*Corresponding author
- Jindal Institute of Behavioral Sciences (JIBS), Jindal Global
Institution of Eminence Deemed to be University, Sonipat 131001, India
;
rama.jayaraj@jgu.edu.in
and Director of Clinical Sciences, Northern Territory Institute of
Research and Training, Darwin 0909, NT, Australia * Correspondence:
Prof Rama Jayaraj, Email:
jramamoorthi@gmail.com
- Department of Oral and Maxillofacial Surgery, College of Dental
Sciences Manipal, Manipal Academy of Higher Education, A Constituent
of MAHE, Mangalore, 575001, India;
sameep.shetty@manipal.edu
- Department of Biotechnology, College of Engineering & Technology,
Kattankulathur – Chennai, Tamil Nadu, India;
devia@srmist.edu.in
- Bharathiar Univ, Dept Biochem, Coimbatore, Tamil Nadu, India;
suja.s@buc.edu.in
- Dept Oral and Maxillofacial Surgery, Dr. D. Y. Patil Dental College
and Hospital, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune, Maharashtra,
Email:merchantyash@gmail.com
Excellent Clinical Research Approach and Adaptation of
Systematic Review Guidelines and Registrations: It is with interest
that we read the relevant systematic review and meta-analysis on the
impact of alcohol consumption on severity of COVID-19 infection.
We laud the efforts of the
authors to contribute to this global research output and provide myth
busting evidence on the contemporary issue. This study is of great
clinical and timely relevance, also adhered the guidelines of Preferred
Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).
Furthermore, it is also recommended that the Protocol OF A Systematic
Review and Meta-Analysis be registered in the International Prospective
Register of Systematic Reviews (PROSPERO) to identify any replication of
the study and act as guide for other similar studies. We would like to
take the opportunity to offer our perspective and constructive critique
in their analysis.
Alcohol and confounding factors (tobacco in the smoked or
smokeless form) : Patients partaking alcohol often smoke during drinking
and alcohol as a solvent has a synergistic and additive deleterious
effect. It is recommended to note that in the subset of patients
partaking alcohol whether
confounding factors like other
habits (tobacco in the smoked or smokeless form) and co-morbidities were
taken into consideration.
Contradicting findings of another impact of alcohol consumption
on COVID-19 severity: It is undisputed that moderate to heavy alcohol
consumption impairs immunity and has no benefits during a pandemic or
otherwise. However, a recent prospective study noted that COVID-19 risk
appears to vary across different alcoholic beverage subtypes, frequency,
and amount. Red wine, white wine, and champagne may reduce the risk of
COVID-19 when consumed in moderation and
occasionally1.
Attempts to inform clinical decision making and Future
directions: It is believed that the higher polyphenolic content of
these beverages enhanced plasma antioxidant activity and reduces the
level of low-density lipoprotein2. Authors of this
study strongly proposed that people do not drink alcohol during the
COVID-19 pandemic and attempts to inform clinical decision during this
crisis. Public health guidance should focus on reducing the risk of
COVID-19 by advocating healthy lifestyle habits and preferential
policies among consumers of beer and cider and spirits.
Conceptual Interpretation of Conclusions from Literature-Based
Meta-Analysis: We would like to recommend that conclusions by Wei and
colleagues should better reflect the indecision of a literature based
Systematic Review and Meta-Analysis. In this scenario, elaborating that
“Alcohol consumption intensifies COVID-19 severity and deteriorates its
clinical outcomes” should be potentially replaced by “alcohol
consumption are likely associated with COVID-19 severity and may be or
could be deteriorate its clinical outcomes.”
Publication bias of the included studies: Publication bias is a
corollary of the publication process. Small sample studies or negative
findings often fail to get published. Abiding the PRISMA, authors have
piloted the publication bias analysis using Egger’s test for continuous
variables but evaded other publication bias indicators in the manuscript
or as supplementary material, which could derail peer-appraisal of the
study (Figure 1). Therefore, a suggestion would be to inculcate Classic
Fail-Safe N, Orwin Fail-Safe N, Duval and Begg and Mazumdar’s rank
correlation test in such studies for comprehensive analysis of
publication bias indicators (Table 1).3,4 Although
this is the first systematic review and meta-analysis on Impact of
alcohol consumption on COVID-19 severity, not assessing the full scale
of publication bias leads to the findings being uncertain in term of
actual clinical utility.
Comparison of Heterogeneity with Hypothesis testing: A robust
statistical analysis can be interpreted with the addition of Tau- Square
in addition to Chi-Square and I-Square static (measures of statistical
heterogeneity). The authors have estimated the Z value, a test static
for the null hypothesis and to obtain the P- value, but fail to
compare the Heterogeneity with Hypothesis testing (Table 2). The ordered
heterogeneity test, that permits testing against simply ordered
alternative hypotheses in the context of almost any nondirectional
test5. Therefore, we recommend comparing the results
of all statistical syntheses including heterogeneity and hypothesis
testing of the included study, conducted according to PRISMA.
We feel that above points should be addressed. Given the current
relevance of this field to medical virology, it is important that this
study that feeds it is free of any possible reproach when under
scientific analysis.