Reanalysis of a Randomized Controlled Trial on Promoting Influenza Vaccination in General Practice Waiting Rooms: A Zelen Design.

In 2014-2015, we conducted a randomized controlled trial (RCT) assessing the effect of an advertising campaign for influenza vaccination using posters and pamphlets in general practitioner (GP) waiting rooms. No effect of the intervention could be demonstrated, but the immunization uptake increased in both arms of the study. In 2019, we deepened the investigations explaining the increased uptake conducting a registry-based 4/2/1 cluster RCT designed by Zelen with two extra years of follow-up of the study cohort. The study population included 23,024 patients eligible to be vaccinated who were registered with 175 GPs. The main outcome remained the number of vaccination units delivered per study group. Data were extracted from the SNIIRAM warehouse claim database for the Lille-Douai district (northern France). No difference in vaccination uptake was found in the Zelen versus the control group of the initial RCT. Overall, the proportion of vaccinated patients increased in the cohort from 51.4% to 70.4% over the three years. Being vaccinated the previous year was a strong predictor of being vaccinated in a subsequent year. The increase in vaccination uptake, especially among people older than 65, can be explained by a cohort effect. Health promotion and the promotion of primary health care may play an important role in this increase.

Antibiotic Prescribing Trends in Belgian Out-of-Hours Primary Care during the COVID-19 Pandemic: Observational Study Using Routinely Collected Health Data.

Antibiotic overprescribing is one of the main drivers of the global and growing problem of antibiotic resistance, especially in primary care and for respiratory tract infections (RTIs). RTIs are the most common reason for patients to consult out-of-hours (OOH) primary care. The COVID-19 pandemic has changed the way general practitioners (GPs) work, both during office hours and OOH. In Belgian OOH primary care, remote consultations with the possibility of issuing prescriptions and telephone triage were implemented. We aimed to describe the impact of COVID-19 on GPs' antibiotic prescribing during OOH primary care. In an observational study, using routinely collected health data from GP cooperatives (GPCs) in Flanders, we analyzed GPs' antibiotic prescriptions in 2019 (10 GPCs) and 2020 (20 GPCs) during OOH consultations (telephone and face-to-face). We used autoregressive integrated moving average (ARIMA) modeling to identify any changes after lockdowns were implemented. In total, 388,293 contacts and 268,430 prescriptions were analyzed in detail. The number of antibiotic prescriptions per weekend, per 100,000 population was 11.47 (95% CI: 9.08-13.87) or 42.9% lower after compared to before the implementation of lockdown among all contacts. For antibiotic prescribing per contact, we found a decrease of 12.2 percentage points (95% CI: 10.6-13.7) or 56.5% among all contacts and of 5.3 percentage points (95% CI: 3.7-6.9) or 23.2% for face-to-face contacts only. The decrease in the number of prescriptions was more pronounced for cases with respiratory symptoms that corresponded with symptoms of COVID-19 and for antibiotics that are frequently prescribed for RTIs, such as amoxicillin (a decrease of 64.9%) and amoxicillin/clavulanate (a decrease of 38.1%) but did not appear for others such as nitrofurantoin. The implementation of COVID-19 lockdown measures coincided with an unprecedented drop in the number of antibiotic prescriptions, which can be explained by a decrease in face-to-face patient contacts, as well as a lower number of antibiotics prescriptions per face-to-face patient contact. The decrease was seen for antibiotics used for RTIs but not for nitrofurantoin, the first-choice antibiotic for urinary tract infections.

An exploration of the impact of COVID-19 on mental health in South Africa.

In response to the COVID-19 pandemic, South Africa implemented a strict stay-at-home order. The mental health effects of the pandemic and related containment measures are minimally documented in this region. This study examines the association between COVID-19 related stressors and mental health during a strict stay-at-home order in South Africa. A total of 860 self-selected participants residing in the Western Cape province completed an online survey from 20-31 May 2020. This sample consisted mainly of higher socioeconomic and higher educated segments of the population. Structural equation modelling was used to assess how sociodemographic factors, membership of vulnerable groups and COVID-19 related stressors were associated with PHQ-9 (depression) and GAD-7 (anxiety) scores. 46.0% and 47.2% of participants met the diagnostic threshold of anxiety and depressive disorder, respectively. Considerable daily life repercussions were linked to these scores. Among these participants, less than 20% consulted a formal practitioner and this was 12% for participants without a pre-existing mental health condition. Distress related to containment measures and distress about being infected were significantly associated with more anxiety and depressive symptoms. Having a pre-existing mental health condition was associated with poorer mental health, but being an active health worker was not. Younger age, being female, and living in a non-rural area were associated with poorer mental health. Our findings suggest a considerable mental health impact of this pandemic and related containment measures, but low attendance of mental health services. The accessibility to tailored mental health support is essential under these circumstances, especially for vulnerable groups.

The pandemic of online research in times of COVID-19.

The COVID-19 pandemic has led to an explosion of online research using rating scales. While this approach can be useful, two of the major challenges affecting the quality of this type of research include selection bias and the use of non-validated scales. Online research is prone to various forms of selection bias, including self-selection bias, non-response bias or only reaching specific subgroups. The use of rating scales requires contextually validated scales that meet psychometrical properties such as validity, reliability and-for cross-country comparisons-invariance across settings. We discuss options to prevent or tackle these challenges. Researchers, readers, editors and reviewers need to take a critical stance towards research using this type of methodology.

Bronchiolitis in COVID-19 times: a nearly absent disease?

Stay-at-home orders, physical distancing, face masks and other non-pharmaceutical interventions (NPIs) do not only impact COVID-19, but also the dynamics of various other infectious diseases. Bronchiolitis is a clinically diagnosed viral infection of the lower respiratory tract, and causes a yearly seasonal wave of admissions in paediatric wards worldwide. We counted 92,5% less bronchiolitis hospitalisations in Antwerp before the expected end of the peak this year (of which only 1 RSV positive), as compared to the last 3 years. Furthermore, there was a >99% reduction in the number of registered RSV cases in Belgium.Conslusion: The 2020 winter bronchiolitis peak is hitherto nonexistent, but we fear a 'delayed' spring/summer bronchiolitis peak when most NPIs will be relaxed and pre-pandemic life restarts. What is known? • Bronchiolitis causes a yearly seasonal wave of admissions in paediatric departments worldwide. • Non-pharmaceutical interventions (NPIs) do not only impact COVID-19, but also the dynamics of various other infectious diseases. What is new? • The 2020 winter bronchiolitis peak is hitherto nonexistent. • A 'delayed' spring or summer bronchiolitis peak could happen when most NPIs will be relaxed and pre-pandemic life restarts.

Disentangling depression in Belgian higher education students amidst the first COVID-19 lockdown (April-May 2020).

BACKGROUND: The surge of COVID-19 infections has prompted many countries to take unprecedented policy measures. In Belgium, the authorities implemented a nation-wide stay-at-home order for several months. Evidence of the mental health effect of such measures is scarce. A recent review by Brooks et al. has compiled a defined list of stressors affecting people's mental health under quarantine during previous epidemic settings. This study aims to test the association between these stressors and the mental health of students attending higher education during the stay-at-home order in Belgium. METHODS: In this cross-sectional study, 18,301 students from 13 higher education institutions (HEI) participated in an online survey between 26 April and 11 May 2020. We assessed the association between potential stressors and depressive symptoms severity scores and structural equation modeling was used to assess how stressors may mediate the association between duration of exposure and depressive symptoms severity. RESULTS: The stressors proposed by Brooks et al. were found to be associated with depressive symptoms severity. The stressors 'perceived academic stress', 'institutional dissatisfaction' and 'fear of being infected' were associated with substantially higher depressive symptoms severity scores. The association between duration of exposure and depressive symptoms severity was mediated by 'academic stress'. Being in a steady relationship and living together with others were both associated with a lower depressive symptoms severity. CONCLUSION: Findings underline the need for a student-centered approach and mental health prevention. Authorities and HEIs should consider whether and if so, how a stay-at-home order should be implemented.