Early-stage predictors of deterioration among 3145 nonsevere SARS-CoV-2-infected people community-isolated in Wuhan, China: A combination of machine learning algorithms and competing risk survival analyses.

OBJECTIVE: To determine which early-stage variables best predicted the deterioration of coronavirus disease 2019 (COVID-19) among community-isolated people infected with severe acute respiratory syndrome coronavirus 2 and to test the performance of prediction using only inexpensive-to-measure variables. METHODS: Medical records of 3145 people isolated in two Fangcang shelter hospitals (large-scale community isolation centers) from February to March 2020 were accessed. Two complementary methods-machine learning algorithms and competing risk survival analyses-were used to test potential predictors, including age, gender, severity upon admission, symptoms (general symptoms, respiratory symptoms, and gastrointestinal symptoms), computed tomography (CT) signs, and comorbid chronic diseases. All variables were measured upon (or shortly after) admission. The outcome was deterioration versus recovery of COVID-19. RESULTS: More than a quarter of the 3145 people did not present any symptoms, while one-third ended isolation due to deterioration. Machine learning models identified moderate severity upon admission, old age, and CT ground-glass opacity as the most important predictors of deterioration. Removing CT signs did not degrade the performance of models. Competing risk models identified age ≥ 35 years, male gender, moderate severity upon admission, cough, expectoration, CT patchy opacity, CT consolidation, comorbid diabetes, and comorbid cardiovascular or cerebrovascular diseases as significant predictors of deterioration, while a stuffy or runny nose as a predictor of recovery. CONCLUSIONS: Early-stage prediction of COVID-19 deterioration can be made with inexpensive-to-measure variables, such as demographic characteristics, severity upon admission, observable symptoms, and self-reported comorbid diseases, among asymptomatic people and mildly to moderately symptomatic patients.

Strengthening primary care for diabetes and hypertension in Eswatini: study protocol for a nationwide cluster-randomized controlled trial.

BACKGROUND: Diabetes and hypertension are increasingly important population health challenges in Eswatini. Prior to this project, healthcare for these conditions was primarily provided through physician-led teams at tertiary care facilities and accessed by only a small fraction of people living with diabetes or hypertension. This trial tests and evaluates two community-based healthcare service models implemented at the national level, which involve health care personnel at primary care facilities and utilize the country's public sector community health worker cadre (the rural health motivators [RHMs]) to help generate demand for care. METHODS: This study is a cluster-randomized controlled trial with two treatment arms and one control arm. The unit of randomization is a primary healthcare facility along with all RHMs (and their corresponding service areas) assigned to the facility. A total of 84 primary healthcare facilities were randomized in a 1:1:1 ratio to the three study arms. The first treatment arm implements differentiated service delivery (DSD) models at the clinic and community levels with the objective of improving treatment uptake and adherence among clients with diabetes or hypertension. In the second treatment arm, community distribution points (CDPs), which previously targeted clients living with human immunodeficiency virus, extend their services to clients with diabetes or hypertension by allowing them to pick up medications and obtain routine nurse-led follow-up visits in their community rather than at the healthcare facility. In both treatment arms, RHMs visit households regularly, screen clients at risk, provide personalized counseling, and refer clients to either primary care clinics or the nearest CDP. In the control arm, primary care clinics provide diabetes and hypertension care services but without the involvement of RHMs and the implementation of DSD models or CDPs. The primary endpoints are mean glycated hemoglobin (HbA1c) and systolic blood pressure among adults aged 40 years and older living with diabetes or hypertension, respectively. These endpoints will be assessed through a household survey in the RHM service areas. In addition to the health impact evaluation, we will conduct studies on cost-effectiveness, syndemics, and the intervention's implementation processes. DISCUSSION: This study has the ambition to assist the Eswatini government in selecting the most effective delivery model for diabetes and hypertension care. The evidence generated with this national-level cluster-randomized controlled trial may also prove useful to policy makers in the wider Sub-Saharan African region. TRIAL REGISTRATION: NCT04183413. Trial registration date: December 3, 2019.

Perceptions of and obstacles to SARS-CoV-2 vaccination among adults in Lebanon: a cross-sectional online survey.

BACKGROUND: The COVID-19 pandemic is an additional burden on Lebanon's stressed population, fragmented healthcare system, and political, economic, and refugee crises. Vaccination is an important means to overcoming the pandemic. OBJECTIVE: Our study's aims were to 1) assess rates of intention to vaccinate and vaccine hesitancy in Lebanon; 2) determine how vaccine hesitancy in Lebanon varies by sociodemographic, economic, and geographic characteristics; and 3) understand individuals' motivations for vaccinating and concerns and obstacles to vaccination. METHODS: We performed a cross-sectional study from 29 Jan 2021 to 11 Mar 2021 using an online questionnaire of open- and closed-ended questions in Arabic via convenience "snowball" sampling to assess the perceptions of adults residing in Lebanon. RESULTS: 1,185 adults participated in the survey. 46.1% [95% CI: 43.2%-49.0%] of survey participants intended to take the SARS-CoV-2 vaccine when available to them, 19.0% [16.8%-21.4%] indicated that they would not, and 34.0% [31.3%-36.8%] were unsure. The most common reasons for hesitancy were concerns about safety, limited testing, side effects, and efficacy. Top motivations for vaccinating were to protect oneself, to protect one's family and the public, and to end the pandemic. Despite financial hardships in Lebanon, barriers to vaccine access were not frequently described as concerns. Established healthcare facilities, rather than new temporary vaccination centers, were most frequently selected as preferred vaccination sites. CONCLUSIONS: Vaccine hesitancy appears to be high in Lebanon. Disseminating clear, consistent, evidence-based safety and efficacy information on vaccines may help reduce vaccine hesitancy, especially among the large proportion of adults who appear to be unsure about (rather than opposed to) vaccination.

Animated, video entertainment-education to improve vaccine confidence globally during the COVID-19 pandemic: an online randomized controlled experiment with 24,000 participants.

BACKGROUND: Science-driven storytelling and entertainment-education (E-E) media demonstrate potential for promoting improved attitudes and behavioral intent towards health-related practices. Months after the outbreak of coronavirus disease 2019 (COVID-19), emerging research highlights the essential role of interventions to improve public confidence in the COVID-19 vaccine. To improve vaccine confidence, we designed three short, animated videos employing three research-informed pedagogical strategies. These can be distributed globally through social media platforms, because of their wordless and culturally accessible design. However, the effectiveness of short, animated storytelling videos, deploying various pedagogic strategies, needs to be explored across different global regions. METHODS/DESIGN: The present study is a multi-site, parallel group, randomized controlled trial (RCT) comparing the effectiveness of (i) a storytelling-instructional-humor approach, (ii) a storytelling-analogy approach, (iii) a storytelling-emotion-focused approach, and (iv) no video. For our primary outcomes, we will measure vaccine hesitancy, and for secondary outcomes, we will measure behavioral intent to seek vaccination and hope. Using online platforms, we will recruit 12,000 participants (aged 18-59 years) from the USA and China, respectively, yielding a total sample size of 24,000. DISCUSSION: This trial uses innovative online technology, reliable randomization algorithms, validated survey instruments, and list experiments to establish the effectiveness of three short, animated videos employing various research-informed pedagogical strategies. Results will be used to scientifically support the broader distribution of these short, animated video as well as informing the design of future videos for rapid, global public health communication. TRIAL REGISTRATION: German Clinical Trials Register DRKS #00023650 . Date of registration: 2021/02/09.

The impact of face-mask mandates on all-cause mortality in Switzerland: a quasi-experimental study.

BACKGROUND: Whereas there is strong evidence that wearing a face mask is effective in reducing the spread of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), evidence on the impact of mandating the wearing of face masks on deaths from coronavirus disease 2019 (COVID-19) and all-cause mortality is more sparse and likely to vary by context. Focusing on a quasi-experimental setting in Switzerland, we aimed to determine (i) the effect of face-mask mandates for indoor public spaces on all-cause mortality; and (ii) how the effect has varied over time, and by age and sex. METHODS: Our analysis exploited the fact that between July and October 2020, nine cantons in Switzerland extended a face-mask mandate at different time points from being restricted to public transportation only to applying to all public indoor places. We used both a Difference-in-Differences approach with fixed-effects for canton and week and an event-study approach. RESULTS: In our main Difference-in-Differences model, the face-mask mandate was associated with a 0.3% reduction in all-cause mortality [95% confidence interval (CI): -3.4% to 2.7%; P = 0.818]. This null effect was confirmed in the event-study approach and a variety of robustness checks. Combining the face-mask mandate with social distancing rules led to an estimated 5.1% (95% CI: -7.9% to -2.4%; P = 0.001) reduction in all-cause mortality. CONCLUSIONS: Mandating face-mask use in public indoor spaces in Switzerland in mid-to-late 2020 does not appear to have resulted in large reductions in all-cause mortality in the short term. There is some suggestion that combining face-mask mandates with social distancing rules reduced all-cause mortality.

Sex differences in the mortality rate for coronavirus disease 2019 compared to other causes of death: an analysis of population-wide data from 63 countries.

Men are more likely than women to die due to coronavirus disease 2019 (COVID-19). An open question is whether these sex differences reflect men's generally poorer health and lower life expectancy compared to women of similar ages or if men face a unique COVID-19 disadvantage. Using age-specific data on COVID-19 mortality as well as cause-specific and all-cause mortality for 63 countries, we compared the sex difference in COVID-19 mortality to sex differences in all-cause mortality and mortality from other common causes of death to determine the magnitude of the excess male mortality disadvantage for COVID-19. We found that sex differences in the age-standardized COVID-19 mortality rate were substantially larger than for the age-standardized all-cause mortality rate and mortality rate for most other common causes of death. The excess male mortality disadvantage for COVID-19 was especially large in the oldest age groups. Our findings suggest that the causal pathways that link male sex to a higher mortality from a SARS-CoV-2 infection may be specific to SARS-CoV-2, rather than shared with the pathways responsible for the shorter life expectancy among men or sex differences for other common causes of death. Understanding these causal chains could assist in the development of therapeutics and preventive measures for COVID-19 and, possibly, other coronavirus diseases.

Attitudes Toward the Global Allocation of Chinese COVID-19 Vaccines: Cross-sectional Online Survey of Adults Living in China.

BACKGROUND: COVID-19 vaccines are in short supply worldwide. China was among the first countries to pledge supplies of the COVID-19 vaccine as a global public product, and to date, the country has provided more than 600 million vaccines to more than 200 countries and regions with low COVID-19 vaccination rates. Understanding the public's attitude in China toward the global distribution of COVID-19 vaccines could inform global and national decisions, policies, and debates. OBJECTIVE: The aim of this study was to determine the attitudes of adults living in China regarding the global allocation of COVID-19 vaccines developed in China and how these attitudes vary across provinces and by sociodemographic characteristics. METHODS: We conducted a cross-sectional online survey among adults registered with the survey company KuRunData. The survey asked participants 31 questions about their attitudes regarding the global allocation of COVID-19 vaccines developed in China. We disaggregated responses by province and sociodemographic characteristics. All analyses used survey sampling weights. RESULTS: A total of 10,000 participants completed the questionnaire. Participants generally favored providing COVID-19 vaccines to foreign countries before fulfilling domestic needs (75.6%, 95% CI 74.6%-76.5%). Women (3778/4921, 76.8%; odds ratio 1.18, 95% CI 1.07-1.32; P=.002) and those living in rural areas (3123/4065, 76.8%; odds ratio 1.13, 95% CI 1.01-1.27; P=.03) were especially likely to hold this opinion. Most respondents preferred providing financial support through international platforms rather than directly offering support to individual countries (72.1%, 95% CI 71%-73.1%), while for vaccine products they preferred direct provision to relevant countries instead of via a delivery platform such as COVAX (77.3%, 95% CI 76.3%-78.2%). CONCLUSIONS: Among our survey sample, we found that adults are generally supportive of the international distribution of COVID-19 vaccines, which may encourage policy makers to support and implement the distribution of COVID-19 vaccines developed in China worldwide. Conducting similar surveys in other countries could help align policy makers' actions on COVID-19 vaccine distribution with the preferences of their constituencies.

Applying systems thinking to identify enablers and challenges to scale-up interventions for hypertension and diabetes in low-income and middle-income countries: protocol for a longitudinal mixed-methods study.

INTRODUCTION: There is an urgent need to reduce the burden of non-communicable diseases (NCDs), particularly in low-and middle-income countries, where the greatest burden lies. Yet, there is little research concerning the specific issues involved in scaling up NCD interventions targeting low-resource settings. We propose to examine this gap in up to 27 collaborative projects, which were funded by the Global Alliance for Chronic Diseases (GACD) 2019 Scale Up Call, reflecting a total funding investment of approximately US$50 million. These projects represent diverse countries, contexts and adopt varied approaches and study designs to scale-up complex, evidence-based interventions to improve hypertension and diabetes outcomes. A systematic inquiry of these projects will provide necessary scientific insights into the enablers and challenges in the scale up of complex NCD interventions. METHODS AND ANALYSIS: We will apply systems thinking (a holistic approach to analyse the inter-relationship between constituent parts of scaleup interventions and the context in which the interventions are implemented) and adopt a longitudinal mixed-methods study design to explore the planning and early implementation phases of scale up projects. Data will be gathered at three time periods, namely, at planning (TP), initiation of implementation (T0) and 1-year postinitiation (T1). We will extract project-related data from secondary documents at TP and conduct multistakeholder qualitative interviews to gather data at T0 and T1. We will undertake descriptive statistical analysis of TP data and analyse T0 and T1 data using inductive thematic coding. The data extraction tool and interview guides were developed based on a literature review of scale-up frameworks. ETHICS AND DISSEMINATION: The current protocol was approved by the Monash University Human Research Ethics Committee (HREC number 23482). Informed consent will be obtained from all participants. The study findings will be disseminated through peer-reviewed publications and more broadly through the GACD network.

Prevalence of depression in China during the early stage of the COVID-19 pandemic: a cross-sectional study in an online survey sample.

OBJECTIVES: We aimed to determine (1) the prevalence of depression during the COVID-19 pandemic among Chinese adults and (2) how depression prevalence varied by province and sociodemographic characteristics. DESIGN: Cross-sectional study. SETTING: National online survey in China. PARTICIPANTS: We conducted a cross-sectional online survey among adults registered with the survey company KuRunData from 8 May 2020 to 8 June 2020. We aimed to recruit 300-360 adults per province (n=14 493), with a similar distribution by sex and rural-urban residency as the general population within each of these provinces. PRIMARY OUTCOME: Participants completed the Patient Health Questionaire-9 (PHQ-9). We calculated the prevalence of depression (defined as a PHQ-9 score ≥10) nationally and separately for each province. ANALYSIS: Covariate-unadjusted and covariate-adjusted logistic regression models were used to examine how the prevalence of depression varied by adults' sociodemographic characteristics. All analyses used survey sampling weights. RESULTS: The survey was initiated by 14 493 participants, with 10 000 completing all survey questions and included in the analysis. The prevalence of depression in the national sample was 6.3% (95% CI 5.7% to 6.8%). A higher odds of depression was associated with living in an urban area (OR 1.50; 95% CI 1.18 to 1.90) and working as a nurse (OR 3.06; 95% CI 1.41 to 6.66). A lower odds of depression was associated with participants who had accurate knowledge of COVID-19 transmission prevention actions (OR 0.71; 95% CI 0.51 to 0.98), the knowledge that saliva is a main transmission route (OR 0.80; 95% CI 0.64 to 0.99) and awareness of COVID-19 symptoms (OR, 0.82; 95% CI 0.68 to 1.00). CONCLUSION: Around one in 20 adults in our online survey sample had a PHQ-9 score suggestive of depression. Interventions and policies to prevent and treat depression during the COVID-19 pandemic in China may be particularly needed for nurses and those living in urban areas.

Factors Predicting Progression to Severe COVID-19: A Competing Risk Survival Analysis of 1753 Patients in Community Isolation in Wuhan, China.

Most studies of coronavirus disease 2019 (COVID-19) progression have focused on the transfer of patients within secondary or tertiary care hospitals from regular wards to intensive care units. Little is known about the risk factors predicting the progression to severe COVID-19 among patients in community isolation, who are either asymptomatic or suffer from only mild to moderate symptoms. Using a multivariable competing risk survival analysis, we identify several important predictors of progression to severe COVID-19-rather than to recovery-among patients in the largest community isolation center in Wuhan, China from 6 February 2020 (when the center opened) to 9 March 2020 (when it closed). All patients in community isolation in Wuhan were either asymptomatic or suffered from mild to moderate COVID-19 symptoms. We performed competing risk survival analysis on time-to-event data from a cohort study of all COVID-19 patients (n = 1753) in the isolation center. The potential predictors we investigated were the routine patient data collected upon admission to the isolation center: age, sex, respiratory symptoms, gastrointestinal symptoms, general symptoms, and computed tomography (CT) scan signs. The main outcomes were time to severe COVID-19 or recovery. The factors predicting progression to severe COVID-19 were: male sex (hazard ratio (HR) = 1.29, 95% confidence interval (CI) 1.04-1.58, p = 0.018), young and old age, dyspnea (HR = 1.58, 95% CI 1.24-2.01, p < 0.001), and CT signs of ground-glass opacity (HR = 1.39, 95% CI 1.04-1.86, p = 0.024) and infiltrating shadows (HR = 1.84, 95% CI 1.22-2.78, p = 0.004). The risk of progression was found to be lower among patients with nausea or vomiting (HR = 0.53, 95% CI 0.30-0.96, p = 0.036) and headaches (HR = 0.54, 95% CI 0.29-0.99, p = 0.046). Our results suggest that several factors that can be easily measured even in resource-poor settings (dyspnea, sex, and age) can be used to identify mild COVID-19 patients who are at increased risk of disease progression. Looking for CT signs of ground-glass opacity and infiltrating shadows may be an affordable option to support triage decisions in resource-rich settings. Common and unspecific symptoms (headaches, nausea, and vomiting) are likely to have led to the identification and subsequent community isolation of COVID-19 patients who were relatively unlikely to deteriorate. Future public health and clinical guidelines should build on this evidence to improve the screening, triage, and monitoring of COVID-19 patients who are asymtomatic or suffer from mild to moderate symptoms.

Knowledge About COVID-19 Among Adults in China: Cross-sectional Online Survey.

BACKGROUND: A detailed understanding of the public's knowledge and perceptions of COVID-19 could inform governments' public health actions in response to the pandemic. OBJECTIVE: The aim of this study was to determine the knowledge and perceptions of COVID-19 among adults in China and its variation among provinces and by sociodemographic characteristics. METHODS: Between May 8 and June 8, 2020, we conducted a cross-sectional online survey among adults in China who were registered with the private survey company KuRunData. We set a target sample size of 10,000 adults, aiming to sample 300-360 adults from each province in China. Participants were asked 25 questions that tested their knowledge about COVID-19, including measures to prevent infection, common symptoms, and recommended care-seeking behavior. We disaggregated responses by age; sex; education; province; household income; rural-urban residency; and whether or not a participant had a family member, friend, or acquaintance who they know to have been infected with SARS-CoV-2. All analyses used survey sampling weights. RESULTS: There were 5079 men and 4921 women who completed the questionnaire and were included in the analysis. Out of 25 knowledge questions, participants answered a mean and median of 21.4 (95% CI 21.3-21.4) and 22 (IQR 20-23) questions correctly, respectively. A total of 83.4% (95% CI 82.7%-84.1%) of participants answered four-fifths or more of the questions correctly. For at least one of four ineffective prevention measures (using a hand dryer, regular nasal irrigation, gargling mouthwash, and taking antibiotics), 68.9% (95% CI 68.0%-69.8%) of participants answered that it was an effective method to prevent a SARS-CoV-2 infection. Although knowledge overall was similar across provinces, the percent of participants who answered the question on recommended care-seeking behavior correctly varied from 47.0% (95% CI 41.4%-52.7%) in Tibet to 87.5% (95% CI 84.1%-91.0%) in Beijing. Within provinces, participants who were male, were middle-aged, were residing in urban areas, and had higher household income tended to answer a higher proportion of the knowledge questions correctly. CONCLUSIONS: This online study of individuals across China suggests that the majority of the population has good knowledge of COVID-19. However, a substantial proportion still holds misconceptions or incorrect beliefs about prevention methods and recommended health care-seeking behaviors, especially in rural areas and some less wealthy provinces in Western China. This study can inform the development of tailored public health policies and promotion campaigns by identifying knowledge areas for which misconceptions are comparatively common and provinces that have relatively low knowledge.

Correction: Knowledge About COVID-19 Among Adults in China: Cross-sectional Online Survey.

[This corrects the article DOI: 10.2196/26940.].

Climate and the spread of COVID-19.

Visual inspection of world maps shows that coronavirus disease 2019 (COVID-19) is less prevalent in countries closer to the equator, where heat and humidity tend to be higher. Scientists disagree how to interpret this observation because the relationship between COVID-19 and climatic conditions may be confounded by many factors. We regress the logarithm of confirmed COVID-19 cases per million inhabitants in a country against the country's distance from the equator, controlling for key confounding factors: air travel, vehicle concentration, urbanization, COVID-19 testing intensity, cell phone usage, income, old-age dependency ratio, and health expenditure. A one-degree increase in absolute latitude is associated with a 4.3% increase in cases per million inhabitants as of January 9, 2021 (p value < 0.001). Our results imply that a country, which is located 1000 km closer to the equator, could expect 33% fewer cases per million inhabitants. Since the change in Earth's angle towards the sun between equinox and solstice is about 23.5°, one could expect a difference in cases per million inhabitants of 64% between two hypothetical countries whose climates differ to a similar extent as two adjacent seasons. According to our results, countries are expected to see a decline in new COVID-19 cases during summer and a resurgence during winter. However, our results do not imply that the disease will vanish during summer or will not affect countries close to the equator. Rather, the higher temperatures and more intense UV radiation in summer are likely to support public health measures to contain SARS-CoV-2.

Mapping physical access to health care for older adults in sub-Saharan Africa and implications for the COVID-19 response: a cross-sectional analysis.

BACKGROUND: Severe acute respiratory syndrome coronavirus 2, the virus causing COVID-19, is rapidly spreading across sub-Saharan Africa. Hospital-based care for COVID-19 is often needed, particularly among older adults. However, a key barrier to accessing hospital care in sub-Saharan Africa is travel time to the nearest health-care facility. To inform the geographical targeting of additional health-care resources, we aimed to estimate travel time at a 1 km × 1 km resolution to the nearest hospital and to the nearest health-care facility of any type for adults aged 60 years and older in sub-Saharan Africa. METHODS: We assembled a dataset on the geolocation of health-care facilities, separately for hospitals and any type of health-care facility and including both private-sector and public-sector facilities, using data from the OpenStreetMap project and the Kenya Medical Research Institute-Wellcome Trust Programme. Population data at a 1 km × 1 km resolution were obtained from WorldPop. We estimated travel time to the nearest health-care facility for each 1 km × 1 km grid using a cost-distance algorithm. FINDINGS: 9·6% (95% CI 5·2-16·9) of adults aged 60 years or older across sub-Saharan Africa had an estimated travel time to the nearest hospital of 6 h or longer, varying from 0·0% (0·0-3·7) in Burundi and The Gambia to 40·9% (31·8-50·7) in Sudan. For the nearest health-care facility of any type (whether primary, secondary, or tertiary care), 15·9% (95% CI 10·1-24·4) of adults aged 60 years or older across sub-Saharan Africa had an estimated travel time of 2 h or longer, ranging from 0·4% (0·0-4·4) in Burundi to 59·4% (50·1-69·0) in Sudan. Most countries in sub-Saharan Africa contained populated areas in which adults aged 60 years and older had a travel time to the nearest hospital of 12 h or longer and to the nearest health-care facility of any type of 6 h or longer. The median travel time to the nearest hospital for the fifth of adults aged 60 years or older with the longest travel times was 348 min (IQR 240-576; equal to 5·8 h) for the entire population of sub-Saharan Africa, ranging from 41 min (34-54) in Burundi to 1655 min (1065-2440; equal to 27·6 h) in Gabon. INTERPRETATION: Our high-resolution maps of estimated travel times to both hospitals and health-care facilities of any type can be used by policy makers and non-governmental organisations to help target additional health-care resources, such as makeshift hospitals or transport programmes to existing health-care facilities, to older adults with the least physical access to care. In addition, this analysis shows the locations of population groups most likely to under-report COVID-19 symptoms because of low physical access to health-care facilities. Beyond the COVID-19 response, this study can inform the efforts of countries to improve physical access to care for conditions that are common among older adults in the region, such as chronic non-communicable diseases. FUNDING: Bill & Melinda Gates Foundation.

Healthcare worker attendance during the early stages of the COVID-19 pandemic: A longitudinal analysis of fingerprint-verified data from all public-sector secondary and tertiary care facilities in Bangladesh.

BACKGROUND: The COVID-19 pandemic has overwhelmed hospitals in several areas in high-income countries. An effective response to this pandemic requires health care workers (HCWs) to be present at work, particularly in low- and middle-income countries (LMICs) where they are already in critically low supply. To inform whether and to what degree policymakers in Bangladesh, and LMICs more broadly, should expect a drop in HCW attendance as COVID-19 continues to spread, this study aims to determine how HCW attendance has changed during the early stages of the COVID-19 pandemic in Bangladesh. METHODS: This study analyzed daily fingerprint-verified attendance data from all 527 public-sector secondary and tertiary care facilities in Bangladesh to describe HCW attendance from January 26, 2019 to March 22, 2020, by cadre, hospital type, and geographic division. We then regressed HCW attendance onto fixed effects for day-of-week, month, and hospital, as well as indicators for each of three pandemic periods: a China-focused period (January 11, 2020 (first confirmed COVID-19 death in China) until January 29, 2020), international-spread period (January 30, 2020 (World Health Organization's declaration of a global emergency) until March 6, 2020), and local-spread period (March 7, 2020 (first confirmed COVID-19 case in Bangladesh) until the end of the study period). FINDINGS: On average between January 26, 2019 and March 22, 2020, 34.1% of doctors, 64.6% of nurses, and 70.6% of other health care staff were present for their scheduled shift. HCWs' attendance rate increased with time in 2019 among all cadres. Nurses' attendance level dropped by 2.5% points (95% confidence interval (CI) = -3.2% to -1.8%) and 3.5% points (95% CI = -4.5% to -2.5%) during the international-spread and the local-spread periods of the COVID-19 pandemic, relative to the China-focused period. Similarly, the attendance level of other health care staff declined by 0.3% points (95% CI = -0.8% to 0.2%) and 2.3% points (95% CI = -3.0% to -1.6%) during the international-spread and local-spread periods, respectively. Among doctors, however, the international-spread and local-spread periods were associated with a statistically significant increase in attendance by 3.7% points (95% CI = 2.5% to 4.8%) and 4.9% points (95% CI = 3.5% to 6.4%), respectively. The reduction in attendance levels across all HCWs during the local-spread period was much greater at large hospitals, where the majority of COVID-19 testing and treatment took place, than that at small hospitals. CONCLUSIONS: After a year of significant improvements, HCWs' attendance levels among nurses and other health care staff (who form the majority of Bangladesh's health care workforce) have declined during the early stages of the COVID-19 pandemic. This finding may portend an even greater decrease in attendance if COVID-19 continues to spread in Bangladesh. Policymakers in Bangladesh and similar LMICs should undertake major efforts to achieve high attendance levels among HCWs, particularly nurses, such as by providing sufficient personal protective equipment as well as monetary and non-monetary incentives.

Curbing the COVID-19 pandemic with facility-based isolation of mild cases: a mathematical modeling study.

BACKGROUND: In many countries, patients with mild coronavirus disease 2019 (COVID-19) are told to self-isolate at home, but imperfect compliance and shared living space with uninfected people limit the effectiveness of home-based isolation. We examine the impact of facility-based isolation compared to self-isolation at home on the continuing epidemic in the USA. METHODS: We developed a compartment model to simulate the dynamic transmission of COVID-19 and calibrated it to key epidemic measures in the USA from March to September 2020. We simulated facility-based isolation strategies with various capacities and starting times under different diagnosis rates. Our primary model outcomes are new infections and deaths over 2 months from October 2020 onwards. In addition to national-level estimations, we explored the effects of facility-based isolation under different epidemic burdens in major US Census Regions. We performed sensitivity analyses by varying key model assumptions and parameters. RESULTS: We find that facility-based isolation with moderate capacity of 5 beds per 10 000 total population could avert 4.17 (95% credible interval 1.65-7.11) million new infections and 16 000 (8000-23 000) deaths in 2 months compared with home-based isolation. These results are equivalent to relative reductions of 57% (44-61%) in new infections and 37% (27-40%) in deaths. Facility-based isolation with high capacity of 10 beds per 10 000 population could achieve reductions of 76% (62-84%) in new infections and 52% (37-64%) in deaths when supported by expanded testing with an additional 20% daily diagnosis rate. Delays in implementation would substantially reduce the impact of facility-based isolation. The effective capacity and the impact of facility-based isolation varied by epidemic stage across regions. CONCLUSION: Timely facility-based isolation for mild COVID-19 cases could substantially reduce the number of new infections and effectively curb the continuing epidemic in the USA. Local epidemic burdens should determine the scale of facility-based isolation strategies.

Revisiting the association between temperature and COVID-19 transmissibility across 117 countries.

There is a robust and significant negative association between #COVID19 transmissibility and ambient temperature at the country level. An increase of 1°C in temperature is associated with a decrease in the prevalence of COVID-19 by ∼5.4%. https://bit.ly/32OTBiS.

The Contribution of the Age Distribution of Cases to COVID-19 Case Fatality Across Countries : A Nine-Country Demographic Study.

BACKGROUND: There is wide variation in coronavirus disease 2019 (COVID-19) case-fatality rates (CFRs) across countries, leading to uncertainty about the true lethality of the disease. A large part of this variation may be due to the ages of individuals who are tested and identified. OBJECTIVE: To measure the contribution of distortions from the age distributions of confirmed cases to CFRs within and across populations. DESIGN: Cross-sectional demographic study using aggregate data on COVID-19 cases and deaths by age. SETTING: Population-based data from China, France, Germany, Italy, the Netherlands, South Korea, Spain, Switzerland, and the United States. PARTICIPANTS: All individuals with confirmed COVID-19, as reported by each country as of 19 April 2020 (n = 1 223 261). MEASUREMENTS: Age-specific COVID-19 CFRs and age-specific population shares by country. RESULTS: The overall observed CFR varies widely, with the highest rates in Italy (9.3%) and the Netherlands (7.4%) and the lowest rates in South Korea (1.6%) and Germany (0.7%). Adjustment for the age distribution of cases explains 66% of the variation across countries, with a resulting age-standardized median CFR of 1.9%. Among a larger sample of 95 countries, the observed variation in COVID-19 CFRs is 13 times larger than what would be expected on the basis of just differences in the age composition of countries. LIMITATION: The age-adjusted rates assume that, conditional on age, COVID-19 mortality among diagnosed cases is the same as that among undiagnosed cases and that individuals of all ages are equally susceptible to severe acute respiratory syndrome coronavirus 2 infection. CONCLUSION: Selective testing and identification of older cases considerably warps estimates of the lethality of COVID-19 within populations and comparisons across countries. Removing age distortions and focusing on differences in age-adjusted case fatality will be essential for accurately comparing countries' performance in caring for patients with COVID-19 and for monitoring the epidemic over time. PRIMARY FUNDING SOURCE: Alexander von Humboldt Foundation.

Using rapid online surveys to assess perceptions during infectious disease outbreaks: a cross-sectional survey on Covid-19 among the general public in the United States and United Kingdom.

BACKGROUND: Given the extensive time needed to conduct a nationally representative household survey and the commonly low response rate in phone surveys, rapid online surveys may be a promising method to assess and track knowledge and perceptions among the general public during fast-moving infectious disease outbreaks. OBJECTIVE: To apply rapid online surveying to determine knowledge and perceptions of coronavirus disease 2019 (Covid-19) among the general public in the United States (US) and the United Kingdom (UK). METHODS: An online questionnaire was administered to 3,000 adults residing in the US and 3,000 adults residing in the UK who had registered with Prolific Academic to participate in online research. Strata by age (18 - 27, 28 - 37, 38 - 47, 48 - 57, or >=58 years), sex (male or female), and ethnicity (White, Black or African American, Asian or Asian Indian, Mixed, or "Other"), and all permutations of these strata, were established. The number of participants who could enrol in each of these strata was calculated to reflect the distribution in the US and UK general population. Enrolment into the survey within the strata was on a first-come, first-served basis. Participants completed the questionnaire between February 23 and March 2 2020. RESULTS: 2,986 and 2,988 adults residing in the US and the UK, respectively, completed the questionnaire. 64.4% (1,924/2,986) of US and 51.5% (1,540/2,988) of UK participants had a tertiary education degree. 67.5% (2,015/2,986) of US participants had a total household income between $20,000 and $99,999, and 74.4% (2,223/2,988) of UK participants had a total household income between GBP15,000 and GBP74,999. US and UK participants' median estimate for the probability of a fatal disease course among those infected with SARS-CoV-2 was 5.0% (IQR: 2.0% - 15.0%) and 3.0% (IQR: 2.0% - 10.0%), respectively. Participants generally had good knowledge of the main mode of disease transmission and common symptoms of Covid-19. However, a substantial proportion of participants had misconceptions about how to prevent an infection and the recommended care-seeking behavior. For instance, 37.8% (95% CI: 36.1% - 39.6%) of US and 29.7% (95% CI: 28.1% - 31.4%) of UK participants thought that wearing a common surgical mask was 'highly effective' in protecting them from acquiring Covid-19. 25.6% (95% CI: 24.1% - 27.2%) of US and 29.6% (95% CI: 28.0% - 31.3%) of UK participants thought it prudent to refrain from eating at Chinese restaurants. Around half (53.8% [95% CI: 52.1% - 55.6%] of US and 39.1% [95% CI: 37.4% - 40.9%] of UK participants) thought that children were at an especially high risk of death when infected with SARS-CoV-2. CONCLUSIONS: The distribution of participants by total household income and education followed approximately that of the general population. The findings from this online survey could guide information campaigns by public health authorities, clinicians, and the media. More broadly, rapid online surveys could be an important tool in tracking the public's knowledge and misperceptions during rapidly moving infectious disease outbreaks.

Trends in Mail-Order Prescription Use among U.S. Adults from 1996 to 2018: A Nationally Representative Repeated Cross-Sectional Study.

BACKGROUND: Mail-order prescriptions are popular in the U.S., but the recent mail delays due to operational changes at the United States Postal Services (USPS) may postpone the delivery of vital medications. Despite growing recognition of the health and economic effects of a postal crisis on mail-order pharmacy consumers, little is known about the extent of mail-order prescription use, and most importantly, the population groups and types of medications that will likely be most affected by these postal delays. METHODS: The prevalence of mail-order prescription use was assessed using a nationally representative repeated cross-sectional survey (the Medical Expenditure Panel Survey) carried out among adults aged 18 and older in each year from 1996 to 2018. We stratified use of mail-order prescription by socio-demographic and health characteristics. Additionally, we calculated which prescription medications were most prevalent among all mailed medications, and for which medications users were most likely to opt for mail-order prescription. FINDINGS: 500,217 adults participated in the survey. Between 1996 and 2018, the prevalence of using at least one mail-order prescription in a year among U.S. adults was 9.8% (95% CI, 9.5%-10.0%). Each user purchased a mean of 19.4 (95% CI, 19.0-19.8) mail-order prescriptions annually. The prevalence of use increased from 6.9% (95% CI, 6.4%-7.5%) in 1996 to 10.3% (95% CI, 9.7%-10.9%) in 2018, and the mean annual number of mail-order prescriptions per user increased from 10.7 (95% CI, 9.8-11.7) to 20.5 (95% CI, 19.3-21.7) over the same period. Use of mail-order prescription in 2018 was common among adults aged 65 and older (23.9% [95% CI, 22.3%-25.4%]), non-Hispanic whites (13.6% [95% CI, 12.8%-14.5%]), married adults (12.7% [95% CI, 11.8%-13.6%]), college graduates (12.2% [95% CI, 11.3%-13.1%]), high-income adults (12.6%, [95% CI, 11.6%-13.6%]), disabled adults (19.3% [95% CI, 17.9%-20.7%]), adults with poor health status (15.6% [95% CI, 11.6%-19.6%]), adults with three or more chronic conditions (24.2% [95% CI, 22.2%-26.2%]), Medicare beneficiaries (22.8% [95% CI, 21.4%-24.3%]), and military-insured adults (13.9% [95% CI, 10.8%-17.1%]). Mail-order prescriptions were commonly filled for analgesics, levothyroxine, cardiovascular agents, antibiotics, and diabetes medications. INTERPRETATION: The use of mail-order prescription, including for critical medications such as insulin, is increasingly common among U.S. adults and displays substantial variation between population groups. A national slowdown of mail delivery could have important health consequences for a considerable proportion of the U.S. population, particularly during the current Coronavirus disease 2019 epidemic.