The impacts of social restrictions during the COVID-19 pandemic on the physical activity levels of over 50-year olds: the CHARIOT COVID-19 Rapid Response (CCRR) cohort study (preprint)

Objectives To quantify the associations between shielding status and loneliness at the start of the COVID-19 pandemic, and physical activity (PA) levels throughout the pandemic. Methods Demographic, health and lifestyle characteristics of 7748 cognitively healthy adults aged >50, and living in London, were surveyed from April 2020 to March 2021. The International Physical Activity Questionnaire (IPAQ) short-form assessed PA before COVID-19 restrictions, and up to 6 times over 11 months. Linear mixed models investigated associations between baseline shielding status, loneliness, and time-varying PA. Results Participants who felt "often lonely" at the outset of the pandemic completed an average of 522 and 547 fewer Metabolic Equivalent of Task (MET) minutes/week (95% CI: -809, -236, p<0.001) (95% CI: -818, -275, p<0.001) than those who felt "never lonely" in univariable and multivariable models adjusted for demographic factors respectively. Those who felt "sometimes lonely" completed 112 fewer MET minutes/week (95% CI: -219, -5, p=0.041) than those who felt "never lonely" following adjustment for demographic factors. Participants who were shielding at the outset of the pandemic completed an average of 352 fewer MET minutes/week than those who were not (95% CI: -432, -273; p<0.001) in univariable models and 228 fewer MET minutes/week (95% CI: -307, -150, p<0.001) following adjustment for demographic factors. No significant associations were found after further adjustment for health and lifestyle factors. Conclusions Those shielding or lonely at pandemic onset were likely to have completed low levels of PA during the pandemic. These associations are influenced by co-morbidities and health status.

Trends and associated factors for Covid-19 hospitalisation and fatality risk in 2.3 million adults in England (preprint)

Background The Covid-19 case fatality ratio varies between countries and over time but it is unclear whether variation is explained by the underlying risk in those infected. This study aims to describe the trends and risk factors for admission and mortality rates over time in England. Methods In this retrospective cohort study, we included all adults ([≥]18 years) in England with a positive Covid-19 test result between 1st October 2020 and 30th April 2021. Data were linked to primary and secondary care electronic health records and death registrations. Our outcomes were i) one or more emergency hospital admissions and ii) death from any cause, within 28 days of a positive test. Multivariable multilevel logistic regression was used to model each outcome with patient risk factors and time. Results 2,311,282 people were included in the study, of whom 164,046 (7.1%) were admitted and 53,156 (2.3%) died within 28 days. There was significant variation in the case hospitalisation and mortality risk over time, peaking in December 2020-February 2021, which remained after adjustment for individual risk factors. Older age groups, males, those resident in more deprived areas, and those with obesity had higher odds of admission and mortality. Of risk factors examined, severe mental illness and learning disability had the highest odds of admission and mortality. Conclusions In one of the largest studies of nationally representative Covid-19 risk factors, case hospitalisation and mortality risk varied significantly over time in England during the second pandemic wave, independent of the underlying risk in those infected.

Population level impact of a pulse oximetry remote monitoring programme on mortality and healthcare utilisation in the people with covid-19 in England: a national analysis using a stepped wedge design (preprint)

Objectives To identify the population level impact of a national pulse oximetry remote monitoring programme for covid-19 (COVID Oximetry @home; CO@h) in England on mortality and health service use. Design Retrospective cohort study using a stepped wedge pre- and post- implementation design. Setting All Clinical Commissioning Groups (CCGs) in England implementing a local CO@h programme. Participants 217,650 people with a positive covid-19 polymerase chain reaction test result and symptomatic, from 1st October 2020 to 3rd May 2021, aged [≥]65 years or identified as clinically extremely vulnerable. Care home residents were excluded. Interventions A pre-intervention period before implementation of the CO@h programme in each CCG was compared to a post-intervention period after implementation. Main outcome measures Five outcome measures within 28 days of a positive covid-19 test: i) death from any cause; ii) any A&E attendance; iii) any emergency hospital admission; iv) critical care admission; and v) total length of hospital stay. Results Implementation of the programme was not associated with mortality or length of hospital stay. Implementation was associated with increased health service utilisation with a 12% increase in the odds of A&E attendance (95% CI: 6%-18%) and emergency hospital admission (95% CI: 5%-20%) and a 24% increase in the odds of critical care admission in those admitted (95% CI: 5%-47%). In a secondary analysis of CO@h sites with at least 10% or 20% of eligible people enrolled, there was no significant association with any outcome measure. However, uptake of the programme was low, with enrolment data received for only 5,527 (2.5%) of the eligible population. Conclusions At a population level, there was no association with mortality following implementation of the CO@h programme, and small increases in health service utilisation were observed. Low enrolment of eligible people may have diluted the effects of the programme at a population level.

Evaluating the impact of a pulse oximetry remote monitoring programme on mortality and healthcare utilisation in patients with covid-19 assessed in Accident and Emergency departments in England: a retrospective matched cohort study (preprint)

Objectives To identify the impact of a national pulse oximetry remote monitoring programme for covid-19 (COVID Oximetry @home; CO@h) on health service use and mortality in patients attending Accident and Emergency (A&E) departments. Design Retrospective matched cohort study of patients enrolled onto the CO@h pathway from A&E. Setting National Health Service (NHS) A&E departments in England. Participants All patients with a positive covid-19 test from 1st October 2020 to 3rd May 2021 who attended A&E from three days before to ten days after the date of the test. All patients who were admitted or died on the same or following day to the first A&E attendance within the time window were excluded. Interventions Participants enrolled onto CO@h were matched using demographic and clinical criteria to participants who were not enrolled. Main outcome measures Five outcome measures were examined within 28 days of first A&E attendance: i) death from any cause; ii) any subsequent A&E attendance; iii) any emergency hospital admission; iv) critical care admission; and v) length of stay. Results 15,621 participants were included in the primary analysis, of whom 639 were enrolled onto CO@h and 14,982 were controls. Odds of death were 52% lower in those enrolled (95% CI: 7%-75% lower) compared to those not enrolled on CO@h. Odds of any A&E attendance or admission were 37% (95% CI: 16-63%) and 59% (95% CI: 16-63%) higher, respectively, in those enrolled. Of those admitted, those enrolled had 53% (95% CI: 7%-76%) lower odds of critical care admission. There was no significant impact on length of stay. Conclusions These findings indicate that for patients assessed in A&E, pulse oximetry remote monitoring may be a clinically effective and safe model for early detection of hypoxia and escalation, leading to increased subsequent A&E attendance and admissions, and reduced critical care requirement and mortality.

Democratic governance and excess mortality during the COVID-19 pandemic (preprint)

BackgroundExcess mortality has been used to assess the health impact of COVID-19 across countries. Democracies aim to build trust in government and enable checks and balances on decision-making, which may be useful in a pandemic. On the other hand, democratic governments have been criticised as slow to enforce restrictive policies and being overly influenced by public opinion. This study sought to understand whether strength of democratic governance is associated with the variation in excess mortality observed across countries during the pandemic. MethodsThrough linking open-access datasets we constructed univariable and multivariable linear regression models investigating the association between country EIU Democracy Index (representing strength of democratic governance on a scale of 0 to 10) and excess mortality rates, from February 2020 to May 2021. We stratified our analysis into high-income and low and middle-income country groups and adjusted for several important confounders. ResultsAcross 78 countries, the mean EIU democracy index was 6.74 (range 1.94 to 9.81) and the mean excess mortality rate was 128 per 100,000 (range -55 to 503 per 100,000). A one-point increase in EIU Democracy Index was associated with a decrease in excess mortality of 26.3 per 100,000 (p=0.002), after accounting for COVID-19 cases, age [≥] 65, gender, prevalence of cardiovascular disease, universal health coverage and the strength of early government restrictions. This association was particularly strong in high-income countries ({beta} -47.5, p<0.001) but non-significant in low and middle-income countries ({beta} -10.8, p=0.40). ConclusionsSocio-political factors related to the way societies are governed have played an important role in mitigating the overall health impact of COVID-19. Given the omission of such considerations from outbreak risk assessment tools, and their particular significance in high-income countries rated most highly by such tools, this study strengthens the case to broaden the scope of traditional pandemic risk assessment. Key MessagesO_ST_ABSWhat is already known?C_ST_ABSO_LIPrevious studies have found that as countries become more democratic they experience a decline in rates of infant and child mortality, infections such as tuberculosis, and non-communicable diseases. C_LIO_LIIn Europe, more democratic countries were initially more reluctant to adopt restrictive COVID-19 measures that could conflict with democratic principles, including lockdowns. C_LI What are the new findings?O_LIWe found that a one-point increase in EIU Democracy Index was associated with a decrease in excess mortality of 26.3 per 100,000 (p=0.002), after accounting for several confounders including demographics, numbers of cases and the strength of early government responses. C_LIO_LIThis association was particularly significant in high-income countries ({beta} - 47.5, p<0.001), suggesting that way societies are governed has played an important role in mitigating the impact of COVID-19. C_LI What do the new findings imply?O_LIGiven the omission of social, political and cultural considerations from outbreak risk assessment tools, and criticisms of such tools that have failed to accurately reflect the observed impact of the pandemic across high-income countries, this study builds on the case to broaden of the scope of traditional pandemic risk assessment. C_LIO_LIFuture research into the mechanisms underlying our findings will help to understand and address the complex and deep-rooted vulnerabilities countries face in a protracted and large-scale public health emergency. C_LI

Associations of Health, Lifestyle and Psycho-Social Factors With Sleep Quality During the Early Phase of the COVID-19 Pandemic: A Focus on UK Older Adults Deemed Clinically Extremely Vulnerable (preprint)

Background: Sleep quality is crucial for health and wellbeing in all ages and sleep abnormalities may contribute to multimorbidity in older adults. The impact of pandemic-related disruptions to sleep quality in older adults, particularly those deemed “clinically extremely vulnerable” to COVID-19-related complications (COVID-19CEV) remains unknown.Methods: In this cross-sectional study, conducted during the first UK lockdown (April- June 2020), we surveyed 5558 adults aged 50 years and over (of whom 523 met criteria for COVID-19CEV) with assessments of sleep quality, health/medical, lifestyle, psychosocial and sociodemographic factors. We identified associations between these factors and sleep quality and explored interactions of COVID-19CEV status with factors significantly associated with sleep quality to identify potential moderating variables.Findings: 37% of participants reported poor sleep quality which was associated with younger age, female sex and multimorbidity. Significant associations with poor sleep included, among health/medical factors: COVID-19CEV status, higher BMI, arthritis, pulmonary disease, and mental health disorders; .and the following lifestyle and psychosocial factors: living alone, higher alcohol consumption, an unhealthy diet and higher depressive and anxiety symptoms. r Moderators of the COVID-19CEV status - sleep quality relationship included marital status, loneliness, anxiety and diet. Within this subgroup, less anxious and less lonely males, as well as females with healthier diets, reported better sleep quality. Interpretation: Sleep quality in older adults was compromised during the sudden unprecedented nation-wide lockdown due to distinct health/medical, lifestyle and psychosocial factors. Male and female older adults with COVID-19CEV status may benefit from targeted mental health and dietary interventions, respectively. Results inform tailored interventions and policy for older adults deemed COVID-19CEV. Funding Information: This study was sponsored by Imperial College London and partly funded by the ICHT BRC.Declaration of Interests: Dr. Middleton reports clinical trial grants from Janssen R&D, Novartis and Takeda outside the submitted work. All authors declare no competing interests related to this study.Ethics Approval Statement: Data collected as in this study are anonymized and kept strictlyconfidential in accordance with the UK General Data Protection Regulations (2016). The CCRR study was ethically approved by the Imperial College London Joint Research Compliance Office (20IC5942) and by the Health Research Authority (16/EM/0213).

The impact of social restrictions during the COVID-19 pandemic on the physical activity levels of older adults: a baseline analysis of the CHARIOT COVID-19 Rapid Response prospective cohort study (preprint)

Objectives Physical inactivity is more common in older adults, is associated with social isolation and loneliness, and contributes to increased morbidity and mortality. We examined the effect of social restrictions, implemented to reduce transmission of COVID-19 in the UK (lockdown), on physical activity (PA) levels of older adults, and the demographic, lifestyle and social predictors of this change. Design Baseline analysis of a survey-based prospective cohort study Setting Adults enrolled in the Cognitive Health in Ageing Register for Investigational and Observational Trials (CHARIOT) cohort from GP practices in North West London were invited to participate from April to July 2020. Participants 6,219 cognitively healthy adults aged 50 to 92 years completed the survey. Main outcome measures Self-reported PA before and after lockdown, as measured by Metabolic Equivalent of Task (MET) minutes. Associations of PA with demographic, lifestyle and social factors, mood and frailty. Results Mean PA was significantly lower following lockdown, from 3,519 MET minutes/week to 3,185 MET minutes/week (p<0.001). After adjustment for confounders and pre-lockdown PA, lower levels of PA after lockdown were found in those who were over 85 years old (640 [95% CI: 246 to 1034] MET minutes/week less); were divorced or single (240 [95% CI: 120 to 360] MET minutes/week less); living alone (277 [95% CI: 152 to 402] MET minutes/week less); reported feeling lonely often (306 [95% CI: 60 to 552] MET minutes/week less); and showed symptoms of depression (1007 [95% CI: 1401 to 612] MET minutes/week less) compared to those aged 50-64 years, married, co-habiting, and not reporting loneliness or depression, respectively. Conclusions and Implications Markers of social isolation, loneliness and depression were associated with lower PA following lockdown in the UK. Interventions to improve PA in older adults should take account of social and community factors, and targeted strategies to increase physical activity in socially isolated, lonely and depressed older adults should be considered.