Understanding health inequalities in Wales using the Blinder-Oaxaca decomposition method.

Background: Throughout Wales and the world, health inequality remains a problem that is interconnected with a wider and complex social, economic and environmental dynamic. Subsequently, action to tackle inequality in health needs to take place at a structural level, acknowledging the constraints affecting an individual's (or community's) capability and opportunity to enable change. While the 'social determinants of health' is an established concept, fully understanding the composition of the health gap is dependent on capturing the relative contributions of a myriad of social, economic and environmental factors within a quantitative analysis. Method: The decomposition analysis sought to explain the differences in the prevalence of these outcomes in groups stratified by their ability to save at least £10 a month, whether they were in material deprivation, and the presence of a limiting long-standing illness, disability of infirmity. Responses to over 4,200 questions within the National Survey for Wales (n = 46,189; 2016-17 to 2019-20) were considered for analysis. Variables were included based on (1) their alignment to a World Health Organization (WHO) health equity framework ("Health Equity Status Report initiative") and (2) their ability to allow for stratification of the survey sample into distinct groups where considerable gaps in health outcomes existed. A pooled Blinder-Oaxaca model was used to analyse inequalities in self-reported health (fair/poor health, low mental well-being and low life satisfaction) and were stratified by the variables relating to financial security, material deprivation and disability status. Results: The prevalence of fair/poor health was 75% higher in those who were financially insecure and 95% higher in those who are materially deprived. Decomposition of the outcome revealed that just under half of the health gap was "explained" i.e., 45.5% when stratifying by the respondent's ability to save and 46% when stratifying by material deprivation status. Further analysis of the explained component showed that "Social/Human Capital" and "Income Security/Social Protection" determinants accounted the most for disparities observed; it also showed that "Health Services" determinants accounted the least. These findings were consistent across the majority of scenarios modeled. Conclusion: The analysis not only quantified the significant health gaps that existed in the years leading up to the COVID-19 pandemic but it has also shown what determinants of health were most influential. Understanding the factors most closely associated with disparities in health is key in identifying policy levers to reduce health inequalities and improve the health and well-being across populations.

Teaching and incentives: Substitutes or complements?

Interventions to promote learning are often categorized into supply- and demand-side approaches. In a randomized experiment to promote learning about COVID-19 among Mozambican adults, we study the interaction between a supply and a demand intervention, respectively: teaching via targeted feedback, and providing financial incentives to learners. In theory, teaching and learner-incentives may be substitutes (crowding out one another) or complements (enhancing one another). Experts surveyed in advance predicted a high degree of substitutability between the two treatments. In contrast, we find substantially more complementarity than experts predicted. Combining teaching and incentive treatments raises COVID-19 knowledge test scores by 0.5 standard deviations, though the standalone teaching treatment is the most cost-effective. The complementarity between teaching and incentives persists in the longer run, over nine months post-treatment.

The public health impact of loneliness during the COVID-19 pandemic.

BACKGROUND: Social distancing measures have been effective in mitigating the spread of COVID-19; however, they have imposed a significant burden on population mental health and well-being. This study aimed to identify factors associated with loneliness during the COVID-19 pandemic, and to describe the relationship between loneliness and the risk of worsening health outcomes and behaviours. METHODS: Data for 8,960 adults were drawn from a national cross-sectional survey undertaken in Wales between January and June 2021. Participants self-reported changes to health and behaviour since the start of the pandemic. Logistic regression was used to identify factors associated with loneliness, and the impact of loneliness on self-reported changes in physical health, physical fitness, mental health, weight, alcohol consumption and social relations in comparison with pre-pandemic experiences. RESULTS: Groups most at risk of loneliness were those aged < 35 years, women (odds ratio [95% confidence interval]: 1.86 [1.70-2.05]), those with chronic health conditions (1.43 [1.29-1.58]) and the unemployed (2.18 [1.76-2.70]). Loneliness was a strong predictor of worsening health outcomes and behaviours, with those reporting often feeling lonely being at increased odds of worsening physical health (3.29 [2.80-3.86]), physical fitness (2.22 [1.90-2.60]), mental health (8.33 [6.95-9.99]), weight (1.39 [1.19-1.62]), alcohol consumption (1.37 [1.12,-1.66]) and social relations (2.45 [2.07-2.89]) during the pandemic. CONCLUSION: This study established an association between loneliness and self-reported worsening health during the pandemic, and identified factors increasing the risk of loneliness. The effect that social control measures have on loneliness should influence the design of future public health policy.

Evidence Based Scarce Resource Allocation During the COVID-19 Pandemic: A Case Study of Bamlanivimab Administration in the Emergency Department.

Background: Patients presenting for emergency department (ED) evaluation may be appropriate for treatment with monoclonal antibodies for mild to moderate COVID-19. While many sites have implemented infusion centers for these agents, EDs will continue to evaluate these patients where appropriate identification and efficient infusion of eligible patients is critical. Objectives: Patients receiving bamlanivimab in the EDs of an academic medical center are described. The primary objective was to describe operational metrics and secondary objectives reported clinical outcomes. Methods: Patients receiving bamlanivimab and discharged from the ED were included from November 16, 2020 to January 16, 2021 in the retrospective, observational cohort. Primary outcome was adherence to institutional criteria. Secondary outcomes included ED visit metrics, clinical characteristics, and return visits within 30 days. Risk factors for return visits were assessed with regression. Results: One hundred nineteen patients were included. Most (71%) were diagnosed with COVID-19 during the ED visit and median symptom duration was 3(IQR 2-5) days. Median number of risk factors for progression to severe disease was 2 (IQR 1-2). Thirty percent had a documented abnormal chest x-ray. Institutional criteria adherence was 99.2%. Median time from ED room to bamlanivimab was 4 (IQR 3.1-5.2) hours. Thirty patients had return visit within 30 days; 19 were COVID-19 related. Two multivariable regression models were analyzed for COVID-19 related return visit. Characteristics on ED presentation were considered in Model I: male gender (OR 3.01[0.97-9.31]), age (per 10 years) (OR 1.49[1.05-2.12]), African-American race (OR 3.46[1.09-11.06]), and symptom duration (per day) (OR 1.34[1.05-1.73]). Model II included labs and imaging acquired in ED. In Model II, age (per 10 years) (OR 1.52[1.07-2.16]) and abnormal CXR (OR 5.74[1.95-16.9]) were associated with COVID-19 related return visits. Conclusions: Administration of bamlanivimab to ED patients can be done efficiently, with the potential to reduce COVID-19 related return visits. Age and abnormal imaging were independent predictors of COVID-19 return visits.

Placing health equity at the heart of the COVID-19 recovery: data analysis from the first Welsh Health Equity Status Report initiative

Background The Welsh Health Equity Status Report initiative (WHESRi) applies an innovative WHO framework to map the wider impacts of COVID-19 on health equity. The framework is a mechanism to promote policy action and commitment for health equity and identifies five essential conditions needed to live a healthy life;namely, health services, income security, living conditions, social and human capital, and working conditions. We used the framework to assess the immediate health equity impacts of COVID-19 in Wales. Methods Ten relevant variables from Public Health Wales' public engagement survey on health and wellbeing during COVID-19 (captured April 3–July 25, 2020) were mapped to each of the five essential conditions, as defined by the European Health Equity Status Report initiative. Variables were chosen based on alignment to the essential conditions, research objectives and data quality. Estimated marginal means were disaggregated by sociodemographic factors on a nationally representative study sample ranging from 862 to 4747 participants (dependent on duration for which question was asked). Ethical approval was not required as per guidance from the National Health Service Health Research Association ethics decision tool. Findings The WHESRi framework allowed the assessment and quantification of the immediate impacts of COVID-19 on the wider determinants of health through the lens of the five essential conditions. For example, in relation to income security, a significantly higher proportion (181 [50·6%] of 358;p<0·05) of survey respondents aged 18–24 years reported being worried about losing their job, or not being able to find one, than any other age group. Of those respondents aged 18–24 years, 54·4% (p<0·05) of men (equivalent to 78 000) reported being worried, compared with 44·3% (p<0·05) of women (equivalent to 72 000), a difference of 10·1%. Interpretation Application of the WHESRi framework allowed us to draw a holistic picture of health and its determinants at the population level. This application has highlighted quantifiable differences in impacts between population groups, and encouraged the dialogue around policy action. A priority moving forward is to apply the framework to vulnerable population groups and population health priorities to assess the health equity impacts according to factors such as rurality, disability, and ethnicity. Our findings resulting from the application of this WHO framework can be used to enable an equitable and sustainable recovery from the pandemic;they form part of a European initiative for health equity and provide learning to other countries from Wales' role as an innovation site. Funding None.

Teaching and Incentives: Substitutes or Complements?

Interventions to promote learning are often categorized into supply- and demand-side approaches. In a randomized experiment to promote learning about COVID-19 among Mozambican adults, we study the interaction between a supply and a demand intervention, respectively: teaching, and providing financial incentives to learners. In theory, teaching and learner-incentives may be substitutes (crowding out one another) or complements (enhancing one another). Experts surveyed in advance predicted a high degree of substitutability between the two treatments. In contrast, we find substantially more complementarity than experts predicted. Combining teaching and incentive treatments raises COVID-19 knowledge test scores by 0.5 standard deviations.

Correcting Perceived Social Distancing Norms to Combat COVID-19

Can informing people of high community support for social distancing encourage them to do more of it? In theory, the impact of such an intervention on social distancing is ambiguous, and depends on the relative magnitudes of free-riding and perceived-infectiousness effects. We randomly assigned a treatment providing information on true high rates of community social distancing support. We estimate impacts on social distancing, measured using a combination of self-reports and reports of others. While experts surveyed in advance expected the treatment to increase social distancing, we find that its average effect is close to zero and significantly lower than expert predictions. The treatment’s effect is heterogeneous, as predicted by theory: it decreases social distancing where current COVID-19 cases are low (where free-riding dominates), but increases it where cases are high (where the perceived-infectiousness effect dominates).

Human neutralizing antibodies against SARS-CoV-2 require intact Fc effector functions for optimal therapeutic protection.

SARS-CoV-2 has caused the global COVID-19 pandemic. Although passively delivered neutralizing antibodies against SARS-CoV-2 show promise in clinical trials, their mechanism of action in vivo is incompletely understood. Here, we define correlates of protection of neutralizing human monoclonal antibodies (mAbs) in SARS-CoV-2-infected animals. Whereas Fc effector functions are dispensable when representative neutralizing mAbs are administered as prophylaxis, they are required for optimal protection as therapy. When given after infection, intact mAbs reduce SARS-CoV-2 burden and lung disease in mice and hamsters better than loss-of-function Fc variant mAbs. Fc engagement of neutralizing antibodies mitigates inflammation and improves respiratory mechanics, and transcriptional profiling suggests these phenotypes are associated with diminished innate immune signaling and preserved tissue repair. Immune cell depletions establish that neutralizing mAbs require monocytes and CD8+ T cells for optimal clinical and virological benefit. Thus, potently neutralizing mAbs utilize Fc effector functions during therapy to mitigate lung infection and disease.

Ensembl 2021.

The Ensembl project (https://www.ensembl.org) annotates genomes and disseminates genomic data for vertebrate species. We create detailed and comprehensive annotation of gene structures, regulatory elements and variants, and enable comparative genomics by inferring the evolutionary history of genes and genomes. Our integrated genomic data are made available in a variety of ways, including genome browsers, search interfaces, specialist tools such as the Ensembl Variant Effect Predictor, download files and programmatic interfaces. Here, we present recent Ensembl developments including two new website portals. Ensembl Rapid Release (http://rapid.ensembl.org) is designed to provide core tools and services for genomes as soon as possible and has been deployed to support large biodiversity sequencing projects. Our SARS-CoV-2 genome browser (https://covid-19.ensembl.org) integrates our own annotation with publicly available genomic data from numerous sources to facilitate the use of genomics in the international scientific response to the COVID-19 pandemic. We also report on other updates to our annotation resources, tools and services. All Ensembl data and software are freely available without restriction.