Why Similar Policies Resulted In Different COVID-19 Outcomes: How Responsiveness And Culture Influenced Mortality Rates.

In the first two years of the COVID-19 pandemic, per capita mortality varied by more than a hundredfold across countries, despite most implementing similar nonpharmaceutical interventions. Factors such as policy stringency, gross domestic product, and age distribution explain only a small fraction of mortality variation. To address this puzzle, we built on a previously validated pandemic model in which perceived risk altered societal responses affecting SARS-CoV-2 transmission. Using data from more than 100 countries, we found that a key factor explaining heterogeneous death rates was not the policy responses themselves but rather variation in responsiveness. Responsiveness measures how sensitive communities are to evolving mortality risks and how readily they adopt nonpharmaceutical interventions in response, to curb transmission. We further found that responsiveness correlated with two cultural constructs across countries: uncertainty avoidance and power distance. Our findings show that more responsive adoption of similar policies saves many lives, with important implications for the design and implementation of responses to future outbreaks.

Behavioral responses to risk promote vaccinating high-contact individuals first.

How should communities prioritize COVID-19 vaccinations? Prior studies found that prioritizing the elderly and most vulnerable minimizes deaths. However, prior research has ignored how behavioral responses to risk of disease endogenously change transmission rates. We show that incorporating risk-driven behavioral responses enhances fit to data and may change prioritization to vaccinating high-contact individuals. Behavioral responses matter because deaths grow exponentially until communities are compelled to reduce contacts, with deaths stabilizing at levels that oblige higher-contact groups to sufficiently cut their interactions and slow transmissions. More lives may be saved by vaccinating and taking those high-contact groups out of transmission chains earlier because the remaining groups will take more precautions while waiting for their turn for vaccination. These findings are especially important considering the need for further vaccination in many countries, the emergence of new variants, and the expected challenge of distributing new vaccines in the coming months and years. © 2022 The Author. System Dynamics Review published by John Wiley & Sons Ltd on behalf of System Dynamics Society.

Quantifying the COVID-19 endgame: Is a new normal within reach?

Eradication of COVID-19 is out of reach. Are we close to a "new normal" in which people can leave behind restrictive non-pharmaceutical interventions (NPIs) yet face a tolerable burden of disease? The answer depends on the ongoing risks versus communities' tolerance for those risks. Using a detailed model of the COVID-19 pandemic spanning 93 countries, we estimate the biological and behavioral factors determining the risks and responses, and project the likely course of COVID-19. Infection fatality rates have fallen significantly due to vaccination, prior infections, better treatments, and the less severe Omicron variant. Yet based on their estimated tolerance for deaths, most nations are not ready to live with COVID-19 without any NPIs. Across the world the increased transmissibility of Omicron, combined with the decay of immunity, leads to repeated episodes of reinfections, hospitalizations, and deaths, complicating the emergence of a new normal in many nations. © 2022 The Authors. System Dynamics Review published by John Wiley & Sons Ltd on behalf of System Dynamics Society.

Enhancing long-term forecasting: Learning from COVID-19 models.

While much effort has gone into building predictive models of the COVID-19 pandemic, some have argued that early exponential growth combined with the stochastic nature of epidemics make the long-term prediction of contagion trajectories impossible. We conduct two complementary studies to assess model features supporting better long-term predictions. First, we leverage the diverse models contributing to the CDC repository of COVID-19 USA death projections to identify factors associated with prediction accuracy across different projection horizons. We find that better long-term predictions correlate with: (1) capturing the physics of transmission (instead of using black-box models); (2) projecting human behavioral reactions to an evolving pandemic; and (3) resetting state variables to account for randomness not captured in the model before starting projection. Second, we introduce a very simple model, SEIRb, that incorporates these features, and few other nuances, offers informative predictions for as far as 20-weeks ahead, with accuracy comparable with the best models in the CDC set. Key to the long-term predictive power of multi-wave COVID-19 trajectories is capturing behavioral responses endogenously: balancing feedbacks where the perceived risk of death continuously changes transmission rates through the adoption and relaxation of various Non-Pharmaceutical Interventions (NPIs).

Evolution and Reproducibility of Simulation Modeling in Epidemiology and Health Policy Over Half a Century.

Simulation models are increasingly being used to inform epidemiologic studies and health policy, yet there is great variation in their transparency and reproducibility. In this review, we provide an overview of applications of simulation models in health policy and epidemiology, analyze the use of best reporting practices, and assess the reproducibility of the models using predefined, categorical criteria. We identified and analyzed 1,613 applicable articles and found exponential growth in the number of studies over the past half century, with the highest growth in dynamic modeling approaches. The largest subset of studies focused on disease policy models (70%), within which pathological conditions, viral diseases, neoplasms, and cardiovascular diseases account for one-third of the articles. Model details were not reported in almost half of the studies. We also provide in-depth analysis of modeling best practices, reporting quality and reproducibility of models for a subset of 100 articles (50 highly cited and 50 randomly selected from the remaining articles). Only 7 of 26 in-depth evaluation criteria were satisfied by more than 80% of samples. We identify areas for increased application of simulation modeling and opportunities to enhance the rigor and documentation in the conduct and reporting of simulation modeling in epidemiology and health policy.

Weather, air pollution, and SARS-CoV-2 transmission: a global analysis.

BACKGROUND: Understanding how environmental factors affect SARS-CoV-2 transmission could inform global containment efforts. Despite high scientific and public interest and multiple research reports, there is currently no consensus on the association of environmental factors and SARS-CoV-2 transmission. To address this research gap, we aimed to assess the relative risk of transmission associated with weather conditions and ambient air pollution. METHODS: In this global analysis, we adjusted for the delay between infection and detection, estimated the daily reproduction number at 3739 global locations during the COVID-19 pandemic up until late April, 2020, and investigated its associations with daily local weather conditions (ie, temperature, humidity, precipitation, snowfall, moon illumination, sunlight hours, ultraviolet index, cloud cover, wind speed and direction, and pressure data) and ambient air pollution (ie, PM2·5, nitrogen dioxide, ozone, and sulphur dioxide). To account for other confounding factors, we included both location-specific fixed effects and trends, controlling for between-location differences and heterogeneities in locations' responses over time. We built confidence in our estimations through synthetic data, robustness, and sensitivity analyses, and provided year-round global projections for weather-related risk of global SARS-CoV-2 transmission. FINDINGS: Our dataset included data collected between Dec 12, 2019, and April 22, 2020. Several weather variables and ambient air pollution were associated with the spread of SARS-CoV-2 across 3739 global locations. We found a moderate, negative relationship between the estimated reproduction number and temperatures warmer than 25°C (a decrease of 3·7% [95% CI 1·9-5·4] per additional degree), a U-shaped relationship with outdoor ultraviolet exposure, and weaker positive associations with air pressure, wind speed, precipitation, diurnal temperature, sulphur dioxide, and ozone. Results were robust to multiple assumptions. Independent research building on our estimates provides strong support for the resulting projections across nations. INTERPRETATION: Warmer temperature and moderate outdoor ultraviolet exposure result in a slight reduction in the transmission of SARS-CoV-2; however, changes in weather or air pollution alone are not enough to contain the spread of SARS-CoV-2 with other factors having greater effects. FUNDING: None.

Behavioral dynamics of COVID-19: estimating underreporting, multiple waves, and adherence fatigue across 92 nations.

Effective responses to the COVID-19 pandemic require integrating behavioral factors such as risk-driven contact reduction, improved treatment, and adherence fatigue with asymptomatic transmission, disease acuity, and hospital capacity. We build one such model and estimate it for all 92 nations with reliable testing data. Cumulative cases and deaths through 22 December 2020 are estimated to be 7.03 and 1.44 times official reports, yielding an infection fatality rate (IFR) of 0.51 percent, which has been declining over time. Absent adherence fatigue, cumulative cases would have been 47 percent lower. Scenarios through June 2021 show that modest improvement in responsiveness could reduce cases and deaths by about 14 percent, more than the impact of vaccinating half of the population by that date. Variations in responsiveness to risk explain two orders of magnitude difference in per-capita deaths despite reproduction numbers fluctuating around one across nations. A public online simulator facilitates scenario analysis over the coming months. © 2021 System Dynamics Society.

Simulation-based estimation of the early spread of COVID-19 in Iran: actual versus confirmed cases.

Understanding the state of the COVID-19 pandemic relies on infection and mortality data. Yet official data may underestimate the actual cases due to limited symptoms and testing capacity. We offer a simulation-based approach which combines various sources of data to estimate the magnitude of outbreak. Early in the epidemic we applied the method to Iran's case, an epicenter of the pandemic in winter 2020. Estimates using data up to March 20th, 2020, point to 916,000 (90% UI: 508 K, 1.5 M) cumulative cases and 15,485 (90% UI: 8.4 K, 25.8 K) total deaths, numbers an order of magnitude higher than official statistics. Our projections suggest that absent strong sustaining of contact reductions the epidemic may resurface. We also use data and studies from the succeeding months to reflect on the quality of original estimates. Our proposed approach can be used for similar cases elsewhere to provide a more accurate, early, estimate of outbreak state. © 2020 System Dynamics Society.

Dynamics of intervention adoption, implementation, and maintenance inside organizations: The case of an obesity prevention initiative.

Overall impact of public health prevention interventions relies not only on the average efficacy of an intervention, but also on the successful adoption, implementation, and maintenance (AIM) of that intervention. In this study, we aim to understand the dynamics that regulate AIM of organizational level intervention programs. We focus on two well-documented obesity prevention interventions, implemented in food carry-outs and stores in low-income urban areas of Baltimore, Maryland, which aimed to improve dietary behaviour for adults by providing access to healthier foods and point-of-purchase promotions. Building on data from field observations, in-depth interviews, and data discussed in previous publications, as well as the strategy and organizational behaviour literature, we developed a system dynamics model of the key processes of AIM. With simulation analysis, we show several reinforcing mechanisms that span stakeholder motivation, communications, and implementation quality and costs can turn small changes in the process of AIM into big difference in the overall impact of the intervention. Specifically, small changes in the allocation of resources to communication with stakeholders of intervention could have a nonlinear long-term impact if those additional resources can turn stakeholders into allies of the intervention, reducing the erosion rates and enhancing sustainability. We present how the dynamics surrounding communication, motivation, and erosion can create significant heterogeneity in the overall impact of otherwise similar interventions. Therefore, careful monitoring of how those dynamics unfold, and timely adjustments to keep the intervention on track are critical for successful implementation and maintenance.

Modeling and estimating the feedback mechanisms among depression, rumination, and stressors in adolescents.

The systemic interactions among depressive symptoms, rumination, and stress are important to understanding depression but have not yet been quantified. In this article, we present a system dynamics simulation model of depression that captures the reciprocal relationships among stressors, rumination, and depression. Building on the response styles theory, this model formalizes three interdependent mechanisms: 1) Rumination contributes to 'keeping stressors alive'; 2) Rumination has a direct impact on depressive symptoms; and 3) Both 'stressors kept alive' and current depressive symptoms contribute to rumination. The strength of these mechanisms is estimated using data from 661 adolescents (353 girls and 308 boys) from two middle schools (grades 6-8). These estimates indicate that rumination contributes to depression by keeping stressors 'alive'-and the individual activated-even after the stressor has ended. This mechanism is stronger among girls than boys, increasing their vulnerability to a rumination reinforcing loop. Different profiles of depression emerge over time depending on initial levels of depressive symptoms, rumination, and stressors as well as the occurrence rate for stressors; levels of rumination and occurrence of stressors are stronger contributors to long-term depression. Our systems model is a steppingstone towards a more comprehensive understanding of depression in which reinforcing feedback mechanisms play a significant role. Future research is needed to expand this simulation model to incorporate other drivers of depression and provide a more holistic tool for studying depression.

Dynamics of Implementation and Maintenance of Organizational Health Interventions.

In this study, we present case studies to explore the dynamics of implementation and maintenance of health interventions. We analyze how specific interventions are built and eroded, how the building and erosion mechanisms are interconnected, and why we can see significantly different erosion rates across otherwise similar organizations. We use multiple comparative obesity prevention case studies to provide empirical information on the mechanisms of interest, and use qualitative systems modeling to integrate our evolving understanding into an internally consistent and transparent theory of the phenomenon. Our preliminary results identify reinforcing feedback mechanisms, including design of organizational processes, motivation of stakeholders, and communication among stakeholders, which influence implementation and maintenance of intervention components. Over time, these feedback mechanisms may drive a wedge between otherwise similar organizations, leading to distinct configurations of implementation and maintenance processes.

A flexible method for aggregation of prior statistical findings.

Rapid growth in scientific output requires methods for quantitative synthesis of prior research, yet current meta-analysis methods limit aggregation to studies with similar designs. Here we describe and validate Generalized Model Aggregation (GMA), which allows researchers to combine prior estimated models of a phenomenon into a quantitative meta-model, while imposing few restrictions on the structure of prior models or on the meta-model. In an empirical validation, building on 27 published equations from 16 studies, GMA provides a predictive equation for Basal Metabolic Rate that outperforms existing models, identifies novel nonlinearities, and estimates biases in various measurement methods. Additional numerical examples demonstrate the ability of GMA to obtain unbiased estimates from potentially mis-specified prior studies. Thus, in various domains, GMA can leverage previous findings to compare alternative theories, advance new models, and assess the reliability of prior studies, extending meta-analysis toolbox to many new problems.

Modeling social norms and social influence in obesity.

The worldwide increase in obesity has led to changes in what is considered "normal" or desirable weight, especially among populations at higher risk. We show that social norms are key to understanding the obesity epidemic, and that social influence mechanisms provide a necessary linkage between individual obesity-related behaviors and population-level characteristics. Because influence mechanisms cannot be directly observed, we show how three complex systems tools may be used to gain insights into observed epidemiologic patterns: social network analysis, agent-based modeling, and systems dynamics modeling. However, simulation and mathematical modeling approaches raise questions regarding acceptance of findings, especially among policy makers. Nevertheless, we point to modeling successes in obesity and other fields, including the NIH-funded National Collaborative on Childhood Obesity Research (NCCOR) Envison project.

Modeling the hypothalamus-pituitary-adrenal axis: A review and extension.

Multiple models of the hypothalamus-pituitary-adrenal (HPA) axis have been developed to characterize the oscillations seen in the hormone concentrations and to examine HPA axis dysfunction. We reviewed the existing models, then replicated and compared five of them by finding their correspondence to a dataset consisting of ACTH and cortisol concentrations of 17 healthy individuals. We found that existing models use different feedback mechanisms, vary in the level of details and complexities, and offer inconsistent conclusions. None of the models fit the validation dataset well. Therefore, we re-calibrated the best performing model using partial calibration and extended the model by adding individual fixed effects and an exogenous circadian function. Our estimated parameters reduced the mean absolute percent error significantly and offer a validated reference model that can be used in diverse applications. Our analysis suggests that the circadian and ultradian cycles are not created endogenously by the HPA axis feedbacks, which is consistent with the recent literature on the circadian clock and HPA axis.

Human growth and body weight dynamics: an integrative systems model.

Quantifying human weight and height dynamics due to growth, aging, and energy balance can inform clinical practice and policy analysis. This paper presents the first mechanism-based model spanning full individual life and capturing changes in body weight, composition and height. Integrating previous empirical and modeling findings and validated against several additional empirical studies, the model replicates key trends in human growth including A) Changes in energy requirements from birth to old ages. B) Short and long-term dynamics of body weight and composition. C) Stunted growth with chronic malnutrition and potential for catch up growth. From obesity policy analysis to treating malnutrition and tracking growth trajectories, the model can address diverse policy questions. For example I find that even without further rise in obesity, the gap between healthy and actual Body Mass Indexes (BMIs) has embedded, for different population groups, a surplus of 14%-24% in energy intake which will be a source of significant inertia in obesity trends. In another analysis, energy deficit percentage needed to reduce BMI by one unit is found to be relatively constant across ages. Accompanying documented and freely available simulation model facilitates diverse applications customized to different sub-populations.

Modeling US adult obesity trends: a system dynamics model for estimating energy imbalance gap.

OBJECTIVES: We present a system dynamics model that quantifies the energy imbalance gap responsible for the US adult obesity epidemic among gender and racial subpopulations. METHODS: We divided the adult population into gender-race/ethnicity subpopulations and body mass index (BMI) classes. We defined transition rates between classes as a function of metabolic dynamics of individuals within each class. We estimated energy intake in each BMI class within the past 4 decades as a multiplication of the equilibrium energy intake of individuals in that class. Through calibration, we estimated the energy gap multiplier for each gender-race-BMI group by matching simulated BMI distributions for each subpopulation against national data with maximum likelihood estimation. RESULTS: No subpopulation showed a negative or zero energy gap, suggesting that the obesity epidemic continues to worsen, albeit at a slower rate. In the past decade the epidemic has slowed for non-Hispanic Whites, is starting to slow for non-Hispanic Blacks, but continues to accelerate among Mexican Americans. CONCLUSIONS: The differential energy balance gap across subpopulations and over time suggests that interventions should be tailored to subpopulations' needs.

Dynamic interplay among homeostatic, hedonic, and cognitive feedback circuits regulating body weight.

Obesity is associated with a prolonged imbalance between energy intake and expenditure, both of which are regulated by multiple feedback processes within and across individuals. These processes constitute 3 hierarchical control systems-homeostatic, hedonic, and cognitive-with extensive interaction among them. Understanding complex eating behavior requires consideration of all 3 systems and their interactions. Existing models of these processes are widely scattered, with relatively few attempts to integrate across mechanisms. We briefly review available empirical evidence and dynamic models, discussing challenges and potential for better integration. We conclude that developing richer models of dynamic interplay among systems should be a priority in the future study of obesity and that systems science modeling offers the potential to aid in this goal.

Reconciling statistical and systems science approaches to public health.

Although systems science has emerged as a set of innovative approaches to study complex phenomena, many topically focused researchers including clinicians and scientists working in public health are somewhat befuddled by this methodology that at times appears to be radically different from analytic methods, such as statistical modeling, to which the researchers are accustomed. There also appears to be conflicts between complex systems approaches and traditional statistical methodologies, both in terms of their underlying strategies and the languages they use. We argue that the conflicts are resolvable, and the sooner the better for the field. In this article, we show how statistical and systems science approaches can be reconciled, and how together they can advance solutions to complex problems. We do this by comparing the methods within a theoretical framework based on the work of population biologist Richard Levins. We present different types of models as representing different tradeoffs among the four desiderata of generality, realism, fit, and precision.

Connecting micro dynamics and population distributions in system dynamics models.

Researchers use system dynamics models to capture the mean behavior of groups of indistinguishable population elements (e.g., people) aggregated in stock variables. Yet, many modeling problems require capturing the heterogeneity across elements with respect to some attribute(s) (e.g., body weight). This paper presents a new method to connect the micro-level dynamics associated with elements in a population with the macro-level population distribution along an attribute of interest without the need to explicitly model every element. We apply the proposed method to model the distribution of Body Mass Index and its changes over time in a sample population of American women obtained from the U.S. National Health and Nutrition Examination Survey. Comparing the results with those obtained from an individual-based model that captures the same phenomena shows that our proposed method delivers accurate results with less computation than the individual-based model.