study. AK and GAW organized the database. ZHA and HKHO wrote the first draft of the manuscript. ATJ, SAA, ASH, and TRA wrote sections of the manuscript. All authors contributed to manuscript revision, read, and approved the submitted version.This study was financially and morally supported by the Al-Mustaqbal University College, Babylon, Hilla, 51001, Iraq.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


MOGAD-transverse myelitis is a rare disorder in children and adults, but with a higher incidence in pediatric patients. We report a case of MOGAD-transverse myelitis in a boy who was admitted to hospital with bilateral motor deficit of the lower limbs associated with the impossibility of defecating and urinating. The symptoms progressively developed with severe fatigue within the week prior to admission, with the impossibility to stand occurring 36 h before admission. The anamnesis found that he was vaccinated for COVID-19 approximately 6 weeks before admission to our clinic. The laboratory tests revealed a normal complete cellular blood count, without any signs of inflammation or infection, except for both cryoglobulins and IgG anti-MOG antibodies. MRI showed a T2 hypersignal on vertebral segments C2-C5, Th2-Th5 and Th7-Th11, confirming the diagnosis of longitudinally extensive transverse myelitis. The patient received intravenous high-dose methylprednisolone (1 g) for 5 days, associated with prophylactic antibiotic treatment, subcutaneous low-molecular-weight heparin and other supportive treatment. The patient was discharged on the 12th day of admission, able to walk without support and with no bladder or bowel dysfunction. We can conclude that an early diagnosis was essential for improving the patient’s long-term outcome. The myelin oligodendrocyte glycoprotein (MOG) is produced by the myelin-forming cells of the central nervous system (CNS), and it was first discovered in the late 1970s . This prThe demyelinating spectrum of disorders triggered by MOG-abs includes transverse myelitis (TM) and longitudinally extensive transverse myelitis (LETM), but also acute disseminated encephalomyelitis (ADEM), brainstem or cortical encephalitis, and unilateral/bilateral optic neuritis (ON), recently referred to as MOG-antibody disease (MOGAD). In spite of its rarity, the prevalence of MOGAD was reported to be higher in pediatric patients, accounting for 40% of the cases when compared to mixed cohorts, while adult samples accounted for 29% of cases with a 22% prevalence . These fBased on the paucity of MOGAD cases, there are no evidence-based treatment guidelines for patients with MOGAD, but similar treatment options as in multiple sclerosis and neuromyelitis optica spectrum have been attempted so far in this group of patients. The election therapy for the acute attacks involves high-dose intravenous methylprednisolone (0.5–2 g for 5–10 days), but other therapeutic options include plasma exchange and intravenous immunoglobulin in patients with more severe attacks or those who are unresponsive to steroids [We describe a case of MOGAD-transverse myelitis in a male teenager in order to highlight the importance of urgent diagnosis and treatment to improve the patient’s outcome. Informed consent from the patient’s mother was obtained prior to the publication of this case.We present the case of a 15-year-old male teenager admitted to our clinic for bilateral motor deficit of the lower limbs associated with the impossibility to defecate for 48 h prior to admission and to urinate for approximately 10 hours. The symptoms developed progressively with severe fatigue within the last week and the impossibility to stand occurring approximately 36 hours before admission. The anamnesis found that he was vaccinated for COVID-19 approximately 6 weeks before admission to our clinic, but without any signs of infection prior to the onset of these symptoms. The clinical exam on admission found motor and sensorial deficits of the lower limbs associated with bladder and bowel disfunction. The neurological exam was performed in dorsal decubitus while the patient was conscious, oriented in time and space regarding his own person, but he could not sit or stand. The patient did not present any signs of meningeal or cranial nerves impairment. The examination of the upper limbs revealed no impairment of the tonus or muscular strength, with equal and symmetrical reflexes, while the examination of the lower limbs found severe and symmetric motor deficits, with bilateral hypotonia, exacerbated reflexes, and the presence of Babinski signs. The cutaneous abdominal reflexes were absent, and the patient presented with a retention-type impairment of vesical and anal sphincters. The neurological exam of the spine was normal. The patient weighed 62 kg. The routine laboratory tests performed on the first day of admission found a normal and complete cellular blood count without any signs of inflammation or infection. The liver and kidney function parameters were within normal limits. Moreover, the creatin kinase and lactate dehydrogenase levels were normal. The serology for Ebstein Barr, Toxoplasma, Rubella, Cytomegalovirus, Herpes virus 1 and 2, as well as Borellia spp was negative. The antibodies for Hepatitis C and the antigen HBs were also negative. Other tests revealed no deficits of vitamin B9, B12 or D. The cranial computed tomography on the day of admission found no pathological findings. We performed a cranial and lumbar MRI, which showed a T2 hypersignal on vertebral segments C2-C5, Th2-Th5 and Th7-Th11, confirming the diagnosis of longitudinally extensive transverse myelitis .We performed a lumbar puncture, but the cytology exam of the spinal fluid was normal with no biochemical signs of infection and a negative culture. Other tests from the spinal fluid, such as oligoclonal bands and albumin, were negative, except for the IgG level, which was mildly positive: 48 mg/L . All serological tests that were performed to rule out the causes of autoimmune disorders—anti-aquaporin 4 antibodies, antinuclear antibodies, anti-DNA antibodies, anti-cardiolipin, citrullinate citric peptide, immune circulating complexes, C3 and C4 fractions of the complement, lupus anticoagulant, and IgM anti-phospholipids antibodies—were either negative or within normal limits, except for cryoglobulins, which were positive. Moreover, the IgG anti-MOG antibodies were positive, 1:60 . Therefore, we established the diagnosis of MOGAD-longitudinally extensive transverse myelitis of the cervical and thoracal spinal cord.We initiated high-dose methylprednisolone (1 g) intravenously for 5 days, which was associated with prophylactic antibiotic treatment according to an infectious diseases specialist, subcutaneous low-molecular-weight heparin, considering the immobilization and other supportive treatments, such as crystalloid solutions and vitamins. We also inserted a bladder catheter immediately after admission and performed an enema each day to relieve bladder and bowel dysfunctions. The motor and sensorial deficits improved after approximately 3 days of treatment, and the patient was able to stand on the fifth day of admission. Thus, we gradually tapered the steroids dose and removed the urinary catheter. The patient was discharged on the 12th day of admission being able to walk without support and with no bladder or bowel dysfunction.We repeated the MOG-abs after approximately 3 months, and they remained positive, albeit with a mild decrease (1:40). We also performed a control MRI that revealed the minimum hypersignal of the C3-C5 segments . The cliMOGADs have a low incidence of approximately 1.1–2.4/million people . The incA recent retrospective study included 54 patients with MOGAD-transverse myelitis, among which 16 (30%) were children with isolated TM (54%) or TM combined with ADEM or ON . PatientThe diagnosis of TM or LTEM should be suspected in cases presenting with the above-mentioned clinical picture and positive MRI signs, such as hyperintense ‘H-sign’ in the axial orientation associated with a narrow vertical line in the T2-weighed sagittal plane image. This suggests a major impairment of grey matter within the spinal cord in comparison to AQP4-positive TM, which might not appear as centrally located in the spinal cord ,35. NeveConsidering that MOGAD is a relatively recent and rare disease, with age-dependent differences in terms of onset symptoms, no evidence-based guidelines are available regarding acute and maintenance immunotherapy since large treatment trials have not yet been performed. Nevertheless, the studies reported so far in patients with MOGAD used similar therapeutic approaches to multiple sclerosis and NMOSD, with high-dose intravenous methylprednisolone for the management of acute exacerbations showing a high effectiveness with complete recovery in more than 50% of the subjects with ON, brainstem and cortical encephalitis ,36,37. OAs far as we know this is the first case of MOGAD-TM in a pediatric patient following COVID-19 vaccination, which might be considered the most likely trigger for our patient.MOGAD-transverse myelitis is generally a rare disorder in both children and adults, but it has a higher incidence in pediatric patients. Its early diagnosis is essential for improving a patient’s long-term outcome. Patients diagnosed with MOGAD should be closely monitored to ensure prompt treatment in the case of future relapses.


Boosted individuals reported motivators tied to efficacy and altruism, whereas non-boosted individuals reported motivators tied to efficacy and safety. Results suggest that messaging will require careful tailoring to address the identified behavioral motivators among non-boosted individuals who emphasize safety and efficacy of additional vaccine doses.Studies have shown that the protection afforded by COVID-19 vaccines against hospitalization and death decreases slowly over time due to the emergence of new variants and waning immunity. Accordingly, booster doses remain critical to minimizing the health impacts of the pandemic. This study examined the prevalence rate, sociodemographic determinants, and motivators of getting a COVID-19 booster vaccine within the Canadian population. We recruited a representative sample of 3001 Canadians aged 18+ years as part of the iCARE study using an online polling form between 20 January and 2 February 2022. Participants self-reported their booster status and were dichotomized into two groups: those who did vs. did not receive at least one booster dose. A total of 67% of participants received a booster dose. Chi-square analyses revealed that older age ( The early stages of the COVID-19 pandemic focused on reducing infection through the implementation of preventive behaviours and development of therapies and vaccines, which became available at the end of 2020 ,4,5. In The success of COVID-19 booster immunization programs is dependent on the population’s willingness to receive the booster dose. Vaccine hesitancy is a major barrier to vaccine uptake, which is important for reducing the risk of disease-related morbidity and mortality, and to protect the most vulnerable in our population. Vaccine hesitancy, defined as the refusal or delayed acceptance of vaccination, was reported as one of the top ten threats to global health by the WHO ,8,9. As Few studies have examined the prevalence, sociodemographic determinants, and motivators associated with getting the COVID-19 booster vaccine across the world. A cross-sectional study in Jordan reported that uptake of booster doses included perceived side effects of the COVID-19 vaccine, perceived severity of COVID-19, and being at high-risk of developing COVID-19 complications . Anotherhttps://www.icarestudy.com, accessed on 28 December 2022) lead by members of the Montreal Behavioural Medicine Centre . This international, cross-sectional, multi-wave observational study aims to examine public awareness, attitudes, and responses to COVID-19 public health policies through a series of online surveys. The study protocol and detailed methods have been published elsewhere [This study represents a sub-analysis of the International COVID-19 Awareness and Responses Evaluation (iCARE) Study . This panel includes over 400,000 Canadians, the majority of which (60%) were recruited within the past 10 years. Two thirds of the panel were recruited randomly by telephone, with the remainder recruited via publicity and social media. Using data from Statistics Canada, the data were weighted within each province according to the sex and age of the respondents to make their profiles representative of the current population within each Canadian province (excluding the three territories). The weight of each province was further adjusted to represent their actual weight within the 10 Canadian provinces.https://osf.io/nswcm/, accessed on 28 December 2022). For the present report, we analzyed the following variables: sociodemographics; COVID-19 booster status; and motivators for getting the booster or not. For more information on the list of measures available in the iCARE study, as well our data dictionaries, see https://osf.io/c5rux, accessed on 28 December 2022.The survey includes approximately 75 questions and takes between 15–20 min to complete. The survey included questions about sociodemographics, physical and mental health, prior COVID-19 infection, general health behaviours, perceptions and attitudes about local COVID-19 prevention policies, concerns about the virus and its impacts, and vaccine attitudes, intentions, motivations, and behaviours. A detailed description and copy of all surveys can be found at the following weblink . In our analyses, participants were dichotomized into two groups: those who did vs. did not receive at least one booster dose. Motivators for getting a booster vaccine were also assessed by presenting participants with a list of 17 potential motivators (informed from the existing literature) ,16, usinAll analyses were weighted using data from Statistics Canada to approximate some degree of representativeness. Descriptive statistics were calculated to describe the sample in terms of sociodemographic characteristics. Bivariate analyses (chi-square tests) were conducted to examine the differences in sociodemographic characteristics (weighted proportions) as a function of getting the booster or not. The frequencies of participants who reported being motivated “to a great extent” for each motivator item was calculated as a function of getting the booster or not. Responses of ‘I don’t know/I prefer not to answer’ were treated as missing values.p < 0.05 being considered as statistically significant. Multivariate logistic regression was conducted to assess the association between having received a booster dose (independent variable) and motivators (dependent variable) while adjusting for covariates . All statistical tests were two-tailed and were performed using SAS version 9.4, with The total sample included 3001 individuals. Just over half the sample were women (52%), nearly half the sample were aged 51 and over (47%), and there was a high proportion who had an education level of high school or lower (73%). Of the sample, 67% received at least one booster dose. A summary of participant characteristics for the whole sample can be found in p < 0.001) and more likely to report being diagnosed with one or more chronic diseases . On the other hand, non-boosted individuals were more likely to report having a depressive  or anxiety  disorder, and were more likely to report being a parent  compared to boosted individuals. Finally, more non-boosted individuals reported being previously infected with COVID-19  compared to the boosted group.Sociodemographic characteristics presented as a function of booster vaccination status are presented in People who received a booster dose reported that the following were the most important motivators for their decision: (1) having information that the booster is effective (65%); (2) wanting to do their part to achieve “herd immunity” (65%); and (3) knowing that getting the booster would help protect others around them (70%). In comparison, people who had not received a booster reported that having information that the booster is: (1) effective (45%); (2) safe and unlikely to have any major long-term (44%); and (3) short-term (42%) side effects would motivate them to get vaccinated. The frequencies of motivators “to a great extent” as a function of booster vaccination status can be found in p > 0.1) were not significant motivators.A summary of the odds ratios for each motivator can be found in This study assessed the prevalence, sociodemographic determinants, and motivators of getting a COVID-19 booster vaccine in a large population sample of Canadians. Overall, 67% of our sample received a booster dose, which is slightly higher than previous reports . Being oThe COVID-19 pandemic has introduced an unprecedented level of stress related to uncertainty and safety concerns. Intolerance to uncertainty can increase anticipatory anxiety regarding a perceived threat , and peoWe also found that non-boosted individuals were more likely to be parents than boosted individuals. Early information about COVID-19 being a mild illness in children, low confidence in the vaccine, and concerns about the risks of side effects may have contributed to hesitancy among parents ,23,24.Non-boosted individuals were also more likely to report not having been previously infected with COVID-19, which may have reduced risk perceptions and the motivation to get boosted in this group. This is consistent with the Health Belief model which predicts that adopting certain health behaviours (such as vaccine uptake) depends on a person’s belief in a personal threat of an illness or disease .Both boosted and non-boosted individuals reported that the effectiveness of the booster was one of the most important motivators, which is consistent with previous reports ,13,26. IBoosters being safe and unlikely to have any major long-term or short-term side effects was reported by non-boosted individuals as their primary motivators for getting the booster, which is consistent with the previous literature . UnderstThe results of the present study should be interpreted in light of some limitations, including selection, response, and social desirability bias. However, this study also has some strengths. We collected data during a crucial period of vaccination: after broad public health campaigns and the arrival of vaccine passports, and the dramatic rise in COVID-19 cases due to the Omicron variant during the Christmas holidays. Additionally, we explored a range of motivators that point to several potential intervention targets for interventions. The results indicate that people who are younger and healthier are less likely to get COVID-19 booster doses. Boosted individuals reported motivators tied to efficacy and altruism, whereas non-boosted individuals reported motivators tied to efficacy and safety (lack of side effects). Given that newer variants have significantly reduced the altruistic benefits of vaccination, results suggest that messaging will require careful tailoring to address the identified behavioral motivators, especially in those who have not accepted a booster dose.