Relative contribution of leaving home for work or education, transport, shopping and other activities on risk of acquiring COVID-19 infection outside the household in the second wave of the pandemic in England and Wales (preprint)

BackgroundWith the potential for and emergence of new COVID-19 variants, such as the reportedly more infectious Omicron, and their potential to escape the existing vaccines, understanding the relative importance of which non-household activities increase risk of acquisition of COVID-19 infection is vital to inform mitigation strategies. MethodsWithin an adult subset of the Virus Watch community cohort study, we sought to identify which non-household activities increased risk of acquisition of COVID-19 infection and which accounted for the greatest proportion of non-household acquired COVID-19 infections during the second wave of the pandemic. Among participants who were undertaking antibody tests and self-reporting PCR and lateral flow tests taken through the national testing programme, we identified those who were thought to be infected outside the household during the second wave of the pandemic. We used exposure data on attending work, using public or shared transport, using shops and other non-household activities taken from monthly surveys during the second wave of the pandemic. We used multivariable logistic regression models to assess the relative independent contribution of these exposures on risk of acquiring infection outside the household. We calculated Adjusted Population Attributable Fractions (APAF - the proportion of non-household transmission in the cohort thought to be attributable to each exposure) based on odds ratios and frequency of exposure in cases. ResultsBased on analysis of 10475 adult participants including 874 infections acquired outside the household, infection was independently associated with: leaving home for work (AOR 1.20 (1.02 - 1.42) p=0.0307, APAF 6.9%); public transport use (AOR for use more than once per week 1.82 (1.49 - 2.23) p<0.0001, APAF for public transport 12.42%); and shopping (AOR for shopping more than once per week 1.69 (1.29 - 2.21) P=0.0003, APAF for shopping 34.56%). Other non-household activities such as use of hospitality and leisure venues were rare due to restrictions and there were no significant associations with infection risk. ConclusionsA high proportion of the second wave of the pandemic was spent under conditions where people were being advised to work from home where possible, and to minimize exposure to shops, and a wide range of other businesses were subject to severe restrictions. Vaccines were being rolled out to high-risk groups. During this time, going to work was an important risk factor for infection but public transport use likely accounted for a lot of this risk. Only a minority of the cohort left home for work or used public or shared transport. By contrast, the majority of participants visited shops and this activity accounted for about one-third of non-household transmission.

Household overcrowding and risk of SARS-CoV-2: analysis of the Virus Watch prospective community cohort study in England and Wales (preprint)

Background: Household overcrowding is associated with increased risk of infectious diseases across cultures and countries. Limited data exist in England and Wales linking household overcrowding and risk of COVID-19. We used data collected from the Virus Watch cohort to examine the association between overcrowded households and infection to pandemic coronavirus SARS-CoV-2. Methods: The Virus Watch study is a household community cohort of acute respiratory infections in England & Wales that began recruitment in June 2020. We calculated the persons per room for each household and classified accommodation as overcrowded when the number of roomswas fewer than the number of people. We considered two primary outcomes - PCR-confirmed positive SARS-CoV-2 antigen tests and laboratory confirmed SARS-CoV-2 antibodies (Roche Elecsys anti-N total immunoglobulin assay). We used mixed effects logistic regression models that accounted for household structure to estimate the association between household overcrowding and SARS-CoV-2 infection. Results: The proportion of participants with a positive SARS-CoV-2 PCR result was highest in the overcrowded group (6.6%; 73/1,102) and lowest in the under-occupied group (2.9%; 682/23,219). In a mixed effects logistic regression model that included age, sex, ethnicity, household income and geographical region as fixed effects, and a household-level random effect, we found strong evidence of an increased odds of having a positive PCR SARS-CoV-2 antigen result (Odds Ratio 3.67; 95% CI: 1.91, 7.06; p-value < 0.001) and increased odds of having a positive SARS-CoV-2 antigen result in individuals living in overcrowded houses (2.99; 95% CI: 1.14, 7.81; p-value =0.03) compared to people living in under-occupied houses. Discussion: Public health interventions to prevent and stop the spread of SARS-CoV-2 should consider the much greater risk of infection for people living in overcrowded households and pay greater attention to reducing household transmission. There is an urgent need to better recognise housing as a leading determinant of health in the context of a pandemic and beyond.

Clinical Outcomes of Patients With and Without HIV Hospitalised with COVID-19 in England During the Early Stages of the Pandemic: A Matched Retrospective Multicentre Analysis (RECEDE-C19 Study) (preprint)

Background: It is unclear from epidemiological data for COVID-19 infections, whether people living with HIV (PLWH) have a different outcomes compared to the general population. We conducted a multi-centre, retrospective matched cohort study of SARS-CoV-2 PCR-positive hospital inpatients analysed by HIV-status.Methods: HIV-negative patients were matched to PLWH admitted to hospital before 31 st May 2020, with a 3:1 ratio by: hospital site, SARS-CoV-2 test date +/- 7 days, age +/- 5 years, gender, and index of multiple deprivation decile (IMDD) +/- 1. The primary objective was clinical improvement (≥2-point improvement on a 7-point ordinal scale) or hospital discharge by day 28, whichever was earlier.Results: 68 PLWH and 181 HIV-negative comparators were included. After adjustment for ethnicity, frailty, baseline hypoxia, duration of symptoms prior to baseline, body mass index categories, and comorbidities (hypertension, chronic cardiac disease, chronic lung disease, active malignancy, diabetes, and chronic renal disease), the effect size of HIV status was not associated with time to clinical improvement or discharge from hospital (aHR 0.70, 95%CI 0.43, 1.17; p=0.18), despite unadjusted hazards of PLWH achieving the primary outcome being 43% lower (p=0.005). Baseline frailty (aHR=0.79; 95%CI 0.65, 0.95; p=0.011), malignancy (aHR=0.37; 95%CI 0.17, 0.82; p=0.014) remained associated with poorer outcomes. PLWH were more likely of black and minority ethnicities (75.0% vs 48.6%, p=0.0002), higher median clinical frailty score (3 IQR 2-5 vs 2 IQR 1-4, p=0.0069), higher proportion of active malignancy (14.4% vs 9.9%, p=0.29). Median body mass index (BMI) was lower amongst PLWH (27.7 IQR 23.9-32.3 vs 29.4 IQR 24.7-34.3, p=0.19). Median CD4 count of PLWH was 352cells/µL (IQR 235-619) and 95.7% had suppressed viral loads <200copies/mL, 63/68 (92.3%) were taking antiretroviral therapy.Conclusions: Differences in clinical outcomes of COVID-19 hospitalisations in PLWH may be due to other important factors including increased frailty and comorbidities such as malignancies, rather than HIV-status alone.Funding Statement: This study has not received any funding sources.Declaration of Interests: MJL has received grants and honoraria from Gilead Sciences and Viiv Healthcare not related to this work. SF has received research grants to her institution from NIH, MRC, BMGF. JT has received support for virtual conference registration from ViiV Healthcare and research grants from the Medical Research Council and the British HIV Association not related to this work. CvH has received educational grants, conference support and advisory board fees from ViiV Healthcare, Gilead Sciences, MSC not related to this work. MP reports grants and personal fees from Gilead Sciences and personal fees from QIAGEN, outside the submitted work. MP is supported by a NIHR Development and Skills Enhancement Award (NIHR301192) and in receipt of funding from UKRI / MRC (MR/V027549/1). He acknowledges the support from UKRI, the NIHR Leicester BRC and NIHR ARC East Midlands. No other competing interests, financial relationships with any organisations that might have an interest in the submitted work, or other relationships or activities that could appear to have influenced the submitted work have been reported by other authors.Ethics Approval Statement: Ethical approval was granted by the UK Health Research Authority (REC reference 20/HRA/2278).

Hospital Trainees Worries, Perceived Sufficiency of Information and Reported Psychological Health During The COVID-19 Pandemic (preprint)

Introduction: The COVID-19 pandemic has been unsurpassed in clinical severity or infectivity since the 1918 Spanish influenza pandemic and continues to impact the world. During the A/H1N1 influenza pandemic, healthcare workers presented frequent concerns regarding their ownand their families health, as well as high levels of psychological distress. Objectives: To assess hospital trainees concerns, perceived sufficiency of information, behaviour and reported psychological health during the COVID-19 pandemic in the NHS Design: Cross-sectional 39-point questionnaire study conducted in May 2020 Setting: A large NHS foundation trust in London Participants: 204 hospital trainee doctors Outcome measures: Quantitative analysis of trainees worries and concerns while working during the COVID-19 pandemic were assessed across 8 domains: trainee demographics; concerns and worries regarding COVID-19; perceived sufficiency of information about the COVID-19 pandemic; social distancing; use of personal protective equipment (PPE) and training in PPE; COVID-19 acquisition and risk; reported psychological health; and medical education. Results: 91.7% looked after COVID-19 patients. 91.6% were worried about COVID-19; the most frequent concern was that of family and friends dying from COVID-19 (74.6%). 22.2% reported being infected with COVID-19. 6.8% of trainees were so concerned about COVID-19 infection that they would avoid going to work. Perceived sufficiency of information about COVID-19 was moderately high. 25.9% reported that they were able to socially distance at work compared to 94.4% able to socially distance outside work. 98.2% reported using PPE and 24.7% were confident the provided PPE protected them against infection with COVID-19. 41.9% reported that their psychological health had been affected by their work with the commonest being anxiety (56.6%), emotional distress (50.9%) and burnout (37.7%). 95.6% felt it is important to have a service that provides psychological support during this pandemic and 62.5% reported they would consider using this at work. Conclusions: A significant proportion of hospital trainees are worried about the COVID-19 pandemic with high levels of reported psychological distress. Given that almost a third would not use psychological support services at work, hospital leaders and liaison psychiatry need to explore the reasons for not wanting to use services at work and highlight the provision of psychological services provided outside work such that provided by the London deaneries professional support unit (PSU). Seeking solutions to support trainee wellbeing in addition to this, such as larger offices, adequate rest facilities and alternative methods of teaching, with their input would enable empowerment of trainees and improve their health and morale while working in a pandemic.