Embedding rapid reviews in health policy and systems decision-making: Impacts and lessons learned from four low- and middle-income countries.

BACKGROUND: Demand for rapid evidence-based syntheses to inform health policy and systems decision-making has increased worldwide, including in low- and middle-income countries (LMICs). To promote use of rapid syntheses in LMICs, the WHO's Alliance for Health Policy and Systems Research (AHPSR) created the Embedding Rapid Reviews in Health Systems Decision-Making (ERA) Initiative. Following a call for proposals, four LMICs were selected (Georgia, India, Malaysia and Zimbabwe) and supported for 1 year to embed rapid response platforms within a public institution with a health policy or systems decision-making mandate. METHODS: While the selected platforms had experience in health policy and systems research and evidence syntheses, platforms were less confident conducting rapid evidence syntheses. A technical assistance centre (TAC) was created from the outset to develop and lead a capacity-strengthening program for rapid syntheses, tailored to the platforms based on their original proposals and needs as assessed in a baseline questionnaire. The program included training in rapid synthesis methods, as well as generating synthesis demand, engaging knowledge users and ensuring knowledge uptake. Modalities included live training webinars, in-country workshops and support through phone, email and an online platform. LMICs provided regular updates on policy-makers' requests and the rapid products provided, as well as barriers, facilitators and impacts. Post-initiative, platforms were surveyed. RESULTS: Platforms provided rapid syntheses across a range of AHPSR themes, and successfully engaged national- and state-level policy-makers. Examples of substantial policy impact were observed, including for COVID-19. Although the post-initiative survey response rate was low, three quarters of those responding felt confident in their ability to conduct a rapid evidence synthesis. Lessons learned coalesced around three themes - the importance of context-specific expertise in conducting reviews, facilitating cross-platform learning, and planning for platform sustainability. CONCLUSIONS: The ERA initiative successfully established rapid response platforms in four LMICs. The short timeframe limited the number of rapid products produced, but there were examples of substantial impact and growing demand. We emphasize that LMICs can and should be involved not only in identifying and articulating needs but as co-designers in their own capacity-strengthening programs. More time is required to assess whether these platforms will be sustained for the long-term.

Ontarians' Perceptions of Public Health Communications and Misinformation During the COVID-19 Pandemic: Survey Study.

BACKGROUND: Clear, accurate, and transparent risk communication is critical to providing policy makers and the public with directions to effectively implement public health strategies during a health emergency. OBJECTIVE: We aimed to explore the public's preferred sources of obtaining COVID-19 information, perceptions on the prevalence and drivers of misinformation during the pandemic, and suggestions to optimize health communications during future public health emergencies. METHODS: We administered a web-based survey that included Likert scale, multiple choice and open-ended response questions to residents of Ontario, Canada. We aimed to recruit a sample that reflected population diversity with respect to age and gender. Data were collected between June 10, 2020, and December 31, 2020, and were analyzed using descriptive statistics; open-ended data were analyzed using content analysis. Subgroup analyses to explore perceptions by age and gender were conducted using ordinal regression. RESULTS: A total of 1823 individuals participated in the survey (n=990, 54% women; n=703, 39% men; n=982, 54% aged 18-40 years; n=518, 28% aged 41-60 years; and n=215, 12% aged ≥61 years). Participants most commonly obtained COVID-19 information from local television news (n=1118, 61%) followed by social media (n=938, 51%), national or international television news (n=888, 49%), and friends and family (n=835, 46%). Approximately 55% (n=1010) of the participants believed they had encountered COVID-19-related misinformation; 70% (n=1284) of the participants reported high levels of trust in health authority websites and health care providers; 66% (n=1211) reported high levels of trust in health ministers or public health organizations. Sources perceived to be less trustworthy included friends and family, talk radio, social media, as well as blogs and opinion websites. Men were more likely to report encountering misinformation and to trust friends or family (odds ratio [OR] 1.49, 95% CI 1.24-1.79) and blogs or opinion websites (OR 1.24, 95% CI 1.03-1.50), compared to women. Compared to those aged 18-40 years, participants aged ≥41years were more likely to trust all assessed information sources, with the exception of web-based media sources, and less likely to report encountering misinformation. Of those surveyed, 58% (n=1053) had challenges identifying or appraising COVID-19 information. CONCLUSIONS: Over half of our participants perceived that they had encountered COVID-19 misinformation, and 58% had challenges identifying or appraising COVID-19 information. Gender and age differences in perceptions of misinformation and trust in information sources were observed. Future research to confirm the validity of these perceptions and to explore information-seeking patterns by population subgroups may provide useful insights on how to optimize health communication during public health emergencies.

Canadian public perceptions and experiences with information during the COVID-19 pandemic: strategies to optimize future risk communications.

BACKGROUND: The COVID-19 pandemic accelerated the spread of misinformation worldwide. The purpose of this study was to explore perceptions of misinformation and preferred sources of obtaining COVID-19 information from those living in Canada. In particular, we sought to explore the perceptions of East Asian individuals in Canada, who experienced stigma related to COVID-19 messaging. METHODS: We conducted a qualitative thematic analysis study. Interviews were offered in English, Mandarin and Cantonese. Interviewers probed for domains related to knowledge about COVID-19, preferred sources of information, perceived barriers and facilitators of misinformation, and preferences for communication during a health emergency. Interviews were recorded, translated, transcribed verbatim and analyzed using a framework approach. Transcripts were independently double-coded until > 60% agreement was reached. This study received research ethics approval. RESULTS: Fifty-five interviews were conducted. The majority of participants were women (67%); median age was 52 years. 55% of participants were of East-Asian descent. Participants obtained information about COVID-19 from diverse English and non-English sources including news media, government agencies or representatives, social media, and personal networks. Challenges to seeking and understanding information included: encountering misinformation, making sense of evolving or conflicting public health guidance, and limited information on topics of interest. 65% of participants reported encountering COVID-19  misinformation. East Asian participants called on government officials to champion messaging to reduce stigmatizing and racist rhetoric and highlighted the importance of having accessible, non-English language information sources. Participants provided recommendations for future public health communications guidance during health emergencies, including preferences for message content, information messengers, dissemination platforms and format of messages. Almost all participants preferred receiving information from the Canadian government and found it helpful to utilize various mediums and platforms such as social media and news media for future risk communication, urging for consistency across all platforms. CONCLUSIONS: We provide insights on Canadian experiences navigating COVID-19 information, where more than half perceived encountering misinformation on platforms when seeking COVID-19 information . We provide recommendations to inform public health communications during future health emergencies.

A qualitative study on health stigma and discrimination in the first year of the COVID-19 pandemic: Lessons learnt from a public health perspective

Background Stigmatisation, misinformation and discrimination have been magnified globally due to the COVID-19 pandemic. The healthcare sector was not spared from this. We conducted a transnational study, using the Health Stigma and Discrimination framework (HSDF) to explore public perception and reactions to the COVID-19 pandemic in a multicultural context. Findings from the Asian arm of the study, sited in Singapore, are reported in this paper. Methods This phenomenological research deployed semi-structured informant interviews using non-probability sampling approaches to recruit members of the public. Interviews were coded independently by two researchers and thematic analysis was used to analyse the responses. Results Twenty-nine members of the public (23–80 years old) were interviewed between Oct 2020 to Feb 2021. Five major themes were identified: (i) perception of stigma amongst respondents, (ii) experiences of stigma amongst respondents, (iii) views on what drove stigma and misinformation, (iv) facilitators in preventing and reducing stigma and misinformation, and (v) ageist attitudes towards older adults. Overall, construction workers living in dormitories, healthcare workers, and to some extent tourists from China, were perceived to have been stigmatised and shunned by the public. Place-based stigmatisation was common;participants responded by avoiding places that had confirmed cases of COVID-19. Perceived stigma was temporary and not enduring, driven at the outset by fear of being infected. This study also identified the role played by trust in reducing stigmatisation. The relative absence of politicising of issues and high-quality information readily disseminated to the public were reported as factors that could have reduced and prevented stigma and misinformation on the various groups. Ageist attitudes were observed in some participants with older adults being labelled as vulnerable, susceptible to misinformation and being less able to cope during the pandemic. Conclusion Through the lens of the HSDF, this study provided an exploratory account of the nature of stigma that resulted from the COVID-19 pandemic in an Asian context. It also shed light on facilitators in preventing and reducing stigma during an outbreak especially the role of trust and communications during a public health crisis.

A qualitative study on health stigma and discrimination in the first year of the COVID-19 pandemic: Lessons learnt from a public health perspective.

Background: Stigmatisation, misinformation and discrimination have been magnified globally due to the COVID-19 pandemic. The healthcare sector was not spared from this. We conducted a transnational study, using the Health Stigma and Discrimination framework (HSDF) to explore public perception and reactions to the COVID-19 pandemic in a multicultural context. Findings from the Asian arm of the study, sited in Singapore, are reported in this paper. Methods: This phenomenological research deployed semi-structured informant interviews using non-probability sampling approaches to recruit members of the public. Interviews were coded independently by two researchers and thematic analysis was used to analyse the responses. Results: Twenty-nine members of the public (23-80 years old) were interviewed between Oct 2020 to Feb 2021. Five major themes were identified: (i) perception of stigma amongst respondents, (ii) experiences of stigma amongst respondents, (iii) views on what drove stigma and misinformation, (iv) facilitators in preventing and reducing stigma and misinformation, and (v) ageist attitudes towards older adults. Overall, construction workers living in dormitories, healthcare workers, and to some extent tourists from China, were perceived to have been stigmatised and shunned by the public. Place-based stigmatisation was common; participants responded by avoiding places that had confirmed cases of COVID-19. Perceived stigma was temporary and not enduring, driven at the outset by fear of being infected. This study also identified the role played by trust in reducing stigmatisation. The relative absence of politicising of issues and high-quality information readily disseminated to the public were reported as factors that could have reduced and prevented stigma and misinformation on the various groups. Ageist attitudes were observed in some participants with older adults being labelled as vulnerable, susceptible to misinformation and being less able to cope during the pandemic. Conclusion: Through the lens of the HSDF, this study provided an exploratory account of the nature of stigma that resulted from the COVID-19 pandemic in an Asian context. It also shed light on facilitators in preventing and reducing stigma during an outbreak especially the role of trust and communications during a public health crisis.

Exploring Canadian perceptions and experiences of stigma during the COVID-19 pandemic.

Background: The COVID-19 pandemic has led to stigmatization of individuals based on race/ethnicity, age, gender, and occupation, among other factors. We canvassed Canadian residents to explore perceptions of and experiences with stigma during the COVID-19 pandemic. Methods: We conducted an online survey between June 10 and December 31 2020. The survey was rooted in the Health Stigma and Discrimination Framework and included multiple choice, Likert and open-ended questions related to perceived and experienced stigma. Residents of Ontario, Canada were eligible to participate and we aimed to recruit a sample that was diverse by race/ethnicity and age. Results: A total of 1,823 individuals participated in the survey (54% women, 39% men; 54% 18-40 years old, 28% 41-60 years old, 12% 61+ years old; 33% White, 26% East/SouthEast Asian, 14% Black, 12% South Asian). Fifty-one percent of participants agreed/strongly agreed that racist views had increased toward certain racial/ethnic groups in Canada during the pandemic. Participants perceived that people in Canada were stigmatized during the pandemic because of race/ethnicity (37%), political beliefs (26%), older age (24%), being a healthcare worker (23%), younger age (22%), being an essential worker (21%), and gender (11%). Thirty-nine percent of respondents feared experiencing and 37% experienced stigmatization during the pandemic. Men, individuals aged 18-40, and racialized participants were more likely to fear or experience stigma. With respect to health behaviors, 74, 68, and 59% of respondents were comfortable masking in public, seeking medical care if they became ill, and getting tested for COVID-19, respectively. Men were less likely to indicate comfort with mask wearing or seeking medical care. Participants aged 18-40 and Black participants were less likely to indicate comfort with all three behaviors compared to those over age 41 and White participants, respectively. South Asian participants were less likely to be comfortable seeking medical care compared to White Participants. Discussion: Participants feared or experienced stigmatization towards various demographic characteristics during the COVID-19 pandemic. It is critical that the factors driving stigma during health emergencies in Canada be better understood in order to develop effective public health messaging and interventions.

Global evidence of gender equity in academic health research: a scoping review.

OBJECTIVES: To chart the global literature on gender equity in academic health research. DESIGN: Scoping review. PARTICIPANTS: Quantitative studies were eligible if they examined gender equity within academic institutions including health researchers. PRIMARY AND SECONDARY OUTCOME MEASURES: Outcomes related to equity across gender and other social identities in academia: (1) faculty workforce: representation of all genders in university/faculty departments, academic rank or position and salary; (2) service: teaching obligations and administrative/non-teaching activities; (3) recruitment and hiring data: number of applicants by gender, interviews and new hires for various rank; (4) promotion: opportunities for promotion and time to progress through academic ranks; (5) academic leadership: type of leadership positions, opportunities for leadership promotion or training, opportunities to supervise/mentor and support for leadership bids; (6) scholarly output or productivity: number/type of publications and presentations, position of authorship, number/value of grants or awards and intellectual property ownership; (7) contextual factors of universities; (8) infrastructure; (9) knowledge and technology translation activities; (10) availability of maternity/paternity/parental/family leave; (11) collaboration activities/opportunities for collaboration; (12) qualitative considerations: perceptions around promotion, finances and support. RESULTS: Literature search yielded 94 798 citations; 4753 full-text articles were screened, and 562 studies were included. Most studies originated from North America (462/562, 82.2%). Few studies (27/562, 4.8%) reported race and fewer reported sex/gender (which were used interchangeably in most studies) other than male/female (11/562, 2.0%). Only one study provided data on religion. No other PROGRESS-PLUS variables were reported. A total of 2996 outcomes were reported, with most studies examining academic output (371/562, 66.0%). CONCLUSIONS: Reviewed literature suggest a lack in analytic approaches that consider genders beyond the binary categories of man and woman, additional social identities (race, religion, social capital and disability) and an intersectionality lens examining the interconnection of multiple social identities in understanding discrimination and disadvantage. All of these are necessary to tailor strategies that promote gender equity. TRIAL REGISTRATION NUMBER: Open Science Framework: https://osf.io/8wk7e/.

Efficacy of virtual interventions for reducing symptoms of depression in community-dwelling older adults: a systematic review.

BACKGROUND: Older adults experience symptoms of depression, leading to suffering and increased morbidity and mortality. Although we have effective depression therapies, physical distancing and other public health measures have severely limited access to in-person interventions. OBJECTIVE: To describe the efficacy of virtual interventions for reducing symptoms of depression in community-dwelling older adults. DESIGN: Systematic review. SETTING: We searched MEDLINE, EMBASE, Cochrane Libraries, PsycINFO, and gray literature from inception to July 5, 2021. PARTICIPANTS AND INTERVENTIONS: We included randomized trials (RCTs) comparing the efficacy of virtual interventions to any other virtual intervention or usual care in community-dwelling adults ≥60 years old experiencing symptoms of depression or depression as an outcome. MEASUREMENTS: The primary outcome was change in symptoms of depression measured by any depression scale. RESULTS: We screened 12,290 abstracts and 830 full text papers. We included 15 RCTs (3100 participants). Five RCTs examined persons with depression symptoms at baseline and ten examined depression as an outcome only. Included studies demonstrated feasibility of interventions such as internet or telephone cognitive behavioral therapy with some papers showing statistically significant improvement in depressive symptoms. CONCLUSIONS: There is a paucity of studies examining virtual interventions in older adults with depression. Given difficulty in accessing in-person therapies in a pandemic and poor access for people living in rural and remote regions, there is an urgent need to explore efficacy, effectiveness, and implementation of virtual therapies.

Early identification of a COVID-19 outbreak detected by wastewater surveillance at a large homeless shelter in Toronto, Ontario.

SETTING: Toronto (Ontario, Canada) is a large urban centre with a significant population of underhoused residents and several dozen shelters for this population with known medical and social vulnerabilities. A sizeable men's homeless shelter piloted a facility-level SARS-CoV-2 wastewater surveillance program. INTERVENTION: Wastewater surveillance was initiated at the shelter in January 2021. One-hour composite wastewater samples were collected twice weekly from a terminal sanitary clean-out pipe. The genetic material of the SARS-CoV-2 virus was extracted from the solid phase of each sample and analyzed using real-time qPCR to estimate the viral level. Wastewater results were reported to facility managers and Toronto Public Health within 4 days. OUTCOMES: There were 169 clients on-site at the time of the investigation. Wastewater surveillance alerted to the presence of COVID-19 activity at the site, prior to clinical detection. This notification acted as an early warning signal, which allowed for timely symptom screening and case finding for shelter managers and the local health unit, in preparation for the declaration of an outbreak. IMPLICATIONS: Wastewater surveillance acted as an advanced notification leading to the timely deployment of enhanced testing prior to clinical presentation in a population with known vulnerabilities. Wastewater surveillance at the facility level is beneficial, particularly in high-risk congregate living settings such as shelters that house transient populations where clinical testing and vaccination can be challenging. Open communication, established individual facility response plans, and a balanced threshold for action are essential to an effective wastewater surveillance program.

RéSUMé: LIEU: Toronto (Ontario, Canada) est un grand centre urbain qui compte une importante population de résidents mal logés et plusieurs douzaines de refuges pour cette population aux vulnérabilités médicales et sociales connues. Un assez gros refuge pour hommes sans-abri a mis à l'essai dans ses installations un programme de surveillance des eaux usées pour le SRAS-CoV-2. INTERVENTION: La surveillance des eaux usées du refuge a commencé en janvier 2021. Des échantillons composites d'une heure ont été prélevés deux fois par semaine à partir d'un regard de nettoyage à l'extrémité du drain sanitaire. Le matériel génétique du virus du SRAS-CoV-2 a été extrait du support solide de chaque échantillon et analysé par PCR quantitative en temps réel pour estimer le niveau du virus. Les résultats des eaux usées ont été déclarés aux gestionnaires du refuge et à Santé publique Toronto dans un délai de quatre jours. RéSULTATS: Il y avait 169 usagers sur place au moment de l'enquête. La surveillance des eaux usées a averti de la présence d'une activité de la COVID-19 sur les lieux avant sa détection clinique. Cet avertissement a servi de signal d'alerte précoce, ce qui a permis aux gestionnaires du refuge et au bureau de santé local de procéder au dépistage rapide des symptômes et à la recherche des cas en préparation pour la déclaration d'une éclosion. CONSéQUENCES: La surveillance des eaux usées a servi de notification préalable et entraîné le déploiement opportun d'un dépistage complémentaire avant la manifestation clinique dans une population qui présente des vulnérabilités connues. La surveillance des eaux usées d'une installation est avantageuse, surtout dans des milieux d'hébergement collectif à risque élevé comme les refuges qui hébergent des populations de passage, où le dépistage clinique et la vaccination peuvent être difficiles. Une communication ouverte, des plans d'intervention établis pour chaque installation et un seuil d'intervention équilibré sont essentiels à l'efficacité d'un programme de surveillance des eaux usées.

Rapid antigen-based and rapid molecular tests for the detection of SARS-CoV-2: a rapid review with network meta-analysis of diagnostic test accuracy studies.

BACKGROUND: The global spread of COVID-19 created an explosion in rapid tests with results in < 1 hour, but their relative performance characteristics are not fully understood yet. Our aim was to determine the most sensitive and specific rapid test for the diagnosis of SARS-CoV-2. METHODS: Design: Rapid review and diagnostic test accuracy network meta-analysis (DTA-NMA). ELIGIBILITY CRITERIA: Randomized controlled trials (RCTs) and observational studies assessing rapid antigen and/or rapid molecular test(s) to detect SARS-CoV-2 in participants of any age, suspected or not with SARS-CoV-2 infection. INFORMATION SOURCES: Embase, MEDLINE, and Cochrane Central Register of Controlled Trials, up to September 12, 2021. OUTCOME MEASURES: Sensitivity and specificity of rapid antigen and molecular tests suitable for detecting SARS-CoV-2. Data extraction and risk of bias assessment: Screening of literature search results was conducted by one reviewer; data abstraction was completed by one reviewer and independently verified by a second reviewer. Risk of bias was not assessed in the included studies. DATA SYNTHESIS: Random-effects meta-analysis and DTA-NMA. RESULTS: We included 93 studies (reported in 88 articles) relating to 36 rapid antigen tests in 104,961 participants and 23 rapid molecular tests in 10,449 participants. Overall, rapid antigen tests had a sensitivity of 0.75 (95% confidence interval 0.70-0.79) and specificity of 0.99 (0.98-0.99). Rapid antigen test sensitivity was higher when nasal or combined samples (e.g., combinations of nose, throat, mouth, or saliva samples) were used, but lower when nasopharyngeal samples were used, and in those classified as asymptomatic at the time of testing. Rapid molecular tests may result in fewer false negatives than rapid antigen tests (sensitivity: 0.93, 0.88-0.96; specificity: 0.98, 0.97-0.99). The tests with the highest sensitivity and specificity estimates were the Xpert Xpress rapid molecular test by Cepheid (sensitivity: 0.99, 0.83-1.00; specificity: 0.97, 0.69-1.00) among the 23 commercial rapid molecular tests and the COVID-VIRO test by AAZ-LMB (sensitivity: 0.93, 0.48-0.99; specificity: 0.98, 0.44-1.00) among the 36 rapid antigen tests we examined. CONCLUSIONS: Rapid molecular tests were associated with both high sensitivity and specificity, while rapid antigen tests were mainly associated with high specificity, according to the minimum performance requirements by WHO and Health Canada. Our rapid review was limited to English, peer-reviewed published results of commercial tests, and study risk of bias was not assessed. A full systematic review is required. REVIEW REGISTRATION: PROSPERO CRD42021289712.

Which Curve Are We Flattening? The Disproportionate Impact of COVID-19 Among Economically Marginalized Communities in Ontario, Canada, Was Unchanged From Wild-Type to Omicron.

Person-level surveillance (N = 14 million) and neighborhood-level income data were used to explore magnitude of inequalities in COVID-19 hospitalizations and deaths over 5 waves in Ontario, Canada. Despite attempts at equity-informed policies alongside fluctuating levels of public health measures, the magnitude of inequalities in hospitalizations and deaths remained unchanged across waves.

COVID-19 Cases Among Congregate Care Facility Staff by Neighborhood of Residence and Social and Structural Determinants: Observational Study.

BACKGROUND: Disproportionate risks of COVID-19 in congregate care facilities including long-term care homes, retirement homes, and shelters both affect and are affected by SARS-CoV-2 infections among facility staff. In cities across Canada, there has been a consistent trend of geographic clustering of COVID-19 cases. However, there is limited information on how COVID-19 among facility staff reflects urban neighborhood disparities, particularly when stratified by the social and structural determinants of community-level transmission. OBJECTIVE: This study aimed to compare the concentration of cumulative cases by geography and social and structural determinants across 3 mutually exclusive subgroups in the Greater Toronto Area (population: 7.1 million): community, facility staff, and health care workers (HCWs) in other settings. METHODS: We conducted a retrospective, observational study using surveillance data on laboratory-confirmed COVID-19 cases (January 23 to December 13, 2020; prior to vaccination rollout). We derived neighborhood-level social and structural determinants from census data and generated Lorenz curves, Gini coefficients, and the Hoover index to visualize and quantify inequalities in cases. RESULTS: The hardest-hit neighborhoods (comprising 20% of the population) accounted for 53.87% (44,937/83,419) of community cases, 48.59% (2356/4849) of facility staff cases, and 42.34% (1669/3942) of other HCW cases. Compared with other HCWs, cases among facility staff reflected the distribution of community cases more closely. Cases among facility staff reflected greater social and structural inequalities (larger Gini coefficients) than those of other HCWs across all determinants. Facility staff cases were also more likely than community cases to be concentrated in lower-income neighborhoods (Gini 0.24, 95% CI 0.15-0.38 vs 0.14, 95% CI 0.08-0.21) with a higher household density (Gini 0.23, 95% CI 0.17-0.29 vs 0.17, 95% CI 0.12-0.22) and with a greater proportion working in other essential services (Gini 0.29, 95% CI 0.21-0.40 vs 0.22, 95% CI 0.17-0.28). CONCLUSIONS: COVID-19 cases among facility staff largely reflect neighborhood-level heterogeneity and disparities, even more so than cases among other HCWs. The findings signal the importance of interventions prioritized and tailored to the home geographies of facility staff in addition to workplace measures, including prioritization and reach of vaccination at home (neighborhood level) and at work.

Saving millions of lives but some resources squandered: emerging lessons from health research system pandemic achievements and challenges.

During the SARS-CoV-2 pandemic, astonishingly rapid research averted millions of deaths worldwide through new vaccines and repurposed and new drugs. Evidence use informed life-saving national policies including non-pharmaceutical interventions. Simultaneously, there was unprecedented waste, with many underpowered trials on the same drugs. We identified lessons from COVID-19 research responses by applying WHO's framework for research systems. It has four functions-governance, securing finance, capacity-building, and production and use of research-and nine components. Two linked questions focused the analysis. First, to what extent have achievements in knowledge production and evidence use built on existing structures and capacity in national health research systems? Second, did the features of such systems mitigate waste? We collated evidence on seven countries, Australia, Brazil, Canada, Germany, New Zealand, the United Kingdom and the United States, to identify examples of achievements and challenges.We used the data to develop lessons for each framework component. Research coordination, prioritization and expedited ethics approval contributed to rapid identification of new therapies, including dexamethasone in the United Kingdom and Brazil. Accelerated vaccines depended on extensive funding, especially through the Operation Warp Speed initiative in the United States, and new platforms created through long-term biomedical research capacity in the United Kingdom and, for messenger ribonucleic acid (mRNA) vaccines, in Canada, Germany and the United States. Research capacity embedded in the United Kingdom's healthcare system resulted in trial acceleration and waste avoidance. Faster publication of research saved lives, but raised challenges. Public/private collaborations made major contributions to vastly accelerating new products, available worldwide, though unequally. Effective developments of living (i.e. regularly updated) reviews and guidelines, especially in Australia and Canada, extended existing expertise in meeting users' needs. Despite complexities, effective national policy responses (less evident in Brazil, the United Kingdom and the United States) also saved lives by drawing on health research system features, including collaboration among politicians, civil servants and researchers; good communications; and willingness to use evidence. Comprehensive health research strategies contributed to success in research production in the United Kingdom and in evidence use by political leadership in New Zealand. In addition to waste, challenges included equity issues, public involvement and non-COVID research. We developed recommendations, but advocate studies of further countries.

An exploration of Canadian government officials' COVID-19 messages and the public's reaction using social media data.

Governments can use social media platforms such as Twitter to disseminate health information to the public, as evidenced during the COVID-19 pandemic [Pershad (2018)]. The purpose of this study is to gain a better understanding of Canadian government and public health officials' use of Twitter as a dissemination platform during the pandemic and to explore the public's engagement with and sentiment towards these messages. We examined the account data of 93 Canadian public health and government officials during the first wave of the pandemic in Canada (December 31, 2019 August 31, 2020). Our objectives were to: 1) determine the engagement rates of the public with Canadian federal and provincial/territorial governments and public health officials' Twitter posts; 2) conduct a hashtag trend analysis to explore the Canadian public's discourse related to the pandemic during this period; 3) provide insights on the public's reaction to Canadian authorities' tweets through sentiment analysis. To address these objectives, we extracted Twitter posts, replies, and associated metadata available during the study period in both English and French. Our results show that the public demonstrated increased engagement with federal officials' Twitter accounts as compared to provincial/territorial accounts. For the hashtag trends analysis of the public discourse during the first wave of the pandemic, we observed a topic shift in the Canadian public discourse over time between the period prior to the first wave and the first wave of the pandemic. Additionally, we identified 11 sentiments expressed by the public when reacting to Canadian authorities' tweets. This study illustrates the potential to leverage social media to understand public discourse during a pandemic. We suggest that routine analyses of such data by governments can provide governments and public health officials with real-time data on public sentiments during a public health emergency. These data can be used to better disseminate key messages to the public.

Comparative-effectiveness research of COVID-19 treatment: a rapid scoping review.

OBJECTIVES: The COVID-19 pandemic has stimulated growing research on treatment options. We aim to provide an overview of the characteristics of studies evaluating COVID-19 treatment. DESIGN: Rapid scoping review DATA SOURCES: Medline, Embase and biorxiv/medrxiv from inception to 15 May 2021. SETTING: Hospital and community care. PARTICIPANTS: COVID-19 patients of all ages. INTERVENTIONS: COVID-19 treatment. RESULTS: The literature search identified 616 relevant primary studies of which 188 were randomised controlled trials and 299 relevant evidence syntheses. The studies and evidence syntheses were conducted in 51 and 39 countries, respectively.Most studies enrolled patients admitted to acute care hospitals (84%), included on average 169 participants, with an average age of 60 years, study duration of 28 days, number of effect outcomes of four and number of harm outcomes of one. The most common primary outcome was death (32%).The included studies evaluated 214 treatment options. The most common treatments were tocilizumab (11%), hydroxychloroquine (9%) and convalescent plasma (7%). The most common therapeutic categories were non-steroidal immunosuppressants (18%), steroids (15%) and antivirals (14%). The most common therapeutic categories involving multiple drugs were antimalarials/antibiotics (16%), steroids/non-steroidal immunosuppressants (9%) and antimalarials/antivirals/antivirals (7%). The most common treatments evaluated in systematic reviews were hydroxychloroquine (11%), remdesivir (8%), tocilizumab (7%) and steroids (7%).The evaluated treatment was in favour 50% and 36% of the evaluations, according to the conclusion of the authors of primary studies and evidence syntheses, respectively. CONCLUSIONS: This rapid scoping review characterised a growing body of comparative-effectiveness primary studies and evidence syntheses. The results suggest future studies should focus on children, elderly ≥65 years of age, patients with mild symptoms, outpatient treatment, multimechanism therapies, harms and active comparators. The results also suggest that future living evidence synthesis and network meta-analysis would provide additional information for decision-makers on managing COVID-19.

Characteristics, treatment and delirium incidence of older adults hospitalized with COVID-19: a multicentre retrospective cohort study.

BACKGROUND: The COVID-19 pandemic has affected older adults disproportionately, and delirium is a concerning consequence; however, the relationship between delirium and corticosteroid use is uncertain. The objective of the present study was to describe patient characteristics, treatments and outcomes among older adults hospitalized with COVID-19, with a focus on dexamethasone use and delirium incidence. METHODS: We completed this retrospective cohort study at 7 sites (including acute care, rehabilitation and long-term care settings) in Toronto, Ontario, Canada. We included adults aged 65 years or older, consecutively hospitalized with confirmed SARS-CoV-2 infection, between Mar. 11, 2020, and Apr. 30, 2021. We abstracted patient characteristics and outcomes from charts and analyzed them descriptively. We used a logistic regression model to determine the association between dexamethasone use and delirium incidence. RESULTS: During the study period, 927 patients were admitted to the acute care hospitals with COVID-19. Patients' median age was 79.0 years (interquartile range [IQR] 72.0-87.0), and 417 (45.0%) were female. Most patients were frail (61.9%), based on a Clinical Frailty Scale score of 5 or greater. The prevalence of delirium was 53.6%, and the incidence was 33.1%. Use of restraints was documented in 20.4% of patients. In rehabilitation and long-term care settings (n = 115), patients' median age was 86.0 years (IQR 78.5-91.0), 72 (62.6%) were female and delirium occurred in 17 patients (14.8%). In patients admitted to acute care during wave 2 of the pandemic (Aug. 1, 2020, to Feb. 20, 2021), dexamethasone use had a nonsignificant association with delirium incidence (adjusted odds ratio 1.38, 95% confidence interval 0.77-2.50). Overall, in-hospital death occurred in 262 (28.4%) patients in acute care settings and 28 (24.3%) patients in rehabilitation or long-term care settings. INTERPRETATION: In-hospital death, delirium and use of restraints were common in older adults admitted to hospital with COVID-19. Further research should be directed to improving the quality of care for this population with known vulnerabilities during continued waves of the COVID-19 pandemic.

Methodological guidance for incorporating equity when informing rapid-policy and guideline development.

OBJECTIVES: We provide guidance for considering equity in rapid reviews through examples of published COVID-19 rapid reviews. STUDY DESIGN AND SETTING: This guidance was developed based on a series of methodological meetings, review of internationally renowned guidance such as the Cochrane Handbook and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis for equity-focused systematic reviews (PRISMA-Equity) guideline. We identified Exemplar rapid reviews by searching COVID-19 databases and requesting examples from our team. RESULTS: We proposed the following key steps: 1. involve relevant stakeholders with lived experience in the conduct and design of the review; 2. reflect on equity, inclusion and privilege in team values and composition; 3. develop research question to assess health inequities; 4. conduct searches in relevant disciplinary databases; 5. collect data and critically appraise recruitment, retention and attrition for populations experiencing inequities; 6. analyse evidence on equity; 7. evaluate the applicability of findings to populations experiencing inequities; and 8. adhere to reporting guidelines for communicating review findings. We illustrated these methods through rapid review examples. CONCLUSION: Implementing this guidance could contribute to improving equity considerations in rapid reviews produced in public health emergencies, and help policymakers better understand the distributional impact of diseases on the population.

Comparative-effectiveness research of COVID-19 treatment: a rapid scoping review

Objectives The COVID-19 pandemic has stimulated growing research on treatment options. We aim to provide an overview of the characteristics of studies evaluating COVID-19 treatment. Design Rapid scoping review Data sources Medline, Embase and biorxiv/medrxiv from inception to 15 May 2021. Setting Hospital and community care. Participants COVID-19 patients of all ages. Interventions COVID-19 treatment. Results The literature search identified 616 relevant primary studies of which 188 were randomised controlled trials and 299 relevant evidence syntheses. The studies and evidence syntheses were conducted in 51 and 39 countries, respectively. Most studies enrolled patients admitted to acute care hospitals (84%), included on average 169 participants, with an average age of 60 years, study duration of 28 days, number of effect outcomes of four and number of harm outcomes of one. The most common primary outcome was death (32%). The included studies evaluated 214 treatment options. The most common treatments were tocilizumab (11%), hydroxychloroquine (9%) and convalescent plasma (7%). The most common therapeutic categories were non-steroidal immunosuppressants (18%), steroids (15%) and antivirals (14%). The most common therapeutic categories involving multiple drugs were antimalarials/antibiotics (16%), steroids/non-steroidal immunosuppressants (9%) and antimalarials/antivirals/antivirals (7%). The most common treatments evaluated in systematic reviews were hydroxychloroquine (11%), remdesivir (8%), tocilizumab (7%) and steroids (7%). The evaluated treatment was in favour 50% and 36% of the evaluations, according to the conclusion of the authors of primary studies and evidence syntheses, respectively. Conclusions This rapid scoping review characterised a growing body of comparative-effectiveness primary studies and evidence syntheses. The results suggest future studies should focus on children, elderly ≥65 years of age, patients with mild symptoms, outpatient treatment, multimechanism therapies, harms and active comparators. The results also suggest that future living evidence synthesis and network meta-analysis would provide additional information for decision-makers on managing COVID-19.

Mortality in hospitalized older adults with COVID‐19 during three waves: A multicenter retrospective cohort study

BackgroundThe waves of COVID‐19 infections in Ontario, Canada, were marked by differences in patient characteristics and treatment. Our objectives were to (i) describe patient characteristics, treatment, and outcomes of hospitalized older adults with COVID‐19 between waves 1, 2, and 3, (ii) determine if there was an improvement in in‐hospital mortality in waves 2 and 3 after adjusting for covariates.MethodsThis retrospective cohort study was done in five acute care hospitals in Toronto, Ontario. Consecutive hospitalized older adults aged ≥65 years with confirmed COVID‐19 infection were included. Wave 1 extended from March 11 to July 31, 2020, wave 2 from August 1, 2020 to February 20, 2021, and wave 3 from February 21 to June 30, 2021. Patient characteristics and outcomes were ed from charts. A logistic regression model was used to determine the association between COVID‐19 and in‐hospital mortality in waves 2 and 3 compared with wave 1.ResultsOf the 1671 patients admitted to acute care, 297 (17.8%) were admitted in wave 1, 751 (44.9%) in wave 2, and 623 (37.3%) in wave 3. The median age of our cohort was 77.0 years (interquartile range: 71.0–85.0) and 775 (46.4%) were female. The prevalence of frailty declined in progressive waves. The use of dexamethasone, remdesivir, and tocilizumab was significantly higher in waves 2 and 3 compared with wave 1. In the unadjusted analysis, in‐hospital mortality was unchanged between waves 1 and 2, but it was lower in wave 3 (18.3% vs. 27.4% in wave 1). After adjustment, in‐hospital mortality was unchanged in waves 2 and 3 compared with wave 1.ConclusionIn‐hospital mortality in hospitalized older adults with COVID‐19 was similar between waves 1 and 3. Further research should be done to determine if COVID‐19 therapies have similar benefits for older adults compared with younger adults.

Study of the epidemiology of COVID-19 in Ontario elementary and secondary school education workers: an interim analysis following the first school year.

OBJECTIVE: To estimate the incidence of SARS-CoV-2 in education workers and the factors associated with infection between March 2020 and July 2021. METHODS: A prospective cohort study of education workers working ≥8 h per week in Ontario, Canada. Participants self-reported results of tests for SARS-CoV-2 and completed online surveys about demographic information, exposures, and vaccinations against SARS-CoV-2. Participants submitted self-collected dried blood spots. Antibodies to SARS-CoV-2 spike, the receptor binding domain of spike, and nucleocapsid were assessed. Multivariable regression was used to assess risk factors for infection. RESULTS: Of 2834 participants, 85% were female, 81% were teaching staff, and 86% had received at least one dose of SARS-CoV-2 vaccine. Of the 1983 who had been tested via a respiratory specimen, 4.9% reported a positive test. Five additional participants had serologic testing suggestive of a previous infection (3.6% overall incidence). In multivariable regression analysis, risk factors for infection included exposure to a SARS-CoV-2 infected adult (adjusted incidence rate ratio (aIRR) 13.6; 95% confidence interval 8.6, 21.3) or child (aIRR 2.3; 1.3, 4.2) in the household, or school student (aIRR 1.9; 1.2, 3.2), or travel outside the province within 14 days of testing (aIRR 6.0; 1.5, 23.6). CONCLUSION: In the first 18 months of the pandemic, education workers had a similar risk of infection with SARS-CoV-2 as other Ontario residents. Practicing protective measures whenever any household member has been exposed to a possible case and at all times when exposed to anyone from outside the home would help reduce the risk of infection.

RéSUMé: OBJECTIF: Estimer l'incidence du SRAS-CoV-2 chez les travailleuses et les travailleurs en éducation et les facteurs associés à l'infection entre mars 2020 et juillet 2021. MéTHODE: Étude prospective de cohortes auprès de travailleuses et de travailleurs en éducation travaillant ≥8 heures par semaine en Ontario, au Canada. Les participants ont autodéclaré les résultats de tests de dépistage du SRAS-CoV-2 et répondu à des questionnaires en ligne portant sur leurs données démographiques, leurs expositions au SRAS-CoV-2 et leurs vaccins contre le virus. Les participants ont soumis des gouttes de sang séché autoprélevées. Les anticorps à la protéine S du SRAS-CoV-2, le domaine de liaison aux récepteurs de la protéine S et la nucléocapside ont été évalués. Une régression multivariée a servi à évaluer les facteurs de risque d'infection. RéSULTATS: Sur les 2 834 participants, 85 % étaient des femmes, 81 % étaient des enseignants et 86 % avaient reçu au moins une dose de vaccin contre le SRAS-CoV-2. Sur les 1 983 personnes ayant été testées au moyen d'un prélèvement respiratoire, 4,9 % ont déclaré un test positif. Chez cinq autres participants, un test sérologique a indiqué une infection antérieure (incidence globale de 3,6 %). Selon l'analyse de régression multivariée, les facteurs de risque d'infection étaient l'exposition à un adulte infecté par le SRAS-CoV-2 (rapport de taux d'incidence ajusté [RTIa] 13,6; intervalle de confiance de 95 % 8,6, 21,3) ou à un enfant infecté (RTIa 2,3; 1,3, 4,2) au sein du ménage, l'exposition à un élève infecté (RTIa 1,9; 1,2, 3,2) ou un déplacement hors province dans les 14 jours ayant précédé le test (RTIa 6,0; 1,5, 23,6). CONCLUSION: Au cours des 18 premiers mois de la pandémie, le risque d'infection par le SRAS-CoV-2 chez les travailleuses et les travailleurs en éducation était semblable au risque des autres résidents de l'Ontario. L'application de mesures de protection chaque fois qu'un membre du ménage a été exposé à un cas possible, et en tout temps lorsqu'on est exposé à une personne de l'extérieur du ménage, contribuerait à réduire le risque d'infection.