Inequality on the frontline: A multi-country study on gender differences in mental health among healthcare workers during the COVID-19 pandemic (preprint)

Purpose Healthcare workers (HCWs) were at increased risk for mental health problems during the COVID-19 pandemic, with data from previous crises suggesting women may be particularly vulnerable. The objective of the study was to examine individual and social factors that may be associated with gender differences in psychological distress and depressive symptoms among HCWs during the initial COVID-19 pandemic outbreak and to examine the consistency of these differences across a diverse range of countries.Methods Data were collected in a cross-sectional design between March 2020 and February 2021 as part of the COVID-19 HEalth caRe wOrkErS (HEROES) study. 32,410 HCWs recruited across 22 countries completed the General Health Questionnaire-12 (GHQ-12), the Patient Health Questionnaire-9 (PHQ-9), and questions about pandemic-relevant exposures.Results Consistently across countries, women reported elevated mental health problems compared to men. Women also reported increased COVID-19-relevant stressors, including less access to sufficient personal protective equipment and less support from colleagues than men; however, men reported increased contact with COVID-19 patients. At the country-level, HCWs working in countries with higher gender inequality reported lower levels of mental health problems. Higher COVID-19 mortality rates were associated with increased psychological distress among women but not among men.Conclusion Our findings suggest that among HCWs, women may have been disproportionately exposed to several COVID-19-relevant stressors at the individual and country-level. This highlights the importance of considering gender in emergency response efforts to protect women’s well-being and ensure adequate healthcare system preparedness during future public health crises.

Residents' Perceptions of a Novel Virtual Livestream Cadaveric Teaching Series for Musculoskeletal Anatomy Education.

ABSTRACT: Musculoskeletal anatomy education is essential to many healthcare providers, but has consistently been considered difficult for various reasons. Traditional methods have focused on in-person cadaveric teaching, which became inaccessible during the COVID-19 pandemic; therefore, new teaching methods were developed to address this gap in education. This project implemented novel virtual livestream musculoskeletal anatomy teaching methodology with cadaveric prosections and evaluated the efficacy of this modality compared to traditional in-person cadaveric teaching. A targeted musculoskeletal anatomy curriculum was developed and delivered via livestream to 12 Canadian physiatry residents. Upon completing the virtual curriculum, residents completed an anonymous survey assessing this new virtual livestream cadaveric methodology compared to prior experiences with traditional in-person anatomy teaching. The survey response rate was 92%. Most participants (73%) rated the virtual livestream sessions as better than traditional in-person teaching. Reasons included better visualization of cadaveric anatomy and easy discussion amongst the group. T-test analysis comparing both methods demonstrated the livestream method was equivalent or better across several domains. Virtual livestream teaching is a viable method for teaching the important subject of musculoskeletal anatomy. Educators should consider how to best integrate this approach into future anatomy curricula.

Associations between the stringency of COVID-19 containment policies and health service disruptions in 10 countries.

BACKGROUND: Disruptions in essential health services during the COVID-19 pandemic have been reported in several countries. Yet, patterns in health service disruption according to country responses remain unclear. In this paper, we investigate associations between the stringency of COVID-19 containment policies and disruptions in 31 health services in 10 low- middle- and high-income countries in 2020. METHODS: Using routine health information systems and administrative data from 10 countries (Chile, Ethiopia, Ghana, Haiti, Lao People's Democratic Republic, Mexico, Nepal, South Africa, South Korea, and Thailand) we estimated health service disruptions for the period of April to December 2020 by dividing monthly service provision at national levels by the average service provision in the 15 months pre-COVID (January 2019-March 2020). We used the Oxford COVID-19 Government Response Tracker (OxCGRT) index and multi-level linear regression analyses to assess associations between the stringency of restrictions and health service disruptions over nine months. We extended the analysis by examining associations between 11 individual containment or closure policies and health service disruptions. Models were adjusted for COVID caseload, health service category and country GDP and included robust standard errors. FINDINGS: Chronic disease care was among the most affected services. Regression analyses revealed that a 10% increase in the mean stringency index was associated with a 3.3 percentage-point (95% CI -3.9, -2.7) reduction in relative service volumes. Among individual policies, curfews, and the presence of a state of emergency, had the largest coefficients and were associated with 14.1 (95% CI -19.6, 8.7) and 10.7 (95% CI -12.7, -8.7) percentage-point lower relative service volumes, respectively. In contrast, number of COVID-19 cases in 2020 was not associated with health service disruptions in any model. CONCLUSIONS: Although containment policies were crucial in reducing COVID-19 mortality in many contexts, it is important to consider the indirect effects of these restrictions. Strategies to improve the resilience of health systems should be designed to ensure that populations can continue accessing essential health care despite the presence of containment policies during future infectious disease outbreaks.

Transformation of Urban–Rural Relationships in the Context of Global Challenges

This article updates and further develops the reflections of "Urbanization and Sustainability after the COVID-19 Pandemic” (Motta 2020). It is now even more urgent to focus on the urban–rural relationships that are being modified by the pandemic, climate change, and the impacts of conflicts, causing serious human insecurities and increasing precarious circumstances worldwide. The fast-changing situation and recurrent emergencies confirm the need for a new urban development approach, related to the specificities of the surrounding environment and based on the revival of towns and settlements spread over territories. This should function as a complementary tool to mitigate urbanization flows and urban–rural gaps, identifying new relationships. This requires the review of current urban paradigms, which are no longer able to respond to modified conditions and demands with an innova-tive vision. This is actualized on the basis of the principles of the social quality theory (SQT) and approach (SQA) and their emphasis on processes in and between the four relevant dimensions of societal life. In the past decade, these principles have been developed tentatively in working papers about sustainability and urban issues from a social quality perspective. © The Author(s).

A Tricky Diagnosis of Poncet's Disease.

Erythema nodosum (EN) is a type of panniculitis often benign and self-limited. It may, however, be associated with numerous causes, the most common being infections (namely streptococcal infections), of which tuberculosis (TB) is also one. We report the case of a 43-year-old woman who was referred to our outpatient department with signs of a recurrent EN along with an asymmetrical oligoarthritis of the lower limbs. The investigation excluded all etiological causes of EN, except the interferon gamma release assay (IGRA) which was positive. It was assumed a latent TB infection was the cause of EN. Treatment with isoniazid was started, besides prednisolone and colchicine, with maintained clinical remission. There are just a few cases published about this subject and this intends to emphasize the importance of medical history and of an exhaustive search for a cause, as it may slip away due to the absence of symptoms.

Tracking health system performance in times of crisis using routine health data: lessons learned from a multicountry consortium.

COVID-19 has prompted the use of readily available administrative data to track health system performance in times of crisis and to monitor disruptions in essential healthcare services. In this commentary we describe our experience working with these data and lessons learned across countries. Since April 2020, the Quality Evidence for Health System Transformation (QuEST) network has used administrative data and routine health information systems (RHIS) to assess health system performance during COVID-19 in Chile, Ethiopia, Ghana, Haiti, Lao People's Democratic Republic, Mexico, Nepal, South Africa, Republic of Korea and Thailand. We compiled a large set of indicators related to common health conditions for the purpose of multicountry comparisons. The study compiled 73 indicators. A total of 43% of the indicators compiled pertained to reproductive, maternal, newborn and child health (RMNCH). Only 12% of the indicators were related to hypertension, diabetes or cancer care. We also found few indicators related to mental health services and outcomes within these data systems. Moreover, 72% of the indicators compiled were related to volume of services delivered, 18% to health outcomes and only 10% to the quality of processes of care. While several datasets were complete or near-complete censuses of all health facilities in the country, others excluded some facility types or population groups. In some countries, RHIS did not capture services delivered through non-visit or nonconventional care during COVID-19, such as telemedicine. We propose the following recommendations to improve the analysis of administrative and RHIS data to track health system performance in times of crisis: ensure the scope of health conditions covered is aligned with the burden of disease, increase the number of indicators related to quality of care and health outcomes; incorporate data on nonconventional care such as telehealth; continue improving data quality and expand reporting from private sector facilities; move towards collecting patient-level data through electronic health records to facilitate quality-of-care assessment and equity analyses; implement more resilient and standardized health information technologies; reduce delays and loosen restrictions for researchers to access the data; complement routine data with patient-reported data; and employ mixed methods to better understand the underlying causes of service disruptions.

Virtual Objective Structured Clinical Examination Experiences and Performance in Physical Medicine and Rehabilitation Residency.

BACKGROUND: Virtual education has been described before and during the COVID-19 pandemic. Studies evaluating virtual objective structured clinical examinations with postgraduate learners are lacking. This study (1) evaluated the experiences of all participants in a virtual objective structured clinical examination and (2) assessed the validity and reliability of selected virtual objective structured clinical examination stations for skills in physical medicine and rehabilitation. METHODS: Convergent mixed-methods design was used. Participants included three physical medicine and rehabilitation residency programs holding a joint virtual objective structured clinical examination. Analysis included descriptive statistics and thematic analysis. Performance of virtual to previous in-person objective structured clinical examination was compared using independent t tests. RESULTS: Survey response rate was 85%. No participants had previous experience with virtual objective structured clinical examination. Participants found the virtual objective structured clinical examination to be acceptable (79.4%), believable (84.4%), and valuable for learning (93.9%). No significant differences between in-person and virtual objective structured clinical examination scores was found for three-fourth stations and improved scores in one fourth. Four themes were identified: (1) virtual objective structured clinical examinations are better for communication stations; (2) significant organization is required to run a virtual objective structured clinical examination; (3) adaptations are required compared with in-person objective structured clinical examinations; and (4) virtual objective structured clinical examinations provide improved accessibility and useful practice for virtual clinical encounters. CONCLUSIONS: Utility of virtual objective structured clinical examinations as a component of a program of assessment should be carefully considered and may provide valuable learning opportunities going forward.

Individual differences and compliance intentions with COVID-19 restrictions: insights from a lockdown in Melbourne (Australia).

The coronavirus (COVID-19) pandemic has caused an international public health and economic crisis. Despite the COVID-19 vaccine rollout in many countries from late 2020, non-pharmaceutical interventions are still required to minimize the spread of the virus. However, notable variation in voluntary compliance with these interventions has been reported. This study investigated various individual differences associated with intentions to comply with COVID-19 restrictions during a sustained (112 day) lockdown in Melbourne (Australia) in late 2020. Participants (N = 363) completed an online survey where they responded to various socio-demographic, health and psychological questions. Participants also responded to a series of vignettes that assessed their intended behaviour in specific situations and their knowledge of the current COVID-19 restrictions. Overall, it was found that greater levels of organization predicted greater intentions to comply with the COVID-19 restrictions, while higher socio-economic status, sociability and anxiety predicted lower compliance intentions. Further, individuals previously diagnosed with COVID-19 reported lower intentions to comply with the COVID-19 restrictions. The strongest predictor of compliance intentions, however, was a greater knowledge of the current restrictions. These findings highlight that public health orders around COVID-19 restrictions should be presented in a clear and uncomplicated manner and should target specific groups to increase compliance.

Effect of COVID-19 pandemic on the implementation of a multimorbidity person-centered care model: A qualitative study from health teams' perspective.

The COVID-19 pandemic has abruptly changed care priority and delivery, delaying others like the multimorbidity approach. The Centro de Innovación en Salud ANCORA UC, the Health National Fund, and the Servicio de Salud Metropolitano Sur Oriente implemented a Multimorbidity Patient-Centered Care Model as a pilot study in the public health network from 2017 to 2020. Its objective was to reorganize the single diagnosis standard care into a new one based on multimorbidity integrated care. It included incorporating new roles, services, and activities according to each patient's risk stratification. This study aims to describe the perception of the health care teams regarding the impact of the COVID-19 pandemic on four main topics: how the COVID-19 pandemic affected the MCPM implementation, how participants adapted it, lessons learned, and recommendations for sustainability. We conducted a qualitative study with 35 semi-structured interviews between October and December 2020. Data analysis was codified, triangulated, and consolidated using MAXQDA 2020. Results showed that the pandemic paused the total of the implementation practically. Positive effects were the improvement of remote health care services, the activation of self-management, and the cohesion of the teamwork. In contrast, frequent abrupt changes and reorganization forced by pandemic evolution were negative effects. This study revealed the magnitude of the pandemic in the cancelation of health services and identified the urgent need to restart chronic services incorporating patient-centered care in our system.

COVID-19 and resilience of healthcare systems in ten countries.

Declines in health service use during the Coronavirus Disease 2019 (COVID-19) pandemic could have important effects on population health. In this study, we used an interrupted time series design to assess the immediate effect of the pandemic on 31 health services in two low-income (Ethiopia and Haiti), six middle-income (Ghana, Lao People's Democratic Republic, Mexico, Nepal, South Africa and Thailand) and high-income (Chile and South Korea) countries. Despite efforts to maintain health services, disruptions of varying magnitude and duration were found in every country, with no clear patterns by country income group or pandemic intensity. Disruptions in health services often preceded COVID-19 waves. Cancer screenings, TB screening and detection and HIV testing were most affected (26-96% declines). Total outpatient visits declined by 9-40% at national levels and remained lower than predicted by the end of 2020. Maternal health services were disrupted in approximately half of the countries, with declines ranging from 5% to 33%. Child vaccinations were disrupted for shorter periods, but we estimate that catch-up campaigns might not have reached all children missed. By contrast, provision of antiretrovirals for HIV was not affected. By the end of 2020, substantial disruptions remained in half of the countries. Preliminary data for 2021 indicate that disruptions likely persisted. Although a portion of the declines observed might result from decreased needs during lockdowns (from fewer infectious illnesses or injuries), a larger share likely reflects a shortfall of health system resilience. Countries must plan to compensate for missed healthcare during the current pandemic and invest in strategies for better health system resilience for future emergencies.

AI Based Monitoring of Different Risk Levels in COVID-19 Context.

COVID-19 was responsible for devastating social, economic, and political effects all over the world. Although the health authorities imposed restrictions provided relief and assisted with trying to return society to normal life, it is imperative to monitor people's behavior and risk factors to keep virus transmission levels as low as possible. This article focuses on the application of deep learning algorithms to detect the presence of masks on people in public spaces (using RGB cameras), as well as the detection of the caruncle in the human eye area to make an accurate measurement of body temperature (using thermal cameras). For this task, synthetic data generation techniques were used to create hybrid datasets from public ones to train state-of-the-art algorithms, such as YOLOv5 object detector and a keypoint detector based on Resnet-50. For RGB mask detection, YOLOv5 achieved an average precision of 82.4%. For thermal masks, glasses, and caruncle detection, YOLOv5 and keypoint detector achieved an average precision of 96.65% and 78.7%, respectively. Moreover, RGB and thermal datasets were made publicly available.

Evaluating SARS-CoV-2 Seroconversion Following Relieve of Confinement Measures.

Seroprevalence studies are crucial both for estimating the prevalence of SARS-CoV-2 exposure and to provide a measure for the efficiency of the confinement measures. Portuguese universities were closed on March 16th 2020, when Portugal only registered 62 SARS-CoV-2 infection cases per million. We have validated a SARS-CoV-2 ELISA assay to a stabilized full-length spike protein using 216 pre-pandemic and 19 molecularly diagnosed SARS-CoV-2 positive individual's samples. At NOVA University of Lisbon, presential work was partially resumed on May 25th with staggered schedules. From June 15th to 30th, 3-4 weeks after the easing of confinement measures, we screened 1,636 collaborators of NOVA university of Lisbon for the presence of SARS-CoV-2 spike specific IgA and IgG antibodies. We found that spike-specific IgG in 50 of 1,636 participants (3.0%), none of which had anti-spike IgA antibodies. As participants self-reported as asymptomatic or paucisymptomatic, our study also provides a measurement of the prevalence of asymptomatic/paucisymptomatic SARS-CoV-2 infections. Our study suggests that essential workers have a 2-fold increase in viral exposure, when compared to non-essential workers that observed confinement. Additional serological surveys in different population subgroups will paint a broader picture of the effect of the confinement measures in the broader community.

Barriers to Accessing Healthy Food and Food Assistance During the COVID-19 Pandemic and Racial Justice Uprisings: A Mixed-Methods Investigation of Emerging Adults' Experiences.

BACKGROUND: A steep rise in food insecurity is among the most pressing US public health problems that has resulted from the COVID-19 pandemic. OBJECTIVE: This study aimed to (1) describe how food-insecure emerging adults are adapting their eating and child-feeding behaviors during COVID-19 and (2) identify barriers and opportunities to improve local food access and access to food assistance. DESIGN: The COVID-19 Eating and Activity Over Time study collected survey data from emerging adults during April to October 2020 and completed interviews with a diverse subset of food-insecure respondents. PARTICIPANTS/SETTING: A total of 720 emerging adults (mean age: 24.7 ± 2.0 years; 62% female; 90% living in Minnesota) completed an online survey, and a predominately female subsample (n = 33) completed an interview by telephone or videoconference. MAIN OUTCOME MEASURES: Survey measures included the short-form of the US Household Food Security Survey Module and 2 items to assess food insufficiency. Interviews assessed eating and feeding behaviors along with barriers to healthy food access. ANALYSES PERFORMED: Descriptive statistics and a hybrid deductive and inductive content analysis. RESULTS: Nearly one-third of survey respondents had experienced food insecurity in the past year. Interviews with food-insecure participants identified 6 themes with regard to changes in eating and feeding behavior (eg, more processed food, sporadic eating), 5 themes regarding local food access barriers (eg, limited enforcement of COVID-19 safety practices, experiencing discrimination), and 4 themes regarding barriers to accessing food assistance (eg, lack of eligibility, difficulty in locating pantries). Identified recommendations include (1) expanding the distribution of information about food pantries and meal distribution sites, and (2) increasing fresh fruit and vegetable offerings at these sites. CONCLUSIONS: Interventions of specific relevance to COVID-19 (eg, stronger implementation of safety practices) and expanded food assistance services are needed to improve the accessibility of healthy food for emerging adults.

Staff SARS-CoV-2 Seroprevalence and Mental Health as Key Factors in University Response to COVID-19 Pandemic.

Background: In response to rapid global spread of the newly emerged coronavirus disease 2019 (COVID-19), universities transitioned to online learning and telework to decrease risks of inter-person contact. To help administrators respond to the COVID-19 pandemic and better understand its impacts, we surveyed SARS-CoV-2 seroprevalence among NOVA University employees and assessed community mental health. Methods: Data were collected from voluntary participants at six NOVA University locations, in the Lisbon metropolitan area, from June 15-30, 2020. All subjects provided written informed consent. Of 1,627 recruited participants (mean age 42.0 ± 12.3 years), 1,624 were tested. Prior to blood collection, participants completed a questionnaire that assessed: COVID-19 symptoms during the previous 14 days, chronic non-communicable diseases, chronic medication, anxiety, and depression symptoms. SARS-CoV-2 serology tests were then performed, and results communicated approximately 4 days after blood draw. Participants with positive serology tests were contacted to assess COVID-19 symptoms since February. Results: Estimated prevalence of SARS-CoV-2 IgG antibodies was 3.1% (n = 50), of which 43.5% reported symptoms in the previous 4 months. The Medical School had the highest seroprevalence (6.2%). Participants reported having at least one chronic disease (63.7%), depression-like symptoms (2.1%), and anxiety symptoms (8.1%). Rates of depression and anxiety symptoms were significantly higher in women, with sleep hours and occasional alcohol consumption negatively associated with depression. Male gender, older age, and sleep hours negatively associated with anxiety symptoms. School of employment and presence of comorbidities positively associated with anxiety. Conclusion: By measuring seroprevalence of SARS-CoV-2 antibodies among NOVA employees and assessing subjects' mental health, we aim to help administrators at European public universities in urban areas, such as Lisbon, Portugal, better understand the needs of their communities. This study resulted in implementation of a stricter contingency plan in the Medical School, while other schools continued to follow Government mitigation guidelines. These findings may also guide the development of tailored strategies to ensure physical and mental health of the academic community during this pandemic crisis. We conclude that, together with COVID-19 contingency plans, psychological support services and facilities to help people effectively face pandemic-associated challenges and minimise anxiety and depression should be implemented.

Detection and Genome Sequencing of SARS-CoV-2 Variants Belonging to the B.1.1.7 Lineage in the Philippines.

We report the sequencing and detection of 36 severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) samples containing lineage-defining mutations specific to viruses belonging to the B.1.1.7 lineage in the Philippines.

Genome sequencing and detection of Philippine SARS-CoV-2 infections with viruses classified under the B.1.1.7 lineage (preprint)

We report the sequencing and detection of 39 Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infections in the Philippines identified to be caused by viruses under the B.1.1.7 lineage (UK variant). Genome sequences obtained from these samples carry the lineage-defining mutations associated with the said variant of concern.

Genome sequencing and analysis of an emergent SARS-CoV-2 variant characterized by multiple spike protein mutations detected from the Central Visayas Region of the Philippines (preprint)

The emergence of SARS-CoV-2 variants of concern such as the B.1.1.7, B.1.35 and the P.1 have prompted calls for governments worldwide to increase their genomic biosurveillance efforts. Globally, quarantine and outbreak management measures have been implemented to stem the introduction of these variants and to monitor any emerging variants of potential clinical significance domestically. Here, we describe the emergence of a new SARS-CoV-2 lineage, mainly from the Central Visayas region of the Philippines. This emergent variant is characterized by 13 lineage-defining mutations, including the co-occurrence of the E484K, N501Y, and P681H mutations at the spike protein region, as well as three additional radical amino acid replacements towards the C-terminal end of the said protein. A three-amino acid deletion at positions 141 to 143 (LGV141_143del) in the spike protein was likewise seen in a region preceding the 144Y deletion found in the B.1.1.7 variant. A single amino acid replacement, K2Q, at the N-terminus of ORF8 was also shared by all 33 samples sequenced. The mutation profile of this new virus variant warrants closer investigation due to its potential public health implications. The current distribution of this emergent variant in the Philippines and its transmission are being monitored and addressed by relevant public health agencies to stem its spread in nearby islands and regions in the country.

Knowledge of social distancing measures and adherence to restrictions during the COVID-19 pandemic.

ISSUE ADDRESSED: With no efficacious treatments or vaccines available, social distancing measures remain the most effective approach for reducing the transmission of the COVID-19 virus. However, adherence to social distance measures presumably requires knowledge and understanding of the current social distancing restrictions. METHODS: A modified version of the Theory of Planned Behaviour examined the role of knowledge and understanding of current social distancing measures in predicting intentions to adhere to social distancing restrictions. An online survey was administered to respondents (N = 374) in Melbourne, Australia during a period of heightened social distancing restrictions. In addition to measuring respondents' general intentions to adhere to restrictions, vignettes were used to assess intended behaviour in specific situations. RESULTS: Knowledge of social distancing restrictions predicted intentions to adhere in specific situations, but not general intentions to adhere. Knowledge of restrictions also predicted positive attitudes towards current restrictions and a greater perceived ability to adhere to the restrictions, while positive attitudes was a good predictor of both general and specific intentions to adhere. CONCLUSIONS: The findings suggest that attitudes towards restrictions may influence whether individuals attempt to adhere to restrictions, but knowledge of the restrictions influences whether the intended behaviour actually adheres to current restrictions. SO WHAT?: These outcomes indicate that members of the public should be educated regarding the negative consequences associated with the COVID-19 virus and the capacity of social distancing to reduce transmission of the virus, and a need for social distancing restrictions to be uncomplicated and clearly communicated.