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1.
JMIR Ment Health ; 9(3): e31780, 2022 Mar 11.
Article in English | MEDLINE | ID: covidwho-1770896

ABSTRACT

BACKGROUND: Mental disorders are a leading cause of distress and disability worldwide. To meet patient demand, there is a need for increased access to high-quality, evidence-based mental health care. Telehealth has become well established in the treatment of illnesses, including mental health conditions. OBJECTIVE: This study aims to conduct a robust evidence synthesis to assess whether there is evidence of differences between telehealth and face-to-face care for the management of less common mental and physical health conditions requiring psychotherapy. METHODS: In this systematic review, we included randomized controlled trials comparing telehealth (telephone, video, or both) versus the face-to-face delivery of psychotherapy for less common mental health conditions and physical health conditions requiring psychotherapy. The psychotherapy delivered had to be comparable between the telehealth and face-to-face groups, and it had to be delivered by general practitioners, primary care nurses, or allied health staff (such as psychologists and counselors). Patient (symptom severity, overall improvement in psychological symptoms, and function), process (working alliance and client satisfaction), and financial (cost) outcomes were included. RESULTS: A total of 12 randomized controlled trials were included, with 931 patients in aggregate; therapies included cognitive behavioral and family therapies delivered in populations encompassing addiction disorders, eating disorders, childhood mental health problems, and chronic conditions. Telehealth was delivered by video in 7 trials, by telephone in 3 trials, and by both in 1 trial, and the delivery mode was unclear in 1 trial. The risk of bias for the 12 trials was low or unclear for most domains, except for the lack of the blinding of participants, owing to the nature of the comparison. There were no significant differences in symptom severity between telehealth and face-to-face therapy immediately after treatment (standardized mean difference [SMD] 0.05, 95% CI -0.17 to 0.27) or at any other follow-up time point. Similarly, there were no significant differences immediately after treatment between telehealth and face-to-face care delivery on any of the other outcomes meta-analyzed, including overall improvement (SMD 0.00, 95% CI -0.40 to 0.39), function (SMD 0.13, 95% CI -0.16 to 0.42), working alliance client (SMD 0.11, 95% CI -0.34 to 0.57), working alliance therapist (SMD -0.16, 95% CI -0.91 to 0.59), and client satisfaction (SMD 0.12, 95% CI -0.30 to 0.53), or at any other time point (3, 6, and 12 months). CONCLUSIONS: With regard to effectively treating less common mental health conditions and physical conditions requiring psychological support, there is insufficient evidence of a difference between psychotherapy delivered via telehealth and the same therapy delivered face-to-face. However, there was no includable evidence in this review for some serious mental health conditions, such as schizophrenia and bipolar disorders, and further high-quality research is needed to determine whether telehealth is a viable, equivalent treatment option for these conditions.

2.
EuropePMC; 2021.
Preprint in English | EuropePMC | ID: ppcovidwho-315146

ABSTRACT

Objective: To determine the impact of the COVID-19 pandemic on surgery for severe endometriosis in the UK at a national, regional and centre-level. Design: Population-based national cohort study. Population: All women undergoing endometriosis surgery requiring dissection of the pararectal space in the UK from 2017 to 2020 inclusive. Methods: The British Society for Gynaecological Endoscopy (BSGE) collects data nationally on all operations for severe endometriosis which involve dissection of the pararectal space. Annual audits of this database were obtained from the BSGE. Publicly available data on COVID-19 deaths and population were obtained from the UK Office for National Statistics. Main outcome measures: Numbers of annual BSGE-registered endometriosis operations. Results: A total of 5916 operations were performed. The number of operations decreased by 49.4% overall between 2019 and 2020. The number of endometriosis centres remained the same, however the median number of operations per centre decreased from 21 to 12.5, with a median percentage decrease at each centre of 51.0% (IQR 29.4% – 75.0%). There was no significant change in the type of surgery performed. All 11 administrative regions of Great Britain had reduced numbers of BSGE-registered operations in 2020 compared with the average for 2017-2019, with a median 56.6% decrease (range 6.13% - 68.62%). Regional reduction in operations was significantly correlated with COVID-19 death rates (r=0.557, 95% CI of r 0.048 – 1.00, p=0.037). Conclusions: There has been a dramatic fall in the number of operations for severe endometriosis in Britain during the COVID-19 pandemic.

3.
EuropePMC; 2020.
Preprint in English | EuropePMC | ID: ppcovidwho-310262

ABSTRACT

By the middle of March, the Democratic primary had effectively ended and the enormity of the Covid-19 pandemic and its human and economic cost began to sink in. The response to the pandemic had already been thoroughly politicized several weeks earlier such that news and information about the pandemic were mediated by political media systems. While the rest of the American media ecosystem focused on describing the pandemic, its economic costs, and criticizing the president for his response, conservative media presented a thoroughly partisan view of events and proactively defended and supported the actions and inactions of the president. For audiences of conservative media, information about the pandemic was communicated not through politically neutral public health authorities but was instead filtered and propagated through media channels shaped by many decades of partisan politics. The mainstream media coverage of the pandemic that got the most attention was highly critical of the president’s response, which may have deepened the politically-rooted differences in perspectives on the pandemic. Compared to conservative media, there was far greater deference among media sources on the center and left to views and perspectives of public health authorities and experts.This report, based on an ecosystem-wide analysis of political media coverage, spans the period of March, April, and May, when the spread and magnitude of the pandemic in the United States became clear, and the response of the government was communicated to the public and debated in the media. In March, coverage of the pandemic dominated political media on both sides of the political spectrum, though significantly less so on the right. The proportion of media attention to the pandemic diminished in April and May on the left. On the right, attention to the pandemic dropped off steeply. In April, conservative media and their audiences devoted substantial attention to coverage of the allegations of sexual harassment by Tara Reade against Joe Biden. In May, there was far more attention in conservative media to relitigating the origins of the Russia investigation under the banner of Obamagate than to the pandemic, which had already exacted a terrible cost and was nowhere near being under control. The collective judgment of the conservative media ecosystem was that this largely unsubstantiated storyline rooted in grievance politics was more deserving of the attention of the American public. For Biden supporters, the drop in attention to Covid-19 was picked up by negative coverage of the Trump administration on other issues. Sanders supporters followed a similar path until the death of George Floyd at the end May took up their attention. This was not replicated in the Biden set. Consistent with our findings in January-February, at the peak of the primaries season, Sanders supporters here too appear more focused on progressive issues, while Biden supporters are largely focused on criticism or rejection of Trump.The basic asymmetric and polarized structure of American political media has changed little over the past several years, and this time period is no exception. The potent role of conservative media in the election victory of Trump in 2016 rested on two distinct factors: first, Trump’s success in securing favorable coverage and strong support in conservative media, and second, the success that conservative media had in influencing media coverage outside of conservative media. The willingness of conservative media and audiences to defend and support Trump is clearly evident during these months. Trump continued to receive strong support in conservative media, which acted to divert, deflect, and reframe negative coverage, despite the rash of negative coverage criticizing the administration’s response to the pandemic. The evidence also points to a further isolation of conservative media in American political discourse and a system less able to shape discourse and coverage outside of its own confines, leaving Americans in more starkly divided pistemic worlds. The administration-friendly narratives about the pandemic and Obamagate got little to no traction outside of conservative media. This finding matches what we found in a prior report in which we describe the inability of conservative media to shape coverage of the Hunter Biden scandal outside of right-wing media during January and February 2020, a pattern that is repeated in October 2020.Neither President Trump nor conservative media have lost their ability to influence the media agenda. For example, in a recent report we describe how Trump was able to create a controversy about mail-in voter fraud that prompted media coverage across the political spectrum. The sexual harassment allegations lodged by Tara Reade against Joe Biden ultimately got a public airing—something conservative media pushed hard on. Despite the fact that the impetus to address this topic came also from the left, the media attention garnered in conservative media was not matched in the center and left. The key difference is that while President Trump and conservative media can still make news, their power to interpret and frame the narrative around key events beyond conservative media is more constrained than in 2016. The asymmetric credibility gap between conservative media and the rest of the media ecosystem appears to have deepened. And professional media seem to succumb less readily to the “bias of balance” problem that had bedeviled much of mainstream coverage of Hillary Clinton’s campaign in 2016.There is plentiful evidence of disinformation in political discourse among partisan media and on social media. The problem is far more acute on the right than the left and considerable attention on the far right is tied to the growing QAnon conspiracy. This development is a troubling symptom of the state of political discourse in the United States and translates into real-world costs. However, the impact of top-down propaganda and disinformation is still a greater problem in the United States, particularly so in relation to Covid-19, as tens of millions of Americans have taken unnecessary risks and helped spread the pandemic because they were misinformed about the dangers of contracting the disease and the value of measures deemed effective by public health authorities in reducing the chance of infection, such as social distancing or mask wearing. Many people, including public health specialists and the general public, have come to the conclusion that compared to the relative successes of other countries in addressing the Covid-19 pandemic, the United States response has been a failure, costing innumerable lives and leaving tens of thousands with long-term health problems, while deepening and extending the economic and social consequences of the pandemic. A large minority of Americans fundamentally disagree with this assessment. These divergent worldviews, the symptom of a larger epistemic crisis in the United States tied to asymmetrically polarized media systems, greatly complicate efforts to effectively meet such collection action challenges, and undermine democratic governance. In this paper, we describe how American media ecosystems are able to sustain such different worldviews and contribute to the mishandling and miscommunication of the pandemic. This report is the second in a series of reports that cover the months running up to the November election.

4.
EuropePMC; 2020.
Preprint in English | EuropePMC | ID: ppcovidwho-310261

ABSTRACT

The decisions voters will make at the ballot box on November 3, 2020 will be influenced in no small part by the media coverage of the candidates and issues, including the reporting by journalists, the media personalities and pundits on radio and television, text messages and campaign phone calls, podcasts, political ads, and for many, the incessant flow of social media posts of friends and family. In this report, the first of a series of reports that cover the months running up to the November election, we track political discourse in the United States for January and February of 2020, the period of time just before (Covid-19) began to dominate political discourse. We also describe the longer-term structure of political media ecosystems in the United States that shape public discourse by curating, amplifying, and propagating political stories and narratives to distinct political audiences.The agenda of political media in January and February 2020 centered on the impeachment of the president, the Democratic primaries, and the killing of Qasem Soleimani. This agenda was picked up throughout the media ecosystem, but there were stark differences across the media camps in the framing and narrative contours applied to these topics, presenting radically different depictions of the underlying evidence, facts, and interpretation of events. These differences between media spheres that often extend beyond spin and emphasis reflect and reinforce the depth and strength of the divide in American politics.Mainstream media described in great detail the rationale for impeaching the president, while in right-wing media the ‘call was perfect’ and the impetus for impeachment was a concocted charade, a witch hunt, to illegitimately overturn the 2016 election. Mainstream media described a rash decision by President Trump to order a missile strike on General Soleimani that was then sold to the American public on the false pretenses of a clear and imminent threat of attack against United States embassies. Conservative media hailed the killing as a decisive strike against adversaries that has unquestionably increased American security and standing in the world.While mainstream media coverage devoted similar levels of attention to the Democratic primaries and the impeachment of the president in January, and a majority of their attention to the primary race in February, politically engaged users on social media were more focused on partisan one-upmanship. For Democrats, attention was directed at the impeachment and the missteps of Trump and his administration, and in February, the intervention of Attorney General Barr and the Department of Justice in the sentencing of Roger Stone. Republicans, in turn, focused their attention on time-honored political foes: Nancy Pelosi and the Democratic leadership, Hillary Clinton, and the hostile and biased mainstream media. The patterns of attention on both sides are consistent with a view that negative partisanship plays a dominant role in American politics. Trump supporters on Facebook provided an exception to the pattern of negative coverage where celebratory videos of appearances and events of Trump were popular.Negative polarization spilled over into the Democratic primary race, which came down to a battle between progressives pursuing a platform of aggressive action on healthcare, climate change, and social and economic justice versus those that put regaining the White House above all else and saw a moderate candidate as a better bet. The media coverage promoted by Sanders supporters placed major focus on the candidate and his policy positions. In contrast, Biden supporters were oriented towards negative coverage of Trump. The outcome of the Democratic race is in keeping with the tenet that negative partisanship dominates American politics.Conservatives in America appear to have survived the barrage of negative coverage from mainstream media with their partisan perspectives and belief systems intact. This is not because conservative media erected an imper eable barrier against negative coverage from the center and left. Politically engaged conservatives were informed of the damaging coverage, but were unfailingly offered a reinterpretation and reframing of events and a plausible alternative narrative designed to preempt any second thoughts about allegiance to party and president. In deflecting and reframing negative coverage, the tactics employed by conservative media follow a well-developed pattern: downplay the validity of the story;deflect attention to the other side;attack the integrity and motives of sources;reinforce distrust in media outside of the right wing;and invoke a strong partisan framing to activate political identity.The formidable narrative crafting power of conservative media is employed not as a mechanism for accountability among its participants and leaders and not to police against disinformation and substandard reporting. Instead, it is wielded as a buffer against external influence and against deviance from the party line. This leaves the system vulnerable to misleading and false reporting and to those propagating conspiracies, such as the Gateway Pundit and True Pundit. Hyperpartisan media sources, which thrive on outrage and frequently misinform their audiences, play a prominent role in conservative media. On the left, partisan and hyperpartisan outlets play a much smaller role and less frequently propagate stories unconfirmed by mainstream media. The biggest change we observe in these first two months of 2020 compared to the election cycle of four years ago is the degree to which conservative media activists have shaped mainstream media coverage. In 2016, right-wing media activists succeeded in influencing mainstream coverage of Hillary Clinton, particularly on the unsubstantiated allegations of wrongdoing associated with the Clinton Foundation, which exacerbated and fed upon coverage of her emails and fueled suspicions of corruption and dishonesty. In the current election cycle, conservative media activists rolled out the same playbook that was so successful in 2016. This time, the corruption allegations were focused on Joe Biden, his son Hunter, and their dealings with Ukraine and China. This story was picked up by mainstream media in 2019, but the core allegation—that Joe Biden pressured Ukraine to remove a prosecutor in order to protect his son—fell apart under scrutiny. By January 2020, while conservative media continued to push out exaggerated and false claims, the dominant mainstream framing of this story had shifted to Donald Trump’s abuse of his presidential power for his own political gain, which overshadowed the well-established and misguided actions of Hunter Biden to cash in on his father’s name. The discredited allegations of corrupt dealings by Joe Biden were getting no play in mainstream media. While conservative media continues to exhibit a remarkable capacity for reframing news coverage to align with the beliefs and perceptions of its core audiences, in January and February of 2020, its power to shape mainstream media coverage was diminished compared to 2016. This is the most notable change we observe and has the potential to alter the electoral calculus in the November election.

5.
EuropePMC; 2020.
Preprint in English | EuropePMC | ID: ppcovidwho-306663

ABSTRACT

The claim that election fraud is a major concern with mail-in ballots has become the central threat to election participation during the COVID-19 pandemic and to the legitimacy of the outcome of the election across the political spectrum. President Trump has repeatedly cited his concerns over voter fraud associated with mail-in ballots as a reason that he may not abide by an adverse electoral outcome. Polling conducted in September 2020 suggests that nearly half of Republicans agree with the president that election fraud is a major concern associated with expanded mail-in voting during the pandemic. Few Democrats share that belief. Despite the consensus among independent academic and journalistic investigations that voter fraud is rare and extremely unlikely to determine a national election, tens of millions of Americans believe the opposite. This is a study of the disinformation campaign that led to widespread acceptance of this apparently false belief and to its partisan distribution pattern. Contrary to the focus of most contemporary work on disinformation, our findings suggest that this highly effective disinformation campaign, with potentially profound effects for both participation in and the legitimacy of the 2020 election, was an elite-driven, mass-media led process. Social media played only a secondary and supportive role.Our results are based on analyzing over fifty-five thousand online media stories, five million tweets, and seventy-five thousand posts on public Facebook pages garnering millions of engagements. They are consistent with our findings about the American political media ecosystem from 2015-2018, published in Network Propaganda , in which we found that Fox News and Donald Trump’s own campaign were far more influential in spreading false beliefs than Russian trolls or Facebook clickbait artists. This dynamic appears to be even more pronounced in this election cycle, likely because Donald Trump’s position as president and his leadership of the Republican Party allow him to operate directly through political and media elites, rather than relying on online media as he did when he sought to advance his then-still-insurgent positions in 2015 and the first half of 2016.Our findings here suggest that Donald Trump has perfected the art of harnessing mass media to disseminate and at times reinforce his disinformation campaign by using three core standard practices of professional journalism. These three are: elite institutional focus (if the President says it, it’s news);headline seeking (if it bleeds, it leads);and balance , neutrality, or the avoidance of the appearance of taking a side. He uses the first two in combination to summon coverage at will, and has used them continuously to set the agenda surrounding mail-in voting through a combination of tweets, press conferences, and television interviews on Fox News. He relies on the latter professional practice to keep audiences that are not politically pre-committed and have relatively low political knowledge confused, because it limits the degree to which professional journalists in mass media organizations are willing or able to directly call the voter fraud frame disinformation. The president is, however, not acting alone. Throughout the first six months of the disinformation campaign, the Republican National Committee (RNC) and staff from the Trump campaign appear repeatedly and consistently on message at the same moments, suggesting an institutionalized rather than individual disinformation campaign. The efforts of the president and the Republican Party are supported by the right-wing media ecosystem, primarily Fox News and talk radio functioning in effect as a party press. These reinforce the message, provide the president a platform, and marginalize or attack those Republican leaders or any conservative media personalities who insist that there is no evidence of widespread voter fraud associated with mail-in voting.The primary cure for the elite-driven, mass media communicated information disorder we observe her is unlikely to be more fact checking on Facebook. Instead, it is likely to require more aggressive policing by traditional professional media, the Associated Press, the television networks, and local TV news editors of whether and how they cover Trump’s propaganda efforts, and how they educate their audiences about the disinformation campaign the president and the Republican Party have waged.

6.
J Telemed Telecare ; : 1357633X211053738, 2021 Dec 03.
Article in English | MEDLINE | ID: covidwho-1551117

ABSTRACT

INTRODUCTION: Worldwide, it is estimated that 264 million people meet the diagnostic criteria for anxiety conditions. Effective treatment regimens consist of cognitive and behavioural therapies. During the COVID-19 pandemic, treatment delivery relied heavily on telemedicine technologies which enabled remote consultation with patients via phone or video platforms. We aim to identify, appraise and synthesise randomised controlled trials comparing telehealth to face-to-face delivery of care to individuals of any age or gender, diagnosed with anxiety disorders, and disorders with anxiety features. METHODS: To conduct this systematic review and meta-analysis, we searched three electronic databases, clinical trial registries and citing-cited references of included studies. RESULTS: A total of five small randomised controlled trials were includable; telehealth was conducted by video in three studies, and by telephone in two. The risk of bias for the 5 studies was low to moderate for most domains. Outcomes related to anxiety, depression symptom severity, obsessive-compulsive disorder, function, working alliance, and satisfaction were comparable between the two modes of delivery at each follow-up time point (immediately post-intervention, 3 months, 6 months and 12 months), with no significant differences reported (p > 0.05). None of the trials reported on the costs of telehealth compared to face-to-face care. DISCUSSION: For effectively treating anxiety and related conditions, interventions delivered by telehealth appear to be as effective as the same therapy delivered in-person. However, further high-quality trials are warranted to determine the effectiveness, acceptability, feasibility, and cost-effectiveness of telehealth interventions for the management of a wider range of anxiety disorders and treatments.

7.
Antimicrob Resist Infect Control ; 10(1): 156, 2021 11 04.
Article in English | MEDLINE | ID: covidwho-1503693

ABSTRACT

BACKGROUND: The effect of eye protection to prevent SARS-CoV-2 infection in the real-world remains uncertain. We aimed to synthesize all available research on the potential impact of eye protection on transmission of SARS-CoV-2. METHODS: We searched PROSPERO, PubMed, Embase, The Cochrane Library for clinical trials and comparative observational studies in CENTRAL, and Europe PMC for pre-prints. We included studies that reported sufficient data to estimate the effect of any form of eye protection including face shields and variants, goggles, and glasses, on subsequent confirmed infection with SARS-CoV-2. RESULTS: We screened 898 articles and included 6 reports of 5 observational studies from 4 countries (USA, India, Columbia, and United Kingdom) that tested face shields, goggles, and wraparound eyewear on 7567 healthcare workers. The three before-and-after and one retrospective cohort studies showed statistically significant and substantial reductions in SARS-CoV-2 infections favouring eye protection with odds ratios ranging from 0.04 to 0.6, corresponding to relative risk reductions of 96% to 40%. These reductions were not explained by changes in the community rates. However, the one case-control study reported odds ratio favouring no eye protection (OR 1.7, 95% CI 0.99, 3.0). The high heterogeneity between studies precluded any meaningful meta-analysis. None of the studies adjusted for potential confounders such as other protective behaviours, thus increasing the risk of bias, and decreasing the certainty of evidence to very low. CONCLUSIONS: Current studies suggest that eye protection may play a role in prevention of SARS-CoV-2 infection in healthcare workers. However, robust comparative trials are needed to clearly determine effectiveness of eye protections and wearability issues in both healthcare and general populations.


Subject(s)
COVID-19/prevention & control , Eye Protective Devices , Infectious Disease Transmission, Professional-to-Patient/prevention & control , Pandemics/prevention & control , COVID-19/transmission , Communicable Disease Control , Humans , SARS-CoV-2
8.
J Clin Epidemiol ; 138: 80-94, 2021 10.
Article in English | MEDLINE | ID: covidwho-1454254

ABSTRACT

OBJECTIVE: We investigated systematic review automation tool use by systematic reviewers, health technology assessors and clinical guideline developerst. STUDY DESIGN AND SETTING: An online, 16-question survey was distributed across several evidence synthesis, health technology assessment and guideline development organizations. We asked the respondents what tools they use and abandon, how often and when do they use the tools, their perceived time savings and accuracy, and desired new tools. Descriptive statistics were used to report the results. RESULTS: A total of 253 respondents completed the survey; 89% have used systematic review automation tools - most frequently whilst screening (79%). Respondents' "top 3" tools included: Covidence (45%), RevMan (35%), Rayyan and GRADEPro (both 22%); most commonly abandoned were Rayyan (19%), Covidence (15%), DistillerSR (14%) and RevMan (13%). Tools saved time (80%) and increased accuracy (54%). Respondents taught themselves to how to use the tools (72%); lack of knowledge was the most frequent barrier to tool adoption (51%). New tool development was suggested for the searching and data extraction stages. CONCLUSION: Automation tools will likely have an increasingly important role in high-quality and timely reviews. Further work is required in training and dissemination of automation tools and ensuring they meet the desirable features of those conducting systematic reviews.


Subject(s)
Attitude to Computers , Automation/methods , Research Personnel/psychology , Systematic Reviews as Topic/methods , Technology Assessment, Biomedical/statistics & numerical data , Technology Assessment, Biomedical/standards , Adult , Female , Humans , Male , Middle Aged
9.
BMC Med ; 19(1): 203, 2021 09 09.
Article in English | MEDLINE | ID: covidwho-1430426

ABSTRACT

BACKGROUND: The sustainable development goals aim to improve health for all by 2030. They incorporate ambitious goals regarding tuberculosis (TB), which may be a significant cause of disability, yet to be quantified. Therefore, we aimed to quantify the prevalence and types of TB-related disabilities. METHODS: We performed a systematic review of TB-related disabilities. The pooled prevalence of disabilities was calculated using the inverse variance heterogeneity model. The maps of the proportions of common types of disabilities by country income level were created. RESULTS: We included a total of 131 studies (217,475 patients) that were conducted in 49 countries. The most common type of disabilities were mental health disorders (23.1%), respiratory impairment (20.7%), musculoskeletal impairment (17.1%), hearing impairment (14.5%), visual impairment (9.8%), renal impairment (5.7%), and neurological impairment (1.6%). The prevalence of respiratory impairment (61.2%) and mental health disorders (42.0%) was highest in low-income countries while neurological impairment was highest in lower middle-income countries (25.6%). Drug-resistant TB was associated with respiratory (58.7%), neurological (37.2%), and hearing impairments (25.0%) and mental health disorders (26.0%), respectively. CONCLUSIONS: TB-related disabilities were frequently reported. More uniform reporting tools for TB-related disability and further research to better quantify and mitigate it are urgently needed. PROSPERO REGISTRATION NUMBER: CRD42019147488.


Subject(s)
Disabled Persons , Mental Disorders , Tuberculosis, Multidrug-Resistant , Tuberculosis , Humans , Prevalence , Tuberculosis/epidemiology
10.
J Crit Care ; 66: 33-43, 2021 12.
Article in English | MEDLINE | ID: covidwho-1370571

ABSTRACT

PURPOSE: This scoping review sought to identify objective factors to assist clinicians and policy-makers in making consistent, objective and ethically sound decisions about resource allocation when healthcare rationing is inevitable. MATERIALS AND METHODS: Review of guidelines and tools used in ICUs, hospital wards and emergency departments on how to best allocate intensive care beds and ventilators either during routine care or developed during previous epidemics, and association with patient outcomes during and after hospitalisation. RESULTS: Eighty publications from 20 countries reporting accuracy or validity of prognostic tools/algorithms, or significant correlation between prognostic variables and clinical outcomes met our eligibility criteria: twelve pandemic guidelines/triage protocols/consensus statements, twenty-two pandemic algorithms, and 46 prognostic tools/variables from non-crisis situations. Prognostic indicators presented here can be combined to create locally-relevant triage algorithms for clinicians and policy makers deciding about allocation of ICU beds and ventilators during a pandemic. No consensus was found on the ethical issues to incorporate in the decision to admit or triage out of intensive care. CONCLUSIONS: This review provides a unique reference intended as a discussion starter for clinicians and policy makers to consider formalising an objective a locally-relevant triage consensus document that enhances confidence in decision-making during healthcare rationing of critical care and ventilator resources.


Subject(s)
COVID-19 , Pandemics , Critical Care , Health Care Rationing , Humans , Triage , Ventilators, Mechanical
12.
PLoS One ; 16(4): e0248946, 2021.
Article in English | MEDLINE | ID: covidwho-1167102

ABSTRACT

BACKGROUND: Accurate seroprevalence estimates of SARS-CoV-2 in different populations could clarify the extent to which current testing strategies are identifying all active infection, and hence the true magnitude and spread of the infection. Our primary objective was to identify valid seroprevalence studies of SARS-CoV-2 infection and compare their estimates with the reported, and imputed, COVID-19 case rates within the same population at the same time point. METHODS: We searched PubMed, Embase, the Cochrane COVID-19 trials, and Europe-PMC for published studies and pre-prints that reported anti-SARS-CoV-2 IgG, IgM and/or IgA antibodies for serosurveys of the general community from 1 Jan to 12 Aug 2020. RESULTS: Of the 2199 studies identified, 170 were assessed for full text and 17 studies representing 15 regions and 118,297 subjects were includable. The seroprevalence proportions in 8 studies ranged between 1%-10%, with 5 studies under 1%, and 4 over 10%-from the notably hard-hit regions of Gangelt, Germany; Northwest Iran; Buenos Aires, Argentina; and Stockholm, Sweden. For seropositive cases who were not previously identified as COVID-19 cases, the majority had prior COVID-like symptoms. The estimated seroprevalences ranged from 0.56-717 times greater than the number of reported cumulative cases-half of the studies reported greater than 10 times more SARS-CoV-2 infections than the cumulative number of cases. CONCLUSIONS: The findings show SARS-CoV-2 seroprevalence is well below "herd immunity" in all countries studied. The estimated number of infections, however, were much greater than the number of reported cases and deaths in almost all locations. The majority of seropositive people reported prior COVID-like symptoms, suggesting that undertesting of symptomatic people may be causing a substantial under-ascertainment of SARS-CoV-2 infections.


Subject(s)
Antibodies, Viral/blood , COVID-19 , Immunoglobulin Isotypes/blood , Adolescent , Adult , Aged , Argentina , COVID-19/epidemiology , COVID-19/immunology , Female , Germany , Humans , Immunity, Herd , Incidence , Iran , Male , Middle Aged , Seroepidemiologic Studies , Sweden , Young Adult
13.
BMJ Open ; 11(3): e045343, 2021 03 16.
Article in English | MEDLINE | ID: covidwho-1138354

ABSTRACT

OBJECTIVES: To determine the extent and nature of changes in utilisation of healthcare services during COVID-19 pandemic. DESIGN: Systematic review. ELIGIBILITY: Eligible studies compared utilisation of services during COVID-19 pandemic to at least one comparable period in prior years. Services included visits, admissions, diagnostics and therapeutics. Studies were excluded if from single centres or studied only patients with COVID-19. DATA SOURCES: PubMed, Embase, Cochrane COVID-19 Study Register and preprints were searched, without language restrictions, until 10 August, using detailed searches with key concepts including COVID-19, health services and impact. DATA ANALYSIS: Risk of bias was assessed by adapting the Risk of Bias in Non-randomised Studies of Interventions tool, and a Cochrane Effective Practice and Organization of Care tool. Results were analysed using descriptive statistics, graphical figures and narrative synthesis. OUTCOME MEASURES: Primary outcome was change in service utilisation between prepandemic and pandemic periods. Secondary outcome was the change in proportions of users of healthcare services with milder or more severe illness (eg, triage scores). RESULTS: 3097 unique references were identified, and 81 studies across 20 countries included, reporting on >11 million services prepandemic and 6.9 million during pandemic. For the primary outcome, there were 143 estimates of changes, with a median 37% reduction in services overall (IQR -51% to -20%), comprising median reductions for visits of 42% (-53% to -32%), admissions 28% (-40% to -17%), diagnostics 31% (-53% to -24%) and for therapeutics 30% (-57% to -19%). Among 35 studies reporting secondary outcomes, there were 60 estimates, with 27 (45%) reporting larger reductions in utilisation among people with a milder spectrum of illness, and 33 (55%) reporting no difference. CONCLUSIONS: Healthcare utilisation decreased by about a third during the pandemic, with considerable variation, and with greater reductions among people with less severe illness. While addressing unmet need remains a priority, studies of health impacts of reductions may help health systems reduce unnecessary care in the postpandemic recovery. PROSPERO REGISTRATION NUMBER: CRD42020203729.


Subject(s)
COVID-19 , Health Services/statistics & numerical data , Pandemics , Patient Acceptance of Health Care/statistics & numerical data , Delivery of Health Care , Humans
14.
J Assoc Med Microbiol Infect Dis Can ; 5(4): 223-234, 2020 Dec.
Article in English | MEDLINE | ID: covidwho-1110217

ABSTRACT

Background: Knowing the prevalence of true asymptomatic coronavirus disease 2019 (COVID-19) cases is critical for designing mitigation measures against the pandemic. We aimed to synthesize all available research on asymptomatic cases and transmission rates. Methods: We searched PubMed, Embase, Cochrane COVID-19 trials, and Europe PMC for primary studies on asymptomatic prevalence in which (1) the sample frame includes at-risk populations and (2) follow-up was sufficient to identify pre-symptomatic cases. Meta-analysis used fixed-effects and random-effects models. We assessed risk of bias by combination of questions adapted from risk of bias tools for prevalence and diagnostic accuracy studies. Results: We screened 2,454 articles and included 13 low risk-of-bias studies from seven countries that tested 21,708 at-risk people, of which 663 were positive and 111 asymptomatic. Diagnosis in all studies was confirmed using a real-time reverse transcriptase-polymerase chain reaction test. The asymptomatic proportion ranged from 4% to 41%. Meta-analysis (fixed effects) found that the proportion of asymptomatic cases was 17% (95% CI 14% to 20%) overall and higher in aged care (20%; 95% CI 14% to 27%) than in non-aged care (16%; 95% CI 13% to 20%). The relative risk (RR) of asymptomatic transmission was 42% lower than that for symptomatic transmission (combined RR 0.58; 95% CI 0.34 to 0.99, p = 0.047). Conclusions: Our one-in-six estimate of the prevalence of asymptomatic COVID-19 cases and asymptomatic transmission rates is lower than those of many highly publicized studies but still sufficient to warrant policy attention. Further robust epidemiological evidence is urgently needed, including in subpopulations such as children, to better understand how asymptomatic cases contribute to the pandemic.


Historique: Il est essentiel de connaître la prévalence des véritables cas asymptomatiques de maladie à coronavirus 2019 (COVID-19) pour concevoir des mesures d'atténuation de la pandémie. Les chercheurs ont voulu synthétiser toutes les recherches disponibles sur les cas asymptomatiques et les taux de transmission. Méthodologie: Les chercheurs ont fouillé les bases de données PubMed, Embase, Cochrane pour trouver les études sur la COVID-19, et Europe PMC pour colliger les études primaires sur la prévalence des cas asymptomatiques dans lesquelles 1) le cadre d'échantillonnage incluait une population à risque et 2) le suivi était suffisant pour dépister les cas présymptomatiques. La méta-analyse a fait appel à des modèles d'effets fixes et d'effets aléatoires. Nous avons évalué le risque de biais par une combinaison de questions adaptées d'outils sur les risques de biais des études de prévalence et de précision diagnostique. Résultats: Les chercheurs ont extrait 2 454 articles, dont 13 études à faible risque de biais de sept pays dans lesquelles 21 708 personnes à risque ont subi le test de dépistage, soit 663 cas positifs et 111 cas asymptomatiques. Dans toutes les études, le diagnostic a été confirmé au moyen du test d'amplification en chaîne par polymérase après transcriptase inverse en temps réel. La proportion de cas asymptomatiques se situait entre 4 % et 41 %. La méta-analyse (à effets fixes) a établi que la proportion de cas asymptomatiques s'élevait à 17 % (IC à 95 %, 14 % à 20 %) dans l'ensemble, mais qu'elles étaient plus élevées dans les soins aux aînés (20 %; IC à 95 %, 14 % à 27 %) qu'auprès du reste de la population (16 %; IC à 95 %, 13 % à 20 %). Le risque relatif [RR] de transmission de cas asymptomatiques était plus faible de 42 % que celui de cas symptomatiques (RR combiné de 0,58; IC à 95 %, 0,34 à 0.99, p = 0,047). Conclusions: L'évaluation de la prévalence d'un sixième de cas asymptomatiques de COVID-19 et de taux de transmission de cas asymptomatiques est inférieure à celle de nombreuses études hautement publicisées, mais suffit tout de même pour justifier l'intérêt de la santé publique. D'autres données épidémiologiques solides s'imposent de toute urgence, y compris dans des sous-populations comme les enfants, pour mieux comprendre l'effet des cas asymptomatiques sur la pandémie.

15.
BMJ Open ; 11(2): e044364, 2021 02 22.
Article in English | MEDLINE | ID: covidwho-1095183

ABSTRACT

OBJECTIVE: To identify, appraise and synthesise studies evaluating the downsides of wearing face masks in any setting. We also discuss potential strategies to mitigate these downsides. DESIGN: Systematic review and meta-analysis. DATA SOURCES: PubMed, Embase, CENTRAL and EuropePMC were searched (inception-18 May 2020), and clinical registries were searched via CENTRAL. We also did a forward-backward citation search of the included studies. INCLUSION CRITERIA: We included randomised controlled trials and observational studies comparing face mask use to any active intervention or to control. DATA EXTRACTION AND ANALYSIS: Two author pairs independently screened articles for inclusion, extracted data and assessed the quality of included studies. The primary outcomes were compliance, discomforts, harms and adverse events of wearing face masks. RESULTS: We screened 5471 articles, including 37 (40 references); 11 were meta-analysed. For mask wear adherence, 47% (95% CI 25% to 68%, p<0.0001), more people wore face masks in the face mask group compared with control; adherence was significantly higher (26%, 95% CI 8% to 46%, p<0.01) in the surgical/medical mask group than in N95/P2 group. The largest number of studies reported on the discomfort and irritation outcome (20 studies); fewest reported on the misuse of masks, and none reported on mask contamination or risk compensation behaviour. Risk of bias was generally high for blinding of participants and personnel and low for attrition and reporting biases. CONCLUSIONS: There are insufficient data to quantify all of the adverse effects that might reduce the acceptability, adherence and effectiveness of face masks. New research on face masks should assess and report the harms and downsides. Urgent research is also needed on methods and designs to mitigate the downsides of face mask wearing, particularly the assessment of possible alternatives. SYSTEMATIC REVIEW REGISTRATION: Open Science Framework website https://osf.io/sa6kf/ (timestamp 20-05-2020).


Subject(s)
Masks , Humans , Masks/adverse effects , Randomized Controlled Trials as Topic
16.
Cochrane Database Syst Rev ; 11: CD006207, 2020 11 20.
Article in English | MEDLINE | ID: covidwho-934984

ABSTRACT

BACKGROUND: Viral epidemics or pandemics of acute respiratory infections (ARIs) pose a global threat. Examples are influenza (H1N1) caused by the H1N1pdm09 virus in 2009, severe acute respiratory syndrome (SARS) in 2003, and coronavirus disease 2019 (COVID-19) caused by SARS-CoV-2 in 2019. Antiviral drugs and vaccines may be insufficient to prevent their spread. This is an update of a Cochrane Review published in 2007, 2009, 2010, and 2011. The evidence summarised in this review does not include results from studies from the current COVID-19 pandemic. OBJECTIVES: To assess the effectiveness of physical interventions to interrupt or reduce the spread of acute respiratory viruses. SEARCH METHODS: We searched CENTRAL, PubMed, Embase, CINAHL on 1 April 2020. We searched ClinicalTrials.gov, and the WHO ICTRP on 16 March 2020. We conducted a backwards and forwards citation analysis on the newly included studies. SELECTION CRITERIA: We included randomised controlled trials (RCTs) and cluster-RCTs of trials investigating physical interventions (screening at entry ports, isolation, quarantine, physical distancing, personal protection, hand hygiene, face masks, and gargling) to prevent respiratory virus transmission. In previous versions of this review we also included observational studies. However, for this update, there were sufficient RCTs to address our study aims.   DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. We used GRADE to assess the certainty of the evidence. Three pairs of review authors independently extracted data using a standard template applied in previous versions of this review, but which was revised to reflect our focus on RCTs and cluster-RCTs for this update. We did not contact trialists for missing data due to the urgency in completing the review. We extracted data on adverse events (harms) associated with the interventions. MAIN RESULTS: We included 44 new RCTs and cluster-RCTs in this update, bringing the total number of randomised trials to 67. There were no included studies conducted during the COVID-19 pandemic. Six ongoing studies were identified, of which three evaluating masks are being conducted concurrent with the COVID pandemic, and one is completed. Many studies were conducted during non-epidemic influenza periods, but several studies were conducted during the global H1N1 influenza pandemic in 2009, and others in epidemic influenza seasons up to 2016. Thus, studies were conducted in the context of lower respiratory viral circulation and transmission compared to COVID-19. The included studies were conducted in heterogeneous settings, ranging from suburban schools to hospital wards in high-income countries; crowded inner city settings in low-income countries; and an immigrant neighbourhood in a high-income country. Compliance with interventions was low in many studies. The risk of bias for the RCTs and cluster-RCTs was mostly high or unclear. Medical/surgical masks compared to no masks We included nine trials (of which eight were cluster-RCTs) comparing medical/surgical masks versus no masks to prevent the spread of viral respiratory illness (two trials with healthcare workers and seven in the community). There is low certainty evidence from nine trials (3507 participants) that wearing a mask may make little or no difference to the outcome of influenza-like illness (ILI) compared to not wearing a mask (risk ratio (RR) 0.99, 95% confidence interval (CI) 0.82 to 1.18. There is moderate certainty evidence that wearing a mask probably makes little or no difference to the outcome of laboratory-confirmed influenza compared to not wearing a mask (RR 0.91, 95% CI 0.66 to 1.26; 6 trials; 3005 participants). Harms were rarely measured and poorly reported. Two studies during COVID-19 plan to recruit a total of 72,000 people. One evaluates medical/surgical masks (N = 6000) (published Annals of Internal Medicine, 18 Nov 2020), and one evaluates cloth masks (N = 66,000). N95/P2 respirators compared to medical/surgical masks We pooled trials comparing N95/P2 respirators with medical/surgical masks (four in healthcare settings and one in a household setting). There is uncertainty over the effects of N95/P2 respirators when compared with medical/surgical masks on the outcomes of clinical respiratory illness (RR 0.70, 95% CI 0.45 to 1.10; very low-certainty evidence; 3 trials; 7779 participants) and ILI (RR 0.82, 95% CI 0.66 to 1.03; low-certainty evidence; 5 trials; 8407 participants). The evidence is limited by imprecision and heterogeneity for these subjective outcomes. The use of a N95/P2 respirator compared to a medical/surgical mask probably makes little or no difference for the objective and more precise outcome of laboratory-confirmed influenza infection (RR 1.10, 95% CI 0.90 to 1.34; moderate-certainty evidence; 5 trials; 8407 participants). Restricting the pooling to healthcare workers made no difference to the overall findings. Harms were poorly measured and reported, but discomfort wearing medical/surgical masks or N95/P2 respirators was mentioned in several studies. One ongoing study recruiting 576 people compares N95/P2 respirators with medical surgical masks for healthcare workers during COVID-19. Hand hygiene compared to control Settings included schools, childcare centres, homes, and offices. In a comparison of hand hygiene interventions with control (no intervention), there was a 16% relative reduction in the number of people with ARIs in the hand hygiene group (RR 0.84, 95% CI 0.82 to 0.86; 7 trials; 44,129 participants; moderate-certainty evidence), suggesting a probable benefit. When considering the more strictly defined outcomes of ILI and laboratory-confirmed influenza, the estimates of effect for ILI (RR 0.98, 95% CI 0.85 to 1.13; 10 trials; 32,641 participants; low-certainty evidence) and laboratory-confirmed influenza (RR 0.91, 95% CI 0.63 to 1.30; 8 trials; 8332 participants; low-certainty evidence) suggest the intervention made little or no difference. We pooled all 16 trials (61,372 participants) for the composite outcome of ARI or ILI or influenza, with each study only contributing once and the most comprehensive outcome reported. The pooled data showed that hand hygiene may offer a benefit with an 11% relative reduction of respiratory illness (RR 0.89, 95% CI 0.84 to 0.95; low-certainty evidence), but with high heterogeneity. Few trials measured and reported harms. There are two ongoing studies of handwashing interventions in 395 children outside of COVID-19. We identified one RCT on quarantine/physical distancing. Company employees in Japan were asked to stay at home if household members had ILI symptoms. Overall fewer people in the intervention group contracted influenza compared with workers in the control group (2.75% versus 3.18%; hazard ratio 0.80, 95% CI 0.66 to 0.97). However, those who stayed at home with their infected family members were 2.17 times more likely to be infected. We found no RCTs on eye protection, gowns and gloves, or screening at entry ports. AUTHORS' CONCLUSIONS: The high risk of bias in the trials, variation in outcome measurement, and relatively low compliance with the interventions during the studies hamper drawing firm conclusions and generalising the findings to the current COVID-19 pandemic. There is uncertainty about the effects of face masks. The low-moderate certainty of the evidence means our confidence in the effect estimate is limited, and that the true effect may be different from the observed estimate of the effect. The pooled results of randomised trials did not show a clear reduction in respiratory viral infection with the use of medical/surgical masks during seasonal influenza. There were no clear differences between the use of medical/surgical masks compared with N95/P2 respirators in healthcare workers when used in routine care to reduce respiratory viral infection. Hand hygiene is likely to modestly reduce the burden of respiratory illness. Harms associated with physical interventions were under-investigated. There is a need for large, well-designed RCTs addressing the effectiveness of many of these interventions in multiple settings and populations, especially in those most at risk of ARIs.


Subject(s)
Hand Hygiene , Masks , Respiratory Tract Infections/prevention & control , Virus Diseases/prevention & control , Virus Shedding , Bias , COVID-19/epidemiology , COVID-19/prevention & control , Case-Control Studies , Epidemics , Humans , Influenza A Virus, H1N1 Subtype , Influenza, Human/epidemiology , Influenza, Human/transmission , Influenza, Human/virology , Randomized Controlled Trials as Topic/statistics & numerical data , Respiratory Tract Infections/epidemiology , Respiratory Tract Infections/transmission , Respiratory Tract Infections/virology , SARS-CoV-2 , Severe Acute Respiratory Syndrome/epidemiology , Severe Acute Respiratory Syndrome/prevention & control , Virus Diseases/epidemiology , Virus Diseases/transmission
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