Molecular epidemiology of carbapenem-resistant Enterobacteriaceae isolated from patients in COVID-19 wards and ICUs in a Bulgarian University Hospital.

Many studies report an increase in antimicrobial resistance of Gram - negative bacteria during the COVID-19 pandemic. Our aim was to evaluate the epidemiological relationship between carbapenem-resistant (CR) Enterobacteriaceae isolates from patients in COVID-19 wards and to investigate the main mechanisms of carbapenem resistance in these isolates during the period April 2020-July 2021. A total of 45 isolates were studied: Klebsiella pneumoniae (n = 37), Klebsiella oxytoca (n = 2), Enterobacter cloacae complex (n = 4) and Escherichia coli (n = 2). Multiplex PCR was used for detection of genes encoding carbapenemases from different classes (blaKPC, blaIMP, blaVIM, blaNDM, blaOXA-48). For epidemiological typing and analysis, ERIC PCR was performed. Two clinical isolates of E. cloacae, previously identified as representatives of two dominant hospital clones from the period 2014-2017, were included in the study for comparison. In the CR K. pneumoniae group, 23 (62.2%) carried blaKPC, 13 (35.1%) blaNDM, 10 (27.0%) blaVIM, and 9 (24.3%) were positive for both blaKPC and blaVIM. The blaKPC was identified also in the two isolates of K. oxytoca and blaVIM in all E. cloacae complex isolates. The two CR isolates of E. coli possessed blaKPC and blaOXA-48 genes. Epidemiological typing identified 18 ERIC profiles among K. pneumoniae, some presented as clusters of identical and/or closely related isolates. The carbapenem resistance in the studied collection of isolates is mediated mainly by blaKPC. During the COVID-19 pandemic intrahospital dissemination of CR K. pneumoniae, producing carbapenemases of different molecular classes, as well as continuing circulation of dominant hospital clones of multidrug-resistant E. cloacae complex was documented.

Low prevalence of influenza viruses and predominance of A(H3N2) virus with respect to SARS-CoV-2 during the 2021-2022 season in Bulgaria.

Social distancing, mask-wearing, and travel restrictions during the COVID-19 pandemic have significantly impacted the spread of influenza viruses. The objectives of this study were to analyze the pattern of influenza virus circulation with respect to that of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in Bulgaria during the 2021-2022 season and to perform a phylogenetic/molecular analysis of the hemagglutinin (HA) and neuraminidase (NA) sequences of representative influenza strains. Influenza infection was confirmed using real-time reverse transcription polymerase chain reaction in 93 (4.2%) of the 2193 patients with acute respiratory illness tested wherein all detected viruses were subtyped as A(H3N2). SARS-CoV-2 was identified in 377 (24.3%) of the 1552 patients tested. Significant differences in the incidence of influenza viruses and SARS-CoV-2 were found between individual age groups, outpatients/inpatients, and in the seasonal distribution of cases. Two cases of coinfections were identified. In hospitalized patients, the Ct values of influenza viruses at admission were lower in adults aged ≥65 years (indicating higher viral load) than in children aged 0-14 years (p < 0.05). In SARS-CoV-2-positive inpatients, this association was not statistically significant. HA genes of all A(H3N2) viruses analyzed belonged to subclade 3C.2a1b.2a. The sequenced viruses carried 11 substitutions in HA and 5 in NA, in comparison to the vaccine virus A/Cambodia/e0826360/2020, including several substitutions in the HA antigenic sites B and C. This study revealed extensive changes in the typical epidemiology of influenza infection, including a dramatic reduction in the number of cases, diminished genetic diversity of circulating viruses, changes in age, and seasonal distribution of cases.

Evaluating computing students' digital skills and health literacy: A case from Bulgaria.

The main purpose of this article is to describe the importance and the challenges of digital health literacy as recognized during the COVID-19 pandemic. First, basic definitions of health literacy and digital health literacy are provided, followed by, and matched against digital competence frameworks, and health literacy skills content and scales. Based on that, a compatibility analysis is provided, against the expectations for satisfactory levels definition for the respective competences and skills. For the approbation of the approach, results received from the participation of computing students at the Sofia University St. Kliment Ohridski in the COVID-19 Health Literacy Survey are used.

Chest CT diagnostic potential as a tool for early detection of suspected COVID-19 cases in pandemic peaks.

INTRODUCTION: The emergence of severe acute respiratory syndrome coronavirus disease (COVID-19) in China at the end of 2019 caused a massive global outbreak that has become a major public health issue. AIM: Our aim was to investigate the diagnostic potential of chest CT in screening patients suspected of having COVID-19 in high-prevalence settings. MATERIALS AND METHODS: This is a real-life, prospective, observational study involving 260 patients. All patients received chest CT scan at the emergency department (ED) of Kaspela University Hospital, Plovdiv, Bulgaria and RT-PCR testing for suspected COVID-19 from March 27 to December 31, 2020. COVID-19 likelihood was assessed by assigning each CT scan to a particular category of the COVID-19 Reporting and Data System (CO-RADS). IBM SPSS v. 26 was used to process the data. RESULTS: The male-to-female distribution ratio was 1.4:1 - 150 (57.7%) males vs. 110 (42.3%) females (p=0.014). The median age was 55 yrs (range 46-65 yrs). Discharged patients were 247 (95.0%), the rest died in the COVID-19 intensive care unit. Males were 4.13 times more likely to be diagnosed with CO-RADS≥3 score than females. Increasing age was associated with an increased likelihood of being classified with higher CO-RADS scores. The ROC curves analysis demonstrated that CO-RADS ≥3 was the optimal cutoff for discrimi-nating between a positive and negative PCR (Youden's index J=0.67), with an AUC of 0.825 (95% CI 0.72-0.93), sensitivity of 91.9% (95% CI 87.7%-95.1%), specificity of 75.0% (95% CI 53.3%-90.2%) and accuracy of 76.4% (95% CI 70.7%-81.4%). CONCLUSIONS: The results of this study reveal that a CT examination can provide a quick and accurate diagnosis of patients with sus-pected COVID-19 infection, whereas the PCR test is time-consuming, and the delay in receiving results can be substantial when the incidence curve begins to grow rapidly.

Geographic distribution of antibiotic resistance of Helicobacter pylori: A study in Bulgaria.

Prevalence of antibiotic resistant Helicobacter pylori was compared between 50 patients living outside the capital city and 50 matched pairs of capital city residents (CCRs). H. pylori isolates from 2018 to 2022 were included. Resistance rates in CCRs and those living elsewhere were 4.0 and 6.0% to amoxicillin, 48.0 and 42.0% to metronidazole, 30 and 30% to clarithromycin, and 4.0 and 4.0% to tetracycline, respectively. Levofloxacin resistance was higher (38.0%) in the capital city vs 20.0% (P = 0.047) in the country. Odd ratio for levofloxacin resistance between pair-matched groups was 2.45 (95% CI, OR 1.0-6.02, P value = 0.05) and relative risk for fluoroquinolone resistance was 1.90 (95% CI for RR 0.98-3.67) for CCRs vs residents in other regions. Resistance rates to levofloxacin and clarithromycin were worryingly high in our study, most probably due to the high quinolone consumption (2.86 DDD/day in 2017) in Bulgaria and the increase in macrolide, lincosamide and streptogramin consumption, especially of azithromycin, by >42% with the start of COVID-19 pandemic. Briefly, antibiotic resistance of H. pylori has a dynamic change, and it can display different patterns in certain geographic regions. The results imply that antibiotic consumption should be carefully controlled and unjustified use of levofloxacin should be restricted, especially in some large cities. Antibiotic policy should be further strengthened and regular monitoring of resistance in various geographic regions is needed for treatment optimization.

Analysis of biofilm formation in nosocomial Stenotrophomonas maltophilia isolates collected in Bulgaria: An 11-year study (2011-2022).

The present study aimed to explore the genotypic and phenotypic characteristics of biofilm formation in Bulgarian nosocomial Stenotrophomonas maltophilia isolates (n = 221) during the period 2011-2022, by screening for the presence of biofilm-associated genes (BAG) (spgM, rmlA and rpfF), their mutational variability, and assessment of the adherent growth on a polystyrene surface. The methodology included: PCR amplification, whole-genome sequencing (WGS) and crystal violet microtiter plate assay for biofilm quantification. The overall incidence of BAG was: spgM 98.6%, rmlA 86%, and rpfF 66.5%. The most prevalent genotype was spgM+/rmlA+/rpfF+ (56.1%), followed by spgM+/rmlA+/rpfF- (28.5%), and spgM+/rmlA-/rpfF+ (9.5%), with their significant predominance in lower respiratory tract isolates compared to those with other origin (P < 0.001). All strains examined were characterized as strong biofilm producers (OD550 from 0.224 ± 0.049 to 2.065 ± 0.023) with a single exception that showed a weak biofilm-forming ability (0.177 ± 0.024). No significant differences were observed in the biofilm formation according to the isolation source, as well as among COVID-19 and non-COVID-19 isolates (1.256 ± 0.028 vs. 1.348 ± 0.128, respectively). Also, no correlation was found between the biofilm amounts and the corresponding genotypes. WGS showed that the rmlA accumulated a larger number of variants (0.0086 per base) compared to the other BAG, suggesting no critical role of its product to the biofilm formation. Additionally, two of the isolates were found to harbour class 1 integrons (7-kb and 2.6-kb sized, respectively) containing sul1 in their 3' conservative ends, which confers sulfonamide resistance. To the best of our knowledge, this is the first study on S. maltophilia biofilm formation in Bulgaria, which also identifies novel sequence types (ST819, ST820 and ST826). It demonstrates the complex nature of this adaptive mechanism in the multifactorial pathogenesis of biofilm-associated infections.

Renin-angiotensin-aldosterone system blockers in Bulgarian COVID-19 patients with or without chronic kidney disease.

When angiotensin-converting enzyme inhibitor/angiotensin receptor blocker-treated patients present with SARS-CoV-2 infection there is a debate to know whether renin-angiotensin-aldosterone (RAAS) blockers should be stopped or not. We conducted a prospective observational study in Bulgarian COVID-19-infected patients with or without chronic kidney disease (CKD) to assess whether maintenance RAAS blocker therapy has an impact on SARS-CoV-2 infection and its complications. We included 120 in-patient COVID-19 subjects, of whom 70 had CKD and 50 had normal renal function. A total of 30% of the patients (total number of 36 patients, 21 females) were receiving RAAS therapy at admission and it was maintained throughout hospitalization. The overall mortality was 19.2% (23 patients); there was no significant difference across the 2 groups (P-value = .21), except in RAAS blockers-treated hypertensive patients who had a significantly lower mortality as compared to non-RAAS-blockers-treated hypertensive patients (P = .04). Regarding subsequent intensive-care unit admission, there were 50% less patients in the RAAS group (4 out of 36, i.e., 11%) as compared to 19 out of 84 from the non-RAAS group, that is, 22.6% (P = .29). Overall, 37 patients developed acute kidney injury (any stage by KDIGO); of them 14 (37.8%) were receiving RAAS blockers. Acute kidney injury was not significantly associated with the use of RAAS blockers (P-value = .28). Likewise, both in non-CKD and in CKD patients the use of RAAS blockers did not have an impact on renal function recovery after SARS-CoV-2 infection. Finally, regarding RAAS blockers and the biological parameters outcome only D-dimers were significantly lower at the follow-up as compared to that in non-RAAS blocker treated patients. RAAS blockers benefited patients with hypertension by lowering mortality rate. Other than that, RAAS blocker therapy continuation during SARS-CoV-2 infection in CKD and non-CKD patients had no significant impact upon major outcomes.

Reporting adverse events of COVID-19 vaccines: The case of Bulgaria.

As a member state of the European Union, where vaccines against COVID-19 are available and affordable, Bulgaria reports the lowest immunization coverage and the most pronounced vaccine distrust. The present study aimed to assess the self-reported adverse reactions following COVID-19 vaccination as a possible tool to increase the trust in vaccines. A cross-sectional survey-based study, covering 761 vaccinated respondents, was conducted in Plovdiv (469 with an mRNA vaccine and 292 with an adenoviral vector vaccine). Descriptive statistics parametric and non-parametric methods were applied. Statistical significance was set at p<0.05. The median age of the respondents was 42 years, females (72.5%). At least one adverse reaction was reported in 89.9% of those immunized with mRNA vaccine and 93.8% in the adenoviral vector vaccine group (p>0.05). They were mild to moderate and resolved within several days. The levels of local reactions were comparable: 91.7% in those who received mRNA and 89.7% in those who received an adenoviral vector vaccine (p = 0.366). The most common types of systemic reactions were fatigue, headache, and muscle pains. An association was found between the systemic reactions and the type of vaccine administered: 59.7% in mRNA recipients and 89.4% in adenoviral vector vaccinees (p<0.001). None of the registered systemic reactions required medical attention. There were 3 reports of generalized urticaria after an mRNA and 2 after an adenoviral vector vaccine. The reported reactions are relatively high but expected and no adverse events have been reported that are not listed in the official Summary of Product Characteristics.

SARS-CoV-2 reinfections during the first three major COVID-19 waves in Bulgaria.

BACKGROUND: The COVID-19 pandemic has had a devastating impact on the world over the past two years (2020-2021). One of the key questions about its future trajectory is the protection from subsequent infections and disease conferred by a previous infection, as the SARS-CoV-2 virus belongs to the coronaviruses, a group of viruses the members of which are known for their ability to reinfect convalescent individuals. Bulgaria, with high rates of previous infections combined with low vaccination rates and an elderly population, presents a somewhat unique context to study this question. METHODS: We use detailed governmental data on registered COVID-19 cases to evaluate the incidence and outcomes of COVID-19 reinfections in Bulgaria in the period between March 2020 and early December 2021. RESULTS: For the period analyzed, a total of 4,106 cases of individuals infected more than once were observed, including 31 cases of three infections and one of four infections. The number of reinfections increased dramatically during the Delta variant-driven wave of the pandemic towards the end of 2021. We observe a moderate reduction of severe outcomes (hospitalization and death) in reinfections relative to primary infections, and a more substantial reduction of severe outcomes in breakthrough infections in vaccinated individuals. CONCLUSIONS: In the available datasets from Bulgaria, prior infection appears to provide some protection from severe outcomes, but to a lower degree than the reduction in severity of breakthrough infections in the vaccinated compared to primary infections in the unvaccinated.

Students' Attitudes toward COVID-19 Vaccination: An Inter-University Study from Bulgaria.

In Bulgaria, vaccination coverage against the SARS-CoV-2 virus is low. The reasons for this fact are many and varied. The aim of the present study was to establish what the attitudes towards the COVID-19 vaccination process are among students from various specialties from several Bulgarian universities. In this research, 600 students participated, divided into two groups: Doctor of Medicine (MD) students (n = 300) and non-MD students, i.e., students of specialties, such as mathematics, engineering, finance and economics, law, human sciences, etc. (n = 300). Each respondent completed a questionnaire which was divided into three parts with closed questions. The mean age of all students was 21.19 ± 1.87 years (95% CI: 20.48-21.90). The female sex dominated among the analyzed participants (sex ratio: female/male = 1/0.85). Nearly 62% (371/600) of individuals declared that they have been COVID-19 vaccinated with at least one dose (p < 0.001). Overall, 33% of the participants sought information on vaccines from video sharing platforms and 36.0% (216/600) from social media platforms. From the conducted multivariable logistic regression the odds of vaccination against COVID-19 were 6.225 times higher in individuals with a positive attitude towards these vaccines than in people with a negative attitude towards them (p < 0.001). We have found that those students who trust the international health organizations had an OR of 2.365 (p = 0.004) to be SARS-CoV-2 vaccinated. We estimated that the odds of vaccination against SARS-CoV-2 among children were 4.794 times higher in parents (students) who had been vaccinated than in non-vaccinated parents (students) (p < 0.001). Our results could support the national public health organizations, the national educational/scientific systems, and the management of Bulgarian universities in making future decisions about the field of COVID-19 control and prevention.

First report of rhino-orbital-cerebral mucormycosis after COVID-19 infection in Bulgaria.

Mucormycosis is a relatively rare infection but with a high mortality rate due to the difficult and time-consuming diagnostic and therapeutic process. The authors present the first case of rhino-orbital-cerebral mucormycosis, histologically and microbiologically proven, in a patient after COVID-19 infection in Bulgaria.

Initial introduction and spread of the SARS-CoV-2 AY.4.2.1 Delta variant in Bulgaria, a genomic insight.

The evolution of the emerging SARS-CoV-2 variants carrying mutations in the spike protein raises concerns about the possibility of accelerated transmission in the ever-evolving COVID-19 pandemic worldwide. AY.4.2, a sublineage of the Delta variant, was considered a variant under investigation (VUI) and also gained the nickname "Delta Plus," due to its extra mutations, Y145H and A222V. In this study, using genomic epidemiology, we provide the first insights into the introduction of AY.4.2 in Bulgaria and the AY.4.2.1 sublineage that found larger dissemination only in Bulgaria and the United Kingdom.

The demographic and geographic impact of the COVID pandemic in Bulgaria and Eastern Europe in 2020.

The COVID-19 pandemic followed a unique trajectory in Eastern Europe compared to other heavily affected regions, with most countries there only experiencing a major surge of cases and deaths towards the end of 2020 after a relatively uneventful first half of the year. However, the consequences of that surge have not received as much attention as the situation in Western countries. Bulgaria, even though it has been one of the most heavily affected countries, has been one of those neglected cases. We use mortality and mobility data from Eurostat, official governmental and other sources to examine the development and impact of the COVID-19 pandemic in Bulgaria and other European countries. We find a very high level of excess mortality in Eastern European countries measured by several metrics including excess mortality rate (EMR), P-scores, potential years of life lost (PYLL) and its age standardised version (ASYR), and working years of life lost (WYLL). By the last three metrics Eastern Europe emerges as the hardest hit region by the pandemic in Europe in 2020. With a record EMR at ~0.27% and a strikingly large and mostly unique to it mortality rate in the working age (15-64 years) demographics, Bulgaria emerges as one of the most affected countries in Eastern Europe. The high excess mortality in Bulgaria correlates with insufficient intensity of testing, with delayed imposition of "lockdown" measures, and with high prevalence of cardiovascular diseases. We also find major geographic and demographic disparities within the country, with considerably lower mortality observed in major cities relative to more remote areas (likely due to disparities in the availability of medical resources). Analysis of the course of the epidemic revealed that individual mobility measures were predictive of the eventual decline in cases and deaths. However, while mobility declined as a result of the imposition of a lockdown, it already trended downwards before such measures were introduced, which resulted in a reduction of deaths independent of the effect of restrictions. Large excess mortality and high numbers of potential years of life lost are observed as a result of the COVID pandemic in Bulgaria, as well as in several other countries in Eastern Europe. Significant delays in the imposition of stringent mobility-reducing measures combined with a lack of medical resources likely caused a substantial loss of life, including in the working age population.

A comparison of health system responses to COVID-19 in Bulgaria, Croatia and Romania in 2020.

This article compares the health system responses to COVID-19 in Bulgaria, Croatia and Romania from February 2020 until the end of 2020. It explores similarities and differences between the three countries, building primarily on the methodology and content compiled in the COVID-19 Health System Response Monitor (HSRM). We find that all three countries entered the COVID-19 crisis with common problems, including workforce shortages and underdeveloped and underutilized preventive and primary care. The countries reacted swiftly to the first wave of the COVID-19 pandemic, declaring a state of emergency in March 2020 and setting up new governance mechanisms. The initial response benefited from a centralized approach and high levels of public trust but proved to be only a short-term solution. Over time, governance became dominated by political and economic considerations, communication to the public became contradictory, and levels of public trust declined dramatically. The three countries created additional bed capacity for the treatment of COVID-19 patients in the first wave, but a greater challenge was to ensure a sufficient supply of qualified health workers. New digital and remote tools for the provision of non-COVID-19 health services were introduced or used more widely, with an increase in telephone or online consultations and a simplification of administrative procedures. However, the provision and uptake of non-COVID-19 health services was still affected negatively by the pandemic. Overall, the COVID-19 pandemic has exposed pre-existing health system and governance challenges in the three countries, leading to a large number of preventable deaths.

Induction of humoral and cellular immune responses to COVID-19 mRNA and vector vaccines: A prospective cohort study in Bulgarian healthcare workers.

Installing efficient protective immunity by anti-SARS-CoV-2 vaccines is the only current means to overcome coronavirus disease 2019 pandemics. The cellular and humoral immune responses induced with an messenger RNA (mRNA) (BNT162b2) or with a vector (ChAdOx1nCoV-19) vaccine among Bulgarian healthcare workers (n = 123, aged 23-71 years) were studied in the course of 16 weeks after priming. Receptor-binding domain (RBD)-blocking Abs and SARS-CoV-2 RBD immunoglobulin A  (IgA) were evaluated in parallel with interferon gamma (IFNγ)-producing virus-specific T cells. Both vaccines induced RBD-blocking Abs in 100% of the participants after complete immunization while the levels of protection after a single dose largely varied (22%-98%). Advanced age had a negative impact on the level and longevity of virus-neutralizing activity induced by one dose mRNA, but not by the vector vaccine. RBD-binding IgA was detected in 100% of tested donors from the mRNA vaccine cohort, and in 67% of tested from the vector vaccine cohort, at least 1 month after completed immunization. One month after completing mRNA immunization, the number of IFNγ-producing T cells correlated significantly with the levels of RBD-specific IgA and virus-neutralizing activity induced after priming. Enumeration of circulating virus-specific IFNγ+ T cells is not recommended for evaluation of protective immunity as their detection may require longer stimulation beyond the firstmonth postimmunization. In conclusion, BNT162B2 and ChAdOx1nCoV-19 induced potent and comparable humoral and cellular anti-SARS-CoV-2 immune responses, peaking between 10 and 30 days after complete immunization. A single dose of any vaccine did not induce adequate protection in a great part of donors, making the shorter interval between mRNA vaccine doses preferable in the settings of increased risk of infection.

Physical Activity among Adults Residing in 11 Countries during the COVID-19 Pandemic Lockdown.

During the novel coronavirus (COVID-19) pandemic, physical activity (PA) behaviors were altered worldwide due to public health measures such as "lockdown." This study described PA among adults residing in 11 countries during COVID-19 lockdown and examined factors associated with PA engagement. We conducted a cross-sectional anonymous survey among adults (≥18 years old) in 11 countries (Brazil, Bulgaria, China, India, Ireland, Malaysia, North Macedonia, Singapore, Spain, Turkey, United States). Of 11,775 participants, 63.7% were female and 52.8% were 18-34 years old. More than 40% of participants were insufficiently active (43.9%) and reported a decrease in their PA during lockdown (44.8%). Statistically significant differences were observed in (1) proportions of participants being insufficiently active, (2) level of PA, and (3) decrease in PA across the 11 countries. More stringent governmental policy responses were associated with greater likelihood of being insufficiently active during lockdown (adjusted odds ratio = 1.22, 95% confidence interval = 1.03, 1.45). Higher depression or anxiety scores were associated with greater likelihood of decreased level of PA during lockdown.We found substantial reductions in PA levels during COVID-19 lockdown across countries. Country-specific PA promotion interventions are needed during this and similar global emergencies.

Increased prevalence of gastrointestinal symptoms and disorders of gut-brain interaction during the COVID-19 pandemic: An internet-based survey.

BACKGROUND: Quarantine with social distancing has reduced transmission of COVID-19; however, fear of the disease and these remedial measures cause anxiety and stress. It is not known whether these events have impacted the prevalence of gastrointestinal (GI) symptoms and disorders of brain-gut interaction (DGBI). METHODS: An online platform evaluated the prevalence of GI symptoms during the COVID-19 pandemic. Data collection utilized validated questionnaires and was fully anonymized. Findings were compared with identical data acquired in 2019. The association of results with stress and anxiety was analyzed. RESULTS: Data were collected from 1896 subjects May - August 2019 to 980 non-identical subjects May - June 2020. GI symptoms were reported by 68.9% during the COVID-19 lockdown compared with 56.0% the previous year (p < 0.001). The prevalence of irritable bowel syndrome (26.3% vs. 20.0%; p < 0.001), functional dyspepsia (18.3% vs. 12.7%; p < 0.001), heartburn (31.7% vs. 26.2%, p = 0.002), and self-reported milk intolerance (43.5% vs. 37.8% p = 0.004) was higher during the pandemic. Many individuals reported multiple symptoms. Anxiety was associated with presence of all GI symptoms. High levels of stress impacted functional dyspepsia (p = 0.045) and abdominal pain (p = 0.013). The presence of DGBI (p < 0.001; OR 22.99), self-reported milk intolerance (p < 0.001; OR 2.50), and anxiety (p < 0.001; OR 2.18) was independently associated with increased GI symptoms during COVID-19 pandemic. CONCLUSIONS: The prevalence of GI symptoms was significantly higher during the COVID-19 lockdown than under normal circumstances the previous year. This increase was attributable to increased numbers of patients with DGBI, an effect that was associated with anxiety.

Mental Health among Adults during the COVID-19 Pandemic Lockdown: A Cross-Sectional Multi-Country Comparison.

Despite the global impact of COVID-19, studies comparing the effects of COVID-19 on population mental health across countries are sparse. This study aimed to compare anxiety and depression symptoms during the COVID-19 lockdown among adults from 11 countries and to examine their associations with country-level COVID-19 factors and personal COVID-19 exposure. A cross-sectional survey was conducted among adults (≥18 years) in 11 countries (Brazil, Bulgaria, China, India, Ireland, North Macedonia, Malaysia, Singapore, Spain, Turkey, United States). Mental health (anxiety, depression, resilient coping, hope) and other study data were collected between June-August 2020. Of the 13,263 participants, 62.8% were female and 51.7% were 18-34 years old. Participants living in Brazil had the highest anxiety and depression symptoms while participants living in Singapore had the lowest. Greater personal COVID-19 exposure was associated with increased anxiety and depression symptoms, but country-level COVID-19 factors were not. Higher levels of hope were associated with reduced anxiety and depression; higher levels of resilient coping were associated with reduced anxiety but not depression. Substantial variations exist in anxiety and depression symptoms across countries during the COVID-19 lockdown, with personal COVID-19 exposure being a significant risk factor. Strategies that mitigate COVID-19 exposure and enhance hope and resilience may reduce anxiety and depression during global emergencies.

University Students' Self-Rated Health in Relation to Perceived Acoustic Environment during the COVID-19 Home Quarantine.

BACKGROUND: Online education became mandatory for many students during the Coronavirus disease 2019 (COVID-19) pandemic and blurred the distinction between settings where processes of stress and restoration used to take place. The lockdown also likely changed perceptions of the indoor acoustic environment (i.e., soundscape) and raised its importance. In the present study, we seek to understand how indoor soundscape related to university students' self-rated health in Bulgaria around the time that the country was under a state of emergency declaration caused by the COVID-19 pandemic. METHODS: Between 17 May and 10 June 2020, we conducted a cross-sectional online survey among 323 students (median age 21 years; 31% male) from two universities in the city of Plovdiv, Bulgaria. Self-rated health (SRH) was measured with a single-item. Participants were asked how frequently they heard different types of sounds while at home and how pleasant they considered each of those sounds to be. Restorative quality of the home (the "being away" dimension of the Perceived Restorativeness Scale) was measured with a single-item. A priori confounders and effect modifiers included sociodemographics, house-related characteristics, general sensitivity to environmental influences, and mental health. Our analysis strategy involved sequential exploratory factor analysis (EFA), multivariate linear and ordinal regressions, effect modification tests, and structural equation modeling (SEM). RESULTS: EFA supported grouping perceived sounds into three distinct factors-mechanical, human, and nature sounds. Regression analyses revealed that greater exposure to mechanical sounds was consistently associated with worse SRH, whereas no significant associations were found for human and nature sounds. In SEM, exposure to mechanical sounds related to lower restorative quality of the home, and then to poorer SRH, whereas nature sounds correlated with higher restorative quality, and in turn with better SRH. CONCLUSIONS: These findings suggest a role of positive indoor soundscape and restorative quality for promoting self-rated health in times of social distancing.