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In this article, we identify ways in which the Covid-19 pandemic has exposed flaws in the UK's regulatory regime for health and safety at work. The characteristics of Covid-19 presented particular challenges for the risk-based approach to regulation embraced by the Health and Safety Executive (HSE). We offer a critique and suggest four principal areas for reform. First, it is clear that HSE and other enforcement bodies need an injection of funds to support their inspection and enforcement activities. Second, the regulatory regime itself is in need of modernisation to reduce reliance on criminal law. Third, wider labour law problems such as the distinction between worker and employee, which impact health and safety law, need to be resolved. Fourth, and most importantly, there must be much greater recognition that health and safety is an issue for every person in the workforce. Even if Covid-19 ceases to pose such a significant workplace risk, we consider that there are a variety of other common health and safety issues that would be better addressed by a modified and modernised regulatory strategy.
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INTRODUCTION: Previous studies have reported an increased risk of procoagulant events such as pulmonary embolism (PE) in adult patients with Coronavirus Disease-19 (COVID-19). However, scant information exists within pediatric samples. This study aimed to investigate the effect of COVID-19 acute infections on the incidence of PE among pediatric patients. METHOD(S): Using Virtual Pediatric Systems (VPS), retrospective data was collected of patients age < 18 years old who were admitted to participating pediatric critical care units from 2018-2021. Patients with an ICD diagnosis of COVID-19 infection or PE were extracted for further analysis. Additional information regarding patient age, gender, race, BMI, comorbidities were also obtained. RESULT(S): In total, there were 488,298 admissions to PICUS participating in VPS from 2018 - 2021. In 2018 and 2019, prior to the COVID-19 pandemic, the incidence of PE among the pediatric population was 2.29 per 1000 patients (n=614). During the COVID-19 pandemic in 2020-2021, the incidence of PE increased to 3.11 per 1000 patients (n=686). Of the PE cases between 2020 to 2021, 12.1% (n=83) patients had an acute COVID-19 infection (53.0% female;42.0% BMI> 35;91.6% >12 years of age;92.8% survival). Patients with acute COVID-19 infection had 3.4 (95% CI, 2.7 - 4.2) times the risk of pulmonary embolism than patients from 2020 to 2021 without acute COVID-19 infection. CONCLUSION(S): In this study, we report an increased incidence of PE among pediatric patients during the COVID-19 pandemic when compared with the years prior to the pandemic. Additionally, we report a significantly increased relative risk of pulmonary embolism in patients with acute COVID-19 infection compared to patients without acute COVID-19 infection. Further analysis is planned to adjust for hypercoagulable states. Additional research is needed to identify risk factors for PE in pediatric patients with COVID-19.
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Introduction: The impact of the COVID-19 pandemic on people living with multiple sclerosis (MS) is expected to be significant. Whilst quantitative research in this area has been undertaken, there is a paucity of qualitative research;this study will therefore provide valuable insights into individual experiences and perceptions of people with MS (PwMS) in the United Kingdom (UK) during this unique period. Objective(s): The ongoing global health crisis leaves us all in a state of uncertainty that requires constant adaptation to the new 'normal' we are living in, and it is important that the challenges faced by the MS community are recognised and addressed as part of this learning process. We explore self-reported data gathered during the pandemic to reach conclusions regarding the impact of the crisis on PwMS. Aim(s): To enhance understanding of the experiences of PwMs during the COVID-19 pandemic and identifying potential areas where further support could be beneficial. Method(s): Between March 3 and October 29, 2020, 1,685 free-text comments regarding the unique experiences of PwMS were collected online by the UK MS Register (UKMSR). Thematic analysis of 1,000 randomly selected responses made by 682 individuals was used to investigate the perceived impact of COVID-19 on the participants, following a constructivist approach. Result(s): Five main themes were identified in the data: connectedness, attitudes towards change, mental health, stigma, and information and advice. Results of the thematic analysis were varied, with significant numbers reporting positive experiences of the pandemic. Conclusion(s): Individual levels of connectedness and attitude towards change significantly influence how PwMS experience life during the COVID-19 outbreak. The data showed the impact of COVID-19 on mental health to be mixed among PwMS. The pandemic hashighlighted that some PwMS remain fearful of being stigmatised in the workplace because of their condition.
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Introduction: Despite the ongoing roll-out of the vaccination programme in Wales, self-isolation remains a crucial strategy to reduce transmission of COVID-19, especially as cases remain high. Test, Trace, Protect (TTP) is Wales' contact tracing programme where people are asked to isolate and provided with information and resources. Public Health Wales ran a real-time text message survey of contacts of cases of COVID-19 to provide insight as people were starting a period of self-isolation after notification from NHS Wales Test Trace Protect (Adherence Confidence Text Survey (ACTS)). This research study was designed to investigate what those being asked to self-isolate felt was good about their experience with TTP and what do they feel could be done better based on their text responses. Method: Text responses between 15th November 2020 and 2nd May 2021 (N = 12,092) were analysed using an automated content analysis (ACA) and sentiment analysis using the software Leximancer. Next, we conducted a qualitative thematic analysis using the software NVivo to explore further the findings of the ACA, as well as to look more deeply into some of the reasons behind people's views of TTP at two time periods for comparison, T1: 15th November- 5th December 2020 (n=2956) and T2: 1st March - 31st 2021 (n = 515). Results: ACA revealed that there were substantially more (roughly ten times as many) instances of favorable (positive affective) (n=4,963) terms within the data than unfavorable (negative affective) (n=425). NVivo analysis were in keeping with this finding as the majority reported a positive experience with TTP (T1 N = 1717, 58%;T2 N = 355, 69%). One of the sources of confusion was the date of the end of required isolation (T1 N= 101, 3.4%;T2 N = 11, 2.1%) though clarity improved from T1 to T2. Another concern was the time it took to be contacted following a positive test (T1 N = 205, 6.9%, T2 N = 14, 2.7%) again improving with time. Less than 1% reported financial concerns at both time periods. Conclusions: The Welsh population responding to the text sent by PHW had a positive experience with TTP. Automated content analysis is a viable method to process large datasets of qualitative content such as text responses.
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Background Dysbiosis of the gut microbiota may be responsible for the pathogenesis of ulcerative colitis (UC). Restoration of gut microbiota diversity by means of faecal microbiota transplantation (FMT) is of increasing interest as a therapeutic option in the management of UC. The aims of this phase II feasibility study are to estimate the magnitude of treatment response to FMT in treatment-naïve patients with newly diagnosed UC, evaluate donor and patient recruitment rates and determine optimal study conditions for phase III study (ISRCTN 58082603). Methods Treatment-naïve patients with histologically confirmed UC below the sigmoid were recruited. Subjects were randomised to single FMT enema, five daily enemas and control group. All groups received antibiotic for 10 days and bowel preparation 48 hours before the interventions. They were followed up for 12 weeks with quality of life (QOL) scores (IBDex, CUCQ-32) and 16S RNA study on faecal samples. Endoscopic (Mayo score) and histological assessments were performed at the baseline and week 12. The primary endpoints were endoscopic remission of UC and rate of persistent microbial engraftment at 12 weeks. Secondary endpoints included QoL and mucosal cytokine profiling with IL-10. Clinical remission was defined as Mayo score ≤ 2 with an endoscopic Mayo score of 0. Results Eighteen UC patients were recruited between July 2016 and February 2020 until the COVID-19 pandemic, of those five achieved clinical remission. One subject from the control group withdrew at week 4 due to worsening symptoms. 72% improved Mayo and QOL scores, and 44% avoided medical treatment. Clinical remission was more observed among subjects with lower baseline QoL and mild-moderate disease, although this did not reach statistical significance (P=0.173). No correlation between FMT dose, frequency and clinical remission were observed. The 16S evaluation of the faecal samples demonstrated successful engraftment of FMT and showed a similar faecal microbiota profile amongst the intervention groups, which was markedly different from the control group. Coprococcus was found to be much more abundant amongst subjects who responded to the FMT intervention. This study also suggested an inverse correlation between IL-10 and the severity of UC. Conclusions FMT intervention protocols were well adhered and 94% completion rate, though the recruitment period was much longer than the original plan due to some unforeseen interruptions. Yet, this feasibility study demonstrated potential for employing this method for a larger multicentre RCT to further evaluate FMT dose and frequency effects. The correlation between IL-10 and IL-10 producing microorganisms should be sought in the future study.
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The coronavirus, COVID-19 pandemic spread across the globe in 2020, with an initial high case mortality in those requiring intensive care treatment due to serious complication. A vaccine programme was quickly developed and currently the UK is one of highest double vaccinated and boosted countries in the world. Despite tremendous efforts by the UK, new cases of COVID-19 are still occurring, due to viral mutation. A major problem associated with COVID-19 is the large a-symptomatic spread within the population. Little investigation into the a-symptomatic population has been carried out and therefore we pose that the residual effects of a-symptomatic infection is still largely unknown. Prior to mass vaccination, a multi-phased single cohort study of IgM and IgG COVID-19 antibody prevalence and the associated haemostatic changes were assessed in a Welsh cohort of 739 participants, at three time points. Positive antibody participants with age and gender matched negative antibody controls were assessed at 0, 3 and 6 months. Antibody positive females appeared to have lower antibody responses in comparison to their a-symptomatic male counterparts. Despite this initial testing showed a unique significant increase in TRAP-6-induced platelet aggregation, prothrombin time (PT) and clot initiation time. Despite coagulation parameters beginning to return to normal at 3 months, significant decreases are observed in both haemoglobin and haematocrit levels. The production of extracellular vesicles (EV) was also determined in this study. Although the overall number of EV does not change throughout the study, at the initial 0 months' time point a significant increase in the percentage of circulating pro-coagulant platelet derived EV is seen, which does not appear to be related to the extent of platelet activation in the subject. We conclude that early, but reversible changes in haemostatic pathways within the a-symptomatic, female, antibody positive COVID-19 individuals are present. These changes may be key in identifying a period of pro-coagulative risk for a-symptomatic female patients.
Subject(s)
COVID-19 , Hemostatics , Cohort Studies , Female , Humans , Immunoglobulin G , Male , Pandemics/prevention & control , SARS-CoV-2ABSTRACT
Introduction: With the evolution of centralised ‘hub and spoke’ microbiology services, the expansion of infectious diseases as a medical specialty and the advent of joint infection training pathways, the infection services within the United Kingdom (UK) are experiencing a period of rapid change. Despite this, to date there has been no comprehensive description of the distribution of specialty staffing and service provision across the country. To this end, the British Infection Association (BIA), in conjunction with the Royal College of Pathologists (RCPath), has undertaken a national survey of National Health Service (NHS) infection services. Methods: Questions were compiled following consultation with an expert panel including BIA Council members. An online survey was distributed to clinical leads at all UK NHS acute trusts or health boards with inpatient beds and data were collected between April and August 2021. Results: The overall response rate was 72% (108 respondents). The median number of infection consultant full time equivalents (FTE) per service was 6.1 overall (5.6 per 1000 acute beds) although this varied between the devolved nations and was lowest in centres with microbiology specialists only. Forty-three services had three or fewer FTE medically qualified infection specialists. Overall, 17.5% of all funded FTE consultant-level posts were vacant, although this was markedly higher for microbiology-accredited posts (20.3%) than for infectious diseases (ID) (9.3%) or medical virology (14.6%). There were fewer vacancies in centres with ID-accredited consultants;median 1.0 (IQR 0–2.2) versus those with microbiology only;1.8 (IQR 0–2.9). Distribution of non-consultant staff was extremely heterogenous with 44 services having none and 25 having one or less FTE (most of which employed microbiology-only accredited consultants). 30% of organisations reported at least one vacant training post. Half of the responding organisations reported at least one consultant accredited in ID but only 28 provided inpatient care with a total of 520 ‘dedicated’ ID beds, of which 235 were negative pressure side-rooms. Geographically, several large areas of the country lacked inpatient ID capacity and/or ID-accredited consultant expertise. The burden of laboratory-related and reporting work in relation to staffing levels is disproportionately greater at smaller centres;there are a median 7.7 (IQR 5.9–9.5) hours/person/week at centres with three or fewer consultants and 4.0 (IQR 2.1–6.3) at larger centres. Conclusion: Microbiology specialists continue to provide the bulk of infection services across the UK and there is marked geographical variation in staffing with regards to other specialities. With Core Infection Training now producing dual-accredited consultants, there is an untapped potential to expand inpatient ID service provision although the requirement for placements on an existing inpatient ID unit may be limiting this currently. There are extremely high vacancies rates across the country but smaller, microbiology-only centres are hardest-hit with many barely attaining the consultant numbers required to staff a safe on-call rota. Workforce planning with utilisation of the valuable expertise of non-medically-trained staff, such as Clinical Scientists, is urgently needed. The results of this survey, in conjunction with Best Practice Standards recently published by the BIA, RCPath and Royal College of Physicians can inform commissioning and delivery of infection expertise in the context of the aftermath of the COVID-19 pandemic.
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The UK’s faith communities were significantly affected by the COVID pandemic from its outset, with massively-increased demand for their social and pastoral care services hitting them at a time when their human, physical and financial resources were all severely restricted by national lockdown. Restrictions to public worship were certainly the subject of concern and some protest, but all told, faith communities responded quickly and creatively, taking worship on line, developing innovative welfare practices under pressure and building new collaborative operations which would previously have been difficult to imagine. The changes that the crisis has forced upon the Church in particular, though, are likely to have lasting effect for years to come, with attendance at worship, community leadership and organisational finances all sure to be impacted. In these ways and more, the pandemic will undoubtedly accelerate the speed at which the role of religion in English society is changing, but the effectiveness of the faith response to the crisis suggests that there is plenty of room and energy for positive innovation still in evidence. © John R. Bryson, Lauren Andres, Aksel Ersoy and Louise Reardon 2021.
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Introduction: A better understanding of the reality for cancer patients during COVID-19 will help us readapt current predication models. To further inform future clinical guidelines, we need a deep dive into rich data sources from apex Cancer Centres. We report on the outcomes of cancer patients receiving radical surgery between March-September 2020 (as well as 2019) in the European Institute of Oncology (EIO) in Milan and the South East London Cancer Alliance (SELCA). Methods: IEO is one of the largest cancer hospitals in Italy. SELCA includes 3 major hospital trust, treating about 8,000 new cancer patients per annum. Both institutions implemented a COVID-19 minimal pathway, whereby patients were required to shield for 14 days prior to admission and were swabbed for COVID-19 within 3 days of surgery. Positive patients had surgery deferred until a negative swab. Surgical outcomes assessed were: ASA grade, surgery time, theatre time, ICU stay>24h, pneumonia, length of stay (LOS), and admissions. For COVID-19, we focused on infection rate and mortality. Results: At IEO the number of radical surgeries (270 for gynaecological, 339 for head and neck, 377 for thoracic, and 491 for urological cancers) declined by 6% as compared to the same period in 2019 (n=1477 vs 1560). The main decline was observed for thoracic surgery (377 vs 460, i.e. -18%). Age, sex, SES, ethnicity, comorbidities, and performance status were all comparable between both periods (e.g. 58% male, 38% aged 70+, 48% high SES, 15% with existing cardiovascular diseases). Readmissions were required for 39%, and <1% (n=9) developed COVID-19, of which only 1 had severe disease and died. 11 died of other causes during follow-up (1%). At SELCA, the number of radical surgeries (321 for breast, 129 for colorectal, 114 for gynaecological, 152 for head and neck, 92 for liver, 56 for plastics/skin, 305 for thoracic, 72 for upper gastrointestinal, and 312 for urology) declined by 29% (n=1553 vs 2182). Even though a different geographical setting, characteristics were fairly comparable with the IEO: 58% males, 30% aged 70+, 34% high SES, 16% with existing cardiovascular diseases. Readmissions were required for 22%, <1% (n=7) developed COVID-19, and none died from it. 19 died of other causes within 30 days (1%). Conclusion: Milan and London were both at the epicentre of the first COVID-19 wave. Whilst a decline in number of surgeries was observed, the implemented COVID-19 minimal pathways have shown to be safe for cancer patients requiring radical treatment, with limited complications and almost no COVID-19 infections.
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Soft power policing is emerging as the policing catch phrase in 2021 in part arising from multiple police-community relations challenges gaining an increasing public focus globally. This article presents the soft power approach to policing engaged by Abu Dhabi police pre- and during the Coronavirus Disease (COVID-19) pandemic and the underpinning strategies and initiatives deployed to sustain community trust and confidence levels in Abu Dhabi Police. A review of global indexes promotes Abu Dhabi Police as a world leader in police-community relations, an achievement sustained throughout the COVID-19 global crisis. This research explores the ways in which achievements are impacted by a sustained and an all-encompassing policing approach that places soft power at the centre of police and community relations.
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In 2020, as the world focused efforts to address the humanitarian challenges presented by the Covid-19 pandemic, the global education community was similarly challenged to demonstrate resilience and innovation to support a level of 'normality' for students at all levels and professions. The research presented in this article offers insight into the preparation and deployment of transitioning education of police students from face-to-face delivery to online delivery in an environment historically unfamiliar with online learning delivery. The results indicate the critical attention placed on the preparation for transition beyond only subject matter delivery, for both students and faculty was pivotal in the resultant positive student learning outcomes. The approach to transitioning to the online learning delivery environment, the early trending data for which indicate minimal impact on achievement of learning for students, contributes to the decision making for education institutions centred on developing resilience professionals such as police officers.
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Introduction: Tumour size, depth of invasion, type and extent of nodal metastasis are some of the key prognostic indicators in operable head and neck cancers. Initial Imaging with USS of neck and FNAC or core biopsy has been established to have a high sensitivity and specificity. In addition, CT neck and thorax and MRI scan of the primary tumour are recommended as part of staging scans. Information from this work up guides the MDT and patients towards a tailored management plan. We aimed to compare preoperative imaging work up and TNM staging with post-operative histopathology. Methods: We retrospectively reviewed 48 patients who underwent resection and selective neck dissection from January 2020 to August 2021, assessing their initial work up and its adherence to current guidelines. We also evaluated its correlation to final histopathology. Results: 100% compliance was noted with USS and FNAC, 94% compliance with CT and MRI and 96% had incisional biopsy. USS showed a 80 % specificity and a 55% sensitivity. CT had a specificity of 62.5% and sensitivity of 75%. MRI specificity was 58.8% and sensitivity 73.6%. Conclusions: Our results compare favourably to other published data on imaging correlation to histopathology in head and neck oncology. Time lapse between preoperative work-up and surgical resection during COVID pandemic may have led to advanced disease that is not evident on preoperative staging scans. Newer modalities including real time imaging and in-vivo surgical margin assessment remain to be explored.
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Background The Acute Clinical Team (ACT) in Neath Port Talbot is a well-established hospital at home service that provides treatments in the community. During the COVID 19 outbreaks, the team proactively telephoned the care home managers on a regular basis to enquire about the residents wellbeing and establish if input was required. This proactive approach worked well with some homes. Where crises developed, we were able to provide hands on support to provide appropriate medical care. Methods A collaborative effort from community teams and volunteers assisted ACT to provide nursing and medical interventions in care homes which accepted our help. Interventions included intravenous (IV) antibiotics, parenteral fluids, IV/oral dexamethasone, low molecular weight heparin, oxygen (up to 10 L face mask), communication with families and palliative care. Results Data is presented from 7 care homes for which ACT provided input;patients who were unwell requiring additional help were referred to the team. Comparative data from a care home in the same area where ACT was not involved is presented. Data was collected from 01/11/20-10/02/21. Table 1 Care homes with ACT involvement (190 patients) Care home without ACT involvement (85 patients) Patients assessed Patients not assessed No. with COVID-19 infection (%) 96/190 (51%) 94/190 (49%) 27/85 (32%) Acute hospital admission related to COVID-19 (%) 3/96 (3%) 7/94 (9%) 8/27 (30%) Died within 28 days of positive test(%) 37/96 (39%) 20/94 (21%) 15/27 (56%). Conclusion ACT had a vital role during the outbreak in supporting the local community. The team was able to provide a range of interventions and prevent avoidable admissions. The team received excellent feedback ‘We couldn’t have survived without the ACT teams input. They were our lifesavers. The whole team were amazing and came to our rescue where everyone else who knew we had COVID bolted to the hills’ Manager.
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Background: Dysbiosis of the gut microbiota may be responsible for the pathogenesis of ulcerative colitis (UC). Restoration of gut microbiota diversity by means of faecal microbiota transplantation (FMT) is of increasing interest as a therapeutic option in the management of UC. The aims of this phase II feasibility study are to estimate the magnitude of treatment response to FMT in treatment-naïve patients with newly diagnosed UC, evaluate donor and patient recruitment rates and determine optimal study conditions for phase III study (ISRCTN 58082603). Methods: Treatment-naïve patients with histologically confirmed UC below the sigmoid were recruited. Subjects were randomised to three arms;single FMT enema, five daily enemas and control. All groups received antibiotic for 10 days and bowel preparation 48 hours before the interventions. They were followed up for 12 weeks with quality of life (QOL) scores (IBDex, CUCQ-32) and 16S RNA study on faecal samples. Endoscopic (Mayo score) and histological assessments were performed at the baseline and week 12. The primary endpoints were endoscopic remission of UC and rate of persistent microbial engraftment at 12 weeks. Secondary endpoints included QoL and mucosal cytokine profiling with IL-10. Clinical remission was defined as Mayo score ≤ 2 with an endoscopic Mayo score of 0. Results: Eighteen UC patients were recruited between July 2016 and February 2020 until the COVID-19 pandemic, of those five achieved Clinical remission. One subject from the control group withdrew at week 4 due to worsening symptoms. 72% improved Mayo and QOL scores, and 44% avoided medical treatment. Clinical remission was more observed among subjects with lower baseline QoL and mildmoderate disease, although this did not reach statistical significance (P=0.173). No correlation between FMT dose, frequency and clinical remission were observed. The 16S evaluation of the faecal samples demonstrated successful engraftment of FMT and showed a similar faecal microbiota profile amongst the intervention groups, which was markedly different from the control group. Coprococcus was found to be much more abundant amongst subjects who responded to the FMT intervention. This study also suggested an inverse correlation between IL-10 and the severity of UC. Conclusion: FMT intervention protocols were well adhered and achieved 94% completion rate, though the recruitment period was much longer than the original plan due to unforeseen interruptions. Yet, this feasibility study demonstrated potential for employing this method for a larger multicentre RCT to further evaluate FMT dose and frequency effects. The correlation between IL-10 and IL-10 producing microorganisms should be sought in the future study.
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Social Design Research, due to its interactive and democratic nature, typically requires access to participants at all stages of the Design process (enquiry, insight gathering, ideation, and testing). This ensures that the designers’ practice is informed with contextual knowledge gained through relationship-building and ethnography, which are key features of Social Design Research [1]. Due to the impact of the COVID-19 pandemic, the delivery of Design education, and the approaches taken by lecturers and students had to adapt. The methods, attitudes and approaches to Design research and practice have evolved due to these changes due to the use of newly adopted digital collaborative environments. This paper presents the adaptations to existing Social Design Research methods and new ones which have been generated by the students through the undertaking of a project aimed at designing for social value delivered to first year Product Design students at The University of Derby. © PDE 2021.
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The COVID-19 pandemic has had a global effect on higher education. Overnight, entire degree programs had to be moved online. Whereas this meant that teaching and learning in political science and international relations also went into "emergency e-learning" mode, as a recent teacher spotlight in PS: Political Science & Politics termed it, moving online also offered opportunities. One opportunity is collaborative online international learning (COIL) that enables students from universities in different countries to work on a common project. This article argues that working together collaboratively online not only mitigates the pandemic's physical restrictions and sustains a global space of learning;it also provides for a particular active and affective learning in an intercultural virtual environment that substantiates classroom experiences even in post-pandemic higher education. To support this argument, this article reflects on the experiences of a British-Japanese COIL project that investigated political responses to COVID-19.
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Surgical services have been hugely disrupted by COVID-19 and have had to evolve rapidly in response. The best practice for consent mandates that risks associated with surgical treatment during a pandemic be discussed. This study aimed to assess whether patients undergoing orthopaedic operations were being consented for the risk of contacting COVID-19 and ITU care. All orthopaedic consent forms from four-week periods in March, June and July were reviewed. Measures such as staff education were implemented after the second cycle. Of consent forms for 37 operations performed in March, only 1 mentioned the risk of contracting COVID-19 and zero mentioned ITU. During June, 89 consent forms were reviewed, 32 mentioned COVID-19 and 10 discussed ITU admission. Following educational measures, the third cycle showed a significant improvement as of 100 consent form records available for review, 73 included risk of COVID-19 whilst 26 mentioned ITU. The results show that earlier in the pandemic, surgeons at our centre were not counselling patients regarding COVID-19. This improved slightly between the first and second cycles, likely reflecting increased awareness of the nosocomial transmission of COVID-19. Educational measures contributed to a significant improvement in the third cycle. Planned interventions include use of electronic consent forms which incorporate COVID-19 infection and associated risks.