Articles related to epidemiology of Covid-19

Covid19 in Uttar Pradesh- Book Chapter.pdf

Uttar Pradesh: state governance and response in COVID-19 pandemic

Neelay Srivastava, Indrajit Pal and Anil Kumar Disaster Preparedness, Mitigation and Management, Asian Institute of Technology, Klong Luang, Pathum Thani, Thailand

The COVID-19 Pandemic has unprecedentedly changed the whole landscape, posing several challenges for the respective state governments in India. The impacts of the pandemic have penetrated through all three major sectors of the Indian Economy, namely primary (agriculture and allied activities), secondary (industrial and manufacturing), and tertiary (health, education, telecom, tourism, etc.). The impacts of the COVID-19 Pandemic in Uttar Pradesh was marked by massive job losses and livelihood in the informal sector like daily wage labors, factory workers, household workers, street vendors, etc.

Analyzing both quantitative and qualitative sources of information of Uttar Pradesh, considering the different factors as well as farmer survey, suggests that the lockdown led severe disruption of farming systems and the agricultural sector as a whole followed by shortages of food supplies and price hike especially for poor and urban population. Thus sustainable agro-policies are very much required anticipating the future pandemic in India (Kumar, Singh, Pandey, et al., 2021).

After the first national level lockdown in March end in 2020, the state government had ordered the closure of nonessential activities like all educational institutes, gyms, malls, cinema hall, and swimming pools till April 2020 and added 52,000 additional beds (17,000 beds by the Health Department, and 35,000 beds by the Medical Educational Department) in the COVID-19 hospitals in the state in the month end. Furthermore four institutes in UP were approved from Indian Council of Medical Research to conduct tests for coronavirus in initial stage. From March 2020, till April 2, 2020, government announced the closure of all educational institutions, cinemas, shopping malls, swimming pool, gyms, multiplexes, and tourist places in the state including slaughterhouses. Anticipating the spike in cases in near future, the strategy of state government in this direction from beginning was to increase the number of beds like 10,000 beds in level one, 5000 beds in level two, and 2000 beds in level three defined in level of Hospital L1, L2 (with oxygen), and L3 (with ventilator). Various training was imparted to frontline health-care workers and had better overall knowledge, attitude, and practice (KAP) toward COVID-19 compared to any HCWs specially technicians and students (Maurya et al., 2021).

COVID-19 pandemic led to eventually very low anthropogenic activities leading to a significant improvement of the environment not only in India but also across the world. The air quality changes during the lockdown in nine major cities in Uttar Pradesh, including three cities Ghaziabad, Noida, and Greater Noida) in the national capital region, which is counted among most polluted cities in the world.

Not only there was significant reduction in the total column density of NO2, CO, and ground-level pollution load of PM10, PM2.5, NO2, and SO2 was observed but also the average summer temperature was recorded (Kumar, Singh, Kumar, et al., 2021).

33 epidem.pdf

Structural and antigenic variations in the spike protein of emerging SARS-CoV-2 variants

Authors: Anshumali MittalID1 *, Arun KhattriID2 , Vikash VermaID3

1 Department of Structural Biology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States of America, 2 Department of Pharmaceutical Engineering and Technology, Indian Institute of Technology (BHU), Varanasi, India, 3 Biology Department, University of Massachusetts, Amherst, Massachusetts, United States of America *


The SRAS-COV-2 virus is continuously evolving and this poses a major threat to antibody therapies and currently authorized Coronavirus Disease 2019 (COVID-19) vaccines ccines. It is therefore of utmost importance to investigate and predict the putative mutations on the spike protein that confer immune evasion. Antibodies are key components of the human immune system’s response to SARSCoV-2, and the spike protein is a prime target of neutralizing antibodies (nAbs) as it plays critical roles in host cell recognition, fusion, and virus entry. The potency of therapeutic antibodies and vaccines partly depends on how readily the virus can escape neutralization. Recent structural and functional studies have mapped the epitope landscape of nAbs on the spike protein, which illustrates the footprints of several nAbs and the site of escape mutations. In this review, we discuss (1) the emerging SARS-CoV-2 variants; (2) the structural basis for antibody-mediated neutralization of SARS-CoV-2 and nAb classification; and (3) identification of the RBD escape mutations for several antibodies that resist antibody binding and neutralization. These escape maps are a valuable tool to predict SARS-CoV-2 fitness, and in conjunction with the structures of the spike-nAb complex, they can be utilized to facilitate the rational design of escape-resistant antibody therapeutics and vaccin es.

32 epidem.pdf

Estimating global, regional, and national daily and cumulative infections with SARS-CoV-2 through Nov 14, 2021: a statistical analysis

Authors: COVID-19 Cumulative Infection Collaborators*


Background Timely, accurate, and comprehensive estimates of SARS-CoV-2 daily infection rates, cumulative infections, the proportion of the population that has been infected at least once, and the effective reproductive number (Reffective) are essential for understanding the determinants of past infection, current transmission patterns, and a population’s susceptibility to future infection with the same variant. Although several studies have estimated cumulative SARS-CoV-2 infections in select locations at specific points in time, all of these analyses have relied on biased data inputs that were not adequately corrected for. In this study, we aimed to provide a novel approach to estimating past SARS-CoV-2 daily infections, cumulative infections, and the proportion of the population infected, for 190 countries and territories from the start of the pandemic to Nov 14, 2021. This approach combines data from reported cases, reported deaths, excess deaths attributable to COVID-19, hospitalisations, and seroprevalence surveys to produce more robust estimates that minimise constituent biases. Methods We produced a comprehensive set of global and location-specific estimates of daily and cumulative SARS-CoV-2 infections through Nov 14, 2021, using data largely from Johns Hopkins University (Baltimore, MD, USA) and national databases for reported cases, hospital admissions, and reported deaths, as well as seroprevalence surveys identified through previous reviews, SeroTracker, and governmental organisations. We corrected these data for known biases such as lags in reporting, accounted for under-reporting of deaths by use of a statistical model of the proportion of excess mortality attributable to SARS-CoV-2, and adjusted seroprevalence surveys for waning antibody sensitivity, vaccinations, and reinfection from SARS-CoV-2 escape variants. We then created an empirical database of infection–detection ratios (IDRs), infection–hospitalisation ratios (IHRs), and infection–fatality ratios (IFRs). To estimate a complete time series for each location, we developed statistical models to predict the IDR, IHR, and IFR by location and day, testing a set of predictors justified through published systematic reviews. Next, we combined three series of estimates of daily infections (cases divided by IDR, hospitalisations divided by IHR, and deaths divided by IFR), into a more robust estimate of daily infections. We then used daily infections to estimate cumulative infections and the cumulative proportion of the population with one or more infections, and we then calculated posterior estimates of cumulative IDR, IHR, and IFR using cumulative infections and the corrected data on reported cases, hospitalisations, and deaths. Finally, we converted daily infections into a historical time series of Reffective by location and day based on assumptions of duration from infection to infectiousness and time an individual spent being infectious. For each of these quantities, we estimated a distribution based on an ensemble framework that captured uncertainty in data sources, model design, and parameter assumptions. Findings Global daily SARS-CoV-2 infections fluctuated between 3 million and 17 million new infections per day between April, 2020, and October, 2021, peaking in mid-April, 2021, primarily as a result of surges in India. Between the start of the pandemic and Nov 14, 2021, there were an estimated 3·80 billion (95% uncertainty interval 3·44–4·08) total SARS-CoV-2 infections and reinfections combined, and an estimated 3·39 billion (3·08–3·63) individuals, or 43·9% (39·9–46·9) of the global population, had been infected one or more times. 1·34 billion (1·20–1·49) of these infections occurred in south Asia, the highest among the seven super-regions, although the sub-Saharan Africa super-region had the highest infection rate (79·3 per 100 population [69·0–86·4]). The high-income super-region had the fewest infections (239 million [226–252]), and southeast Asia, east Asia, and Oceania had the lowest infection rate (13·0 per 100 population [8·4–17·7]). The cumulative proportion of the population ever infected varied greatly between countries and territories, with rates higher than 70% in 40 countries and lower than 20% in 39 countries. There was no discernible relationship between Reffective and total immunity, and even at total immunity levels of 80%, we observed no indication of an abrupt drop in Reffective, indicating that there is not a clear herd immunity threshold observed in the data. Interpretation COVID-19 has already had a staggering impact on the world up to the beginning of the omicron (B.1.1.529) wave, with over 40% of the global population infected at least once by Nov 14, 2021. The vast differences in cumulative proportion of the population infected across locations could help policy makers identify the transmissionprevention strategies that have been most effective, as well as the populations at greatest risk for future infection. This information might also be useful for targeted transmission-prevention interventions, including vaccine prioritisation. Our statistical approach to estimating SARS-CoV-2 infection allows estimates to be updated and disseminated rapidly on the basis of newly available data, which has and will be crucially important for timely COVID-19 research, science, and policy responses. Funding Bill & Melinda Gates Foundation, J Stanton, T Gillespie, and J and E Nordstrom. Copyright © 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license.

COVID-19 related knowledge, attitudes, and practices in Indian Population: An online national cross-sectional survey

Authors: Piyoosh Kumar SinghID1*, Anup Anvikar2 , Abhinav Sinha2 1 Ranchi Field Unit, ICMR-National Institute of Malaria Research, Delhi, India, 2 ICMR-National Institute of Malaria Research, Delhi, India


Introduction: This highly contagious zoonotic corona virus (SARS-CoV-2) spread to most parts of the world (200 countries) and created a public health emergency. Due to its novel nature and indistinctness, different sources of information and suggestions were developed to guide the individuals about its transmission and prevent its infection. Responses to the active intervention efforts have posed some relevant questions on population understanding and attitudes toward COVID-19. The present study is aims to assess the COVID-19 related knowledge, attitude, and practices (KAP) in a heterogeneous Indian population.

Material and methods: 501 respondents across India participated in a questionnaire-based online survey from April 2020 to May 2020. The questionnaire incorporated 56 questions about demographic characteristics and KAP dimensions. The mixed (quantitative and qualitative) methods were employed to evaluate KAP dimensions. Descriptive analysis was estimated as means, SD, and proportion. The bivariate (χ2 ), correlation, and regression analysis were utilized for the response analysis. In addition, qualitative analysis, including content and thematic analysis were done for open-ended questions.

Result: High knowledge and positive attitude were reported in more than half of the study population, with a proportion of 58.6% and 62.1%, respectively. Education shows a significant difference in the knowledge and attitude dimensions. The good practice (50.5% of the total population) reported a significant difference in age and gender categories with the test of independence (χ2). Prevention (56.89%) in knowledge domain and risk (17.56%), information-seeking (45.51%), prevention (51.50%), and treatment-seeking (54.29%) in attitude domains recorded low proportion. KAP variables were found in association in Pearson correlation analysis. In logistic regression analysis, knowledge was the strongest predictor for the positive attitude, whereas attitude was reported as the best predictor for good practice outcome.

Conclusion: The study presents a moderate level of covid related knowledge, Attitudes, and Practices in Indian population.

30 epidem.pdf

Implementation of infection prevention and control practices in an upcoming COVID-19 hospital in India: An opportunity not missed

Authors: Arghya Das1 , Rahul GargID1 , E. Sampath Kumar2 , Dharanidhar Singh2 , Bisweswar Ojha3 , H. Larikyrpang Kharchandy1 , Bhairav Kumar Pathak3 , Pushkar Srikrishnan2 , Ravindra Singh4 , Immanuel JoshuaID2 , Sanket Nandekar2 , Vinothini J.2 , Reenu Reghu2 , Nikitha Pedapanga2 , Tuhina BanerjeeID1 *, Kamal Kumar Yadav1 1 Department of Microbiology, Institute of Medical Sciences, BHU, Varanasi, India, 2 Department of Community Medicine, Institute of Medical Sciences, BHU, Varanasi, India, 3 Department of Pharmacology, Institute of Medical Sciences, BHU, Varanasi, India, 4 Trauma Centre, Institute of Medical Sciences, BHU, Varanasi, India *


Infection prevention and control (IPC) program is obligatory for delivering quality services in any healthcare setup. Lack of administrative support and resource-constraints (under-staffing, inadequate funds) were primary barriers to successful implementation of IPC practices in majority of the hospitals in the developing countries. The Coronavirus Disease 2019 (COVID-19) brought a unique opportunity to improve the IPC program in these hospitals. A PDSA (Plan—Do—Study- Act) model was adopted for this study in a tertiary care hospital which was converted into a dedicated COVID-19 treatment facility in Varanasi, India. The initial focus was to identify the deficiencies in existing IPC practices and perceive the opportunities for improvement. Repeated IPC training (induction and reinforce) was conducted for the healthcare personnel (HCP) and practices were monitored by direct observation and closed-circuit television. Cleaning audits were performed by visual inspection, review of the checklists and qualitative assessment of the viewpoints of the HCP was carried out by the feedbacks received at the end of the training sessions. A total of 2552 HCP and 548 medical students were trained in IPC through multiple offline/onsite sessions over a period of 15 months during the ongoing pandemic. Although the overall compliance to surface disinfection and cleaning increased from 50% to >80% with repeated training, compliance decreased whenever newly recruited HCP were posted. Fear psychosis in the pandemic was the greatest facilitator for adopting the IPC practices. Continuous wearing of personal protective equipment for long duration, dissatisfaction with the duty rosters as well as continuous posting in high-risk areas were the major obstacles to the implementation of IPC norms. Recognising the role of an infection control team, repeated training, monitoring and improvisation of the existing resources are keys for successful implementation of IPC practices in hospitals during the COVID-19 pandemic.

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Impacts of the COVID-19 pandemic on food prices: Evidence from storable and perishable commodities in India

Authors: Subir BairagiID1 *, Ashok K. Mishra2 , Khondoker A. Mottaleb3 1 Department of Agricultural Economics and Agribusiness, University of Arkansas, Fayetteville, Arkansas, United States of America, 2 Morrison School of Agribusiness, Arizona State University, Mesa, Arizona, United States of America, 3 International Maize and Wheat Improvement Center (CIMMYT), El Bata´n, Texcoco, Me´xico *


The supply chain disruptions caused by the COVID-19 outbreak have led to changes in food prices globally. The impact of COVID-19 on the price of essential and perishable food items in developing and emerging economies has been lacking. Using a recent phone survey by the World Bank, this study examines the impact of the COVID-19 pandemic on the prices of the three essential food items in India. The results indicate that price of basic food items such as atta (wheat flour) and rice increased significantly during the pandemic compared to the pre-pandemic period. In contrast, during the same period, the price of onions declined significantly. The findings may suggest panic-buying, hoarding, and storability of food items. The results further reveal that remittance income and cash transfers from the government negatively affected commodity prices. Thus, this study’s findings suggest that families may have shifted the demand away from essential foods during the pandemic.

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Knowledge, attitude, and practices related to COVID-19 among poor and marginalized communities in central India: A crosssectional study

Authors: Krithika Murali1 , Nitya BalagopalanID1 *, Jyoti Benawri2 , Anand Kumar Bairagi2 , Nagappa Veerappa Heggannanavar3 , Ashish SrivastavaID1‡, Swati Mahajan1‡ 1 Jhpiego, New Delhi, India, 2 Jhpiego, Madhya Pradesh, India, 3 Jhpiego, Jharkhand, India ‡ AS and SM are joint senior authors on this work. *


COVID-19 has led to unprecedented challenges and requires local and global efforts for its mitigation. Poor and marginalized populations are more vulnerable to the health, social and economic effects of the pandemic. The objective of this study was to know about the knowledge, attitude and practices towards COVID-19 among poor and marginalized communities in central India and the factors associated with them so that effective risk communication messages can be designed and community engagement needs and strategies can be identified. A cross-sectional survey was conducted using an Interactive Voice Response System as part of the NISHTHA-Swasthya Vani intervention, which is a platform for dissemination of key messages related to COVID-19, social welfare schemes, national health programs and other important information. A total of 1673 respondents participated in the survey. The mean knowledge, attitude and practice scores of the respondents was 4.06 (SD = 1.67) out of 8, 2.46 (SD = 1.18) out of 4 and 3.65 (SD = 0.73) out of 4 respectively. More than 50% respondents exhibited stigma towards recovered COVID-19 patients(n = 347) and towards health workers(n = 384) catering to COVID-19 patients. The factors associated with higher KAP scores were education, occupation, age and primary source of information on COVID19. There was a positive correlation between knowledge and attitude (co-efficient: 0.32) and a negative correlation between knowledge and stigma (co-efficient: -0.28). The knowledge, and attitude scores related to COVID-19 were low among the poor and marginalized communities, while the prevalence of stigma was high. Therefore, there is a need for effective risk communication for these communities through alternate channels.

27 epidem.pdf

Governing the Access to COVID-19 Tools Accelerator: towards greater participation, transparency, and accountability

Authors: Suerie Moon, Jana Armstrong, Brian Hutler, Ross Upshur, Rachel Katz, Caesar Atuire, Anant Bhan, Ezekiel Emanuel, Ruth Faden, Prakash Ghimire, Dirceu Greco, Calvin WL Ho, Sonali Kochhar, G Owen Schaefer, Ehsan Shamsi-Gooshki, Jerome Amir Singh, Maxwell J Smith, Jonathan Wolff


The Access to COVID-19 Tools Accelerator (ACT-A) is a multistakeholder initiative quickly constructed in the early months of the COVID-19 pandemic to respond to a catastrophic breakdown in global cooperation. ACT-A is now the largest international effort to achieve equitable access to COVID-19 health technologies, and its governance is a matter of broad public importance. We traced the evolution of ACT-A’s governance through publicly available documents and analysed it against three principles embedded in the founding mission statement of ACT-A: participation, transparency, and accountability. We found three challenges to realising these principles. First, the roles of the various organisations in ACT-A decision making are unclear, obscuring who might be accountable to whom and for what. Second, the absence of a clearly defined decision making body; ACT-A instead has multiple centres of legally binding decision making and uneven arrangements for information transparency, inhibiting meaningful participation. Third, the nearly indiscernible role of governments in ACT-A, raising key questions about political legitimacy and channels for public accountability. With global public health and billions in public funding at stake, short-term improvements to governance arrangements can and should now be made. Efforts to strengthen pandemic preparedness for the future require attention to ethical, legitimate arrangements for governance.

26 EPIDEM.pdf

‘Imperfect but useful’: pandemic response in the Global South can benefit from greater use of mathematical modelling

Authors: Sandip Mandal ,1 Kanchan Parchani,2 Nimalan Arinaminpathy ,2 Swarup Sarkar ,3 Balram Bhargava,4 Samiran Panda 1


Mathematical modelling has been a helpful resource for planning public health responses to COVID-19. However, there is a need to improve the accessibility of models built within country contexts in the Global South. Immediately following the overwhelming ‘second wave’ of COVID-19 in India, we developed a user-friendly, web-based modelling simulator in partnership with the public health experts and health administrators for subnational planning. The purpose was to help policy-makers and programme officials at the state and district levels, to construct model-based scenarios for a possible third wave. Here, we describe our experiences of developing and deploying the simulator and propose the following recommendations for future such initiatives: early preparation will be the key for pandemic management planning, including establishment of networks with potential simulator users. Ideally, this preparedness should be conducted during ‘peace time’, and coordinated by agencies such as WHO. Second, flexible modelling frameworks will be needed, to respond rapidly to future emergencies as the precise nature of any pandemic is impossible to predict. Modelling resources will, therefore, need to be rapidly adaptable to respond as soon as a novel pathogen emerges. Third, limitations of modelling must be communicated clearly and consistently to end users. Finally, systematic mechanisms are required for monitoring the use of models in decision making, which will help in providing modelling support to those local authorities who may benefit most from it. Overall, these lessons from India can be relevant for other countries in the South-Asian-Region, to incorporate modelling resources into their pandemic preparedness planning.

25 epidem.pdf

Which actionable statements qualify as good practice statements In Covid-19 guidelines? A systematic appraisal

Authors: Omar Dewidar ,1,2 Tamara Lotfi,3,4,5 Miranda Langendam,6 Elena Parmelli,7 Zuleika Saz Parkinson,8 Karla Solo ,3,4,5 Derek K Chu ,3,9 Joseph L Mathew,10 Elie A Akl,3,11 Romina Brignardello-Petersen,3,4 Reem A Mustafa,3,12 Lorenzo Moja,13 Alfonso Iorio,3,4,9 Yuan Chi,14,15 Carlos Canelo-Aybar,16 Tamara Kredo ,17,18 Justine Karpusheff,19 Alexis F Turgeon,20,21 Pablo Alonso-Coello,16 Wojtek Wiercioch,3,4,5 Annette Gerritsen,17 Miloslav Klugar,22 María Ximena Rojas,23 Peter Tugwell,24,25 Vivian Andrea Welch ,1,2 Kevin Pottie,26 Zachary Munn,27 Robby Nieuwlaat,3 Nathan Ford,28 Adrienne Stevens,3,4 Joanne Khabsa ,29 Zil Nasir,3,4 Grigorios I Leontiadis,4,9 Joerg J Meerpohl,30,31 Thomas Piggott ,3,4,5 Amir Qaseem,32 Micayla Matthews,3,4,5 Holger J Schünemann ,3,4,5,9,33,34 the eCOVID-19 recommendations map collaborators


Objectives: To evaluate the development and quality of actionable statements that qualify as good practice statements (GPS) reported in COVID-19 guidelines.

Design and setting: Systematic review. We searched MEDLINE, MedSci, China National Knowledge Infrastructure (CNKI), databases of Grading of Recommendations Assessment, Development and Evaluation (GRADE) Guidelines, NICE, WHO and Guidelines International Network (GIN) from March 2020 to September 2021. We included original or adapted recommendations addressing any COVID-19 topic.

Main outcome measures: We used GRADE Working Group criteria for assessing the appropriateness of issuing a GPS: (1) clear and actionable; (2) rationale necessitating the message for healthcare practice; (3) practicality of systematically searching for evidence; (4) likely net positive consequences from implementing the GPS and (5) clear link to the indirect evidence. We assessed guideline quality using the Appraisal of Guidelines for Research and Evaluation II tool.

Results: 253 guidelines from 44 professional societies issued 3726 actionable statements. We classified 2375 (64%) as GPS; of which 27 (1%) were labelled as GPS by guideline developers. 5 (19%) were labelled as GPS by their authors but did not meet GPS criteria. Of the 2375 GPS, 85% were clear and actionable; 59% provided a rationale necessitating the message for healthcare practice, 24% reported the net positive consequences from implementing the GPS. Systematic collection of evidence was deemed impractical for 13% of the GPS, and 39% explained the chain of indirect evidence supporting GPS development. 173/2375 (7.3%) statements explicitly satisfied all five criteria. The guidelines’ overall quality was poor regardless of the appropriateness of GPS development and labelling.

Conclusions: Statements that qualify as GPS are common in COVID-19 guidelines but are characterised by unclear designation and development processes, and methodological weaknesses.

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Impact of the COVID-19-induced lockdown on the incidence of ocular trauma presenting to a tertiary care hospital

Authors: Ranjana Pande,1 Smita Sachin Mohod,1 Padmapriya V ,1 Siddhi Shanbhag,1 Nandish S Kumar2


Objective: To assess the effects of lockdown and unlock phases mandated in view of COVID-19 on the incidence and characteristics of ocular trauma presenting to a tertiary care hospital.

Methods and Analysis: The study was carried out as a hospital record based retrospective comparative analysis on patients presenting with ocular trauma in the lockdown period (March–July 2020) compared with the same time frame of the previous year considered as prelockdown period (March–July 2019) and during the unlock phases (August–December 2020).

Results: Overall, the casualty department saw 464 patients of ocular trauma in the prelockdown period, 173 in the lockdown and 253 in unlock. The study showed a 44% reduction in patients visiting the casualty department for trauma during the lockdown compared with prelockdown, and a 62% reduction specifically in ocular trauma. The unlock phase showed a 21% reduction in ocular trauma compared with prelockdown and a 41% increase compared with the lockdown. In all three phases, the majority of people affected by ocular trauma were middle aged males from a rural background, sustained by assault. The lockdown saw a decrease in outdoor assaults (45%) and road traffic accidents (22%). Trauma sustained by females (18%) increased in the lockdown, as did home-based assaults (150%) and sexual assaults. The presentation of trauma, especially road traffic accidents and outdoor assaults saw a steady rise during the unlock.

Conclusion: The lockdown mandated by the government in response to the COVID-19 pandemic had a significant impact on the trends of trauma presenting to healthcare facilities. There was a decrease in the overall number of patients approaching the casualty during the lockdown. However, during the lockdown, there was an increase in home-based trauma as opposed to outdoor assaults being the primary cause of trauma prior to the lockdown.

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An in-depth statistical analysis of the COVID-19 pandemic’s initial spread in the WHO African region

Authors: Ananthu James,1,2 Jyoti Dalal,2 Timokleia Kousi ,2,3 Daniela Vivacqua,2,4 Daniel Cardoso Portela Câmara ,2,5,6,7 Izabel Cristina Dos Reis,2,5,6 Sara Botero Mesa,2,3 Wignston Ng’ambi,2,3,8 Papy Ansobi,2,9 Lucas M Bianchi,2,7,10 Theresa M Lee,7 Opeayo Ogundiran,7 Beat Stoll,3 Cleophas Chimbetete,2,11 Franck Mboussou,7 Benido Impouma,7 Cristina Barroso Hofer ,2,4 Flávio Codeço Coelho,2,12 Olivia Keiser,2,3 Jessica Lee Abbate 2,7,13,14


During the first wave of the COVID-19 pandemic, subSaharan African countries experienced comparatively lower rates of SARS-CoV-2 infections and related deaths than in other parts of the world, the reasons for which remain unclear. Yet, there was also considerable variation between countries. Here, we explored potential drivers of this variation among 46 of the 47 WHO African region Member States in a cross-sectional study. We described five indicators of early COVID-19 spread and severity for each country as of 29 November 2020: delay in detection of the first case, length of the early epidemic growth period, cumulative and peak attack rates and crude case fatality ratio (CFR). We tested the influence of 13 pre-pandemic and pandemic response predictor variables on the country level variation in the spread and severity indicators using multivariate statistics and regression analysis. We found that wealthier African countries, with larger tourism industries and older populations, had higher peak (p<0.001) and cumulative (p<0.001) attack rates, and lower CFRs (p=0.021). More urbanised countries also had higher attack rates (p<0.001 for both indicators). Countries applying more stringent early control policies experienced greater delay in detection of the first case (p<0.001), but the initial propagation of the virus was slower in relatively wealthy, touristic African countries (p=0.023). Careful and early implementation of strict government policies were likely pivotal to delaying the initial phase of the pandemic, but did not have much impact on other indicators of spread and severity. An over-reliance on disruptive containment measures in more resource-limited contexts is neither effective nor sustainable. We thus urge decision-makers to prioritise the reduction of resource-based health disparities, and surveillance and response capacities in particular, to ensure global resilience against future threats to public health and economic stability.

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COVID-19 pandemic in Africa’s island nations during the first 9 months: a descriptive study of variation in patterns of infection, severe disease, and response measures

Authors: Timokleia Kousi ,1,2 Daniela Vivacqua,2,3 Jyoti Dalal,2,4 Ananthu James,2,5 Daniel Cardoso Portela Câmara ,2,6,7,8 Sara Botero Mesa,1,2 Cleophas Chimbetete,2,9 Benido Impouma,8 George Sie Williams,8 Franck Mboussou,8 Tamayi Mlanda,8 Arish Bukhari,8 Olivia Keiser,1,2 Jessica Lee Abbate ,2,8,10,11 Cristina Barroso Hofer


The geographic and economic characteristics unique to island nations create a different set of conditions for, and responses to, the spread of a pandemic compared with those of mainland countries. Here, we aimed to describe the initial period of the COVID-19 pandemic, along with the potential conditions and responses affecting variation in the burden of infections and severe disease burden, across the six island nations of the WHO’s Africa region: Cabo Verde, Comoros, Madagascar, Mauritius, São Tomé e Príncipe and Seychelles. We analysed the publicly available COVID-19 data on confirmed cases and deaths from the beginning of the pandemic through 29 November 2020. To understand variation in the course of the pandemic in these nations, we explored differences in their economic statuses, healthcare expenditures and facilities, age and sex distributions, leading health risk factors, densities of the overall and urban populations and the main industries in these countries. We also reviewed the non-pharmaceutical response measures implemented nationally. We found that the burden of SARS-CoV-2 infection was reduced by strict early limitations on movement and biased towards nations where detection capacity was higher, while the burden of severe COVID-19 was skewed towards countries that invested less in healthcare and those that had older populations and greater prevalence of key underlying health risk factors. These findings highlight the need for Africa’s island nations to invest more in healthcare and in local testing capacity to reduce the need for reliance on border closures that have dire consequences for their economies.

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Implications of COVID-19 for safeguarding in international development research: learning, action and reflection from a research hub

Authors: Bintu Mansaray,1,2 Laura Dean ,3 Phil Tubb,4 Kunhi Lakshmi Josyula,5 Linet Okoth,6 Ivy Chumo ,7 Jane Waritu,8 Andrea Klingel,9 Farzana Manzoor,10 Bachera Aktar,10 Surekha Garimella,11 Shrutika Murthy,11 Rachel Tolhurst,12 Lana Whittaker,12 Linsay Gray,13 Ross Forsyth,13 Helen Elsey,14 Linda Waldman,15 Sally Theobald 4


COVID-19 brings uncertainties and new precarities for communities and researchers, altering and amplifying relational vulnerabilities (vulnerabilities which emerge from relationships of unequal power and place those less powerful at risk of abuse and violence). Research approaches have changed too, with increasing use of remote data collection methods. These multiple changes necessitate new or adapted safeguarding responses. This practice piece shares practical learnings and resources on safeguarding from the Accountability for Informal Urban Equity hub, which uses participatory action research, aiming to catalyse change in approaches to enhancing accountability and improving the health and well-being of marginalised people living and working in informal urban spaces in Bangladesh, India, Kenya and Sierra Leone. We outline three new challenges that emerged in the context of the pandemic (1): exacerbated relational vulnerabilities and dilemmas for researchers in responding to increased reports of different forms of violence coupled with support services that were limited prior to the pandemic becoming barely functional or non-existent in some research sites, (2) the increased use of virtual and remote research methods, with implications for safeguarding and (3) new stress, anxiety and vulnerabilities experienced by researchers. We then outline our learning and recommended action points for addressing emerging challenges, linking practice to the mnemonic ‘the four Rs: recognise, respond, report, refer’. COVID-19 has intensified safeguarding risks. We stress the importance of communities, researchers and coresearchers engaging in dialogue and ongoing discussions of power and positionality, which are important to foster co-learning and co-production of safeguarding processes.

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Traumatic brain injury during COVID-19 pandemic—time-series analysis of a natural experiment

Authors: Banu Manickam Rajalu,1 Bhagavatula Indira Devi ,2,3 Dhaval P Shukla,2 Lekhansh Shukla ,1,4 Mini Jayan,2 Krishna Prasad,1 Deepak Jayarajan,1 Arun Kandasamy,1,4 Pratima Murthy


Objectives: This study aims to find if the incidence and pattern of traumatic brain injury (TBI) changed during the COVID-19pandemic. We also aim to build an explanatory model for change in TBI incidence using Google community mobility and alcohol sales data.

Design: A retrospective time-series analysis.

Setting: Emergency department of a tertiary level hospital located in a metropolitan city of southern India. This centre is dedicated to neurological, neurosurgical and psychiatric care.

Participants: Daily counts of TBI patients seen between 1 December 2019 and 3 January 2021 (400 days); n=8893. To compare the profile of TBI cases seen before and during the pandemic, a subset of these cases seen between 1 December 2019 and 31 July 2020 (244 days), n=5259, are studied in detail.

Result: An optimal changepoint is detected on 20 March 2020 following which the mean number of TBI cases seen every day has decreased and variance has increased (mean 1=29.4, variance 1=50.1; mean 2=19.5, variance 2=59.7, loglikelihood ratio test: χ2 =130, df=1, p<0.001) Two principal components of community mobility, alcohol sales and weekday explain the change in the number of TBI cases (pseudo R2 =58.1). A significant decrease in traffic accidents, falls, mild/moderate injuries and, an increase in assault and severe injuries is seen during the pandemic period.

Conclusions: Decongestion of roads and regulation of alcohol sales can decrease TBI occurrence substantially. An increase in violent trauma during lockdown needs further research in the light of domestic violence. Acute care facilities for TBI should be maintained even during a strict lockdown as the proportion of severe TBI requiring admission increases.

19 epidem.pdf

Impact of major disease outbreaks in the third millennium on adolescent and youth sexual and reproductive health and rights in low and/or middle-income countries: a systematic scoping review protocol

Authors: Hossein Akbarialiabad ,1 Rahul Shidhaye,2 Pallavi Shidhaye,3 Pim Cuijpers ,4 Marcia R Weaver ,5 Mina Bahrololoom,1 Sarah Kiburi,6 Irene N Njuguna,7 Mohammad Hossein Taghrir,1 Manasi Kumar


Introduction: Sexual and Reproductive Health and Rights (SRHR) of young people continue to present a high burden and remain underinvested. This is more so in low and middle-income countries (LMICs), where empirical evidence reveals disruption of SRHR maintenance, need for enhancement of programmes, resources and services during pandemics. Despite the importance of the subject, there is no published review yet combining recent disease outbreaks such as (H1N1/09, Zika, Ebola and SARS-COV-2) to assess their impact on adolescents and youth SRHR in LMICs. Methods and analysis: We will adopt a four-step search to reach the maximum possible number of studies. In the first step, we will carry out a limitedpreliminary search in databases for getting relevant keywords (appendix 1). Second, we will search in four databases: Pubmed, Cochrane Library, Embase and PsycINFO. The search would begin from the inception of the first major outbreak in 2009 (H1N1/09) up to the date of publication of the protocol in early 2022. We will search databases using related keywords, screen title & abstract and review full texts of the selected titles to arrive at the list of eligible studies. In the third stage, we will check their eligibility to the included article’s reference list. In the fourth stage, we will check the citations of included papers in phase 2 to complete our study selection. We will include all types of original studies and without any language restriction in our final synthesis. Our review results will be charted for each pandemic separately and include details pertaining to authors, year, country, region of the study, study design, participants (disaggregated by age and gender), purpose and report associated SRHR outcomes. The review will adhere to the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews guideline (PRISMA-ScR).

Patient and public involvement: Patients or public were not involved in this study.

Ethics and dissemination: Ethical assessment is not required for this study. The results of the study will be presented in peer-reviewed publications and conferences on adolescent SRHR.

18 epidem.pdf

Risk of COVID-19 re-infection and its predictors (CORES): protocol for a community-based longitudinal cohort study in Vellore, India

Authors: Ramya Madhavan,1 Jackwin Sam Paul,2 Sudhir Babji,1 Dilesh Kumar,1 Savit B Prabhu,1 Harsha Kandi Pulleri,3 Ravikiran Annadorai,3 Sampreeth Ravi Gowda,3 Jacob John,2 Gagandeep Kang 1


Introduction: The incidence of SARS-CoV-2 re-infection has not been widely evaluated in low-income and middle income countries. Understanding immune responses elicited by SARS-CoV-2 natural infection and factors that lead to re-infection in a community setting is important for public health policy. We aim to investigate the risk of primary infection and re-infection among those without and with evidence of prior infection as defined by the presence of antibodies to SARS-CoV-2 spike protein.

Methods and analysis: A baseline seroprevalence survey will test for SARS-CoV-2 antibodies among healthy adults in Vellore, India. Based on an expected seropositivity rate of 50% in the general population, with annual attack rates of 12%, 6%, 4.8% and 4% among those unvaccinated and seronegative, vaccinated and seronegative, unvaccinated and seropositive, and vaccinated and seropositive, respectively, we will recruit 1200 adults who will be followed up for a total of 24 months. Weekly self-collected saliva samples will be tested by reverse transcriptionPCR (RT-PCR) to detect SARS-CoV-2 infections, for a period of 1 year. For any person testing RT-PCR positive, blood samples will be collected within 2 days of RT-PCR positivity and on days 30 and 90 to assess the kinetics and longevity of the antibody responses, B cell memory and T cell memory post-infection. The data will be analysed to estimate seroprevalence at baseline and over time, the risk factors for infection, rates of primary infection and re-infection, and provide a comparison of the rates across groups based on infection and vaccination status.

Ethics and dissemination: The study has been approved by the Institutional Review Board (IRB No: 13585) of Christian Medical College and Hospital, Vellore. The results of the study will be made available through journal publications and conference presentations.

Trial registration number: Central Trial Registry of India: CTRI/2020/11/029438.

17 epidem.pdf

Assessment of COVID-19-related awareness, knowledge, prevention practices and challenges faced by truck drivers in major transport cities of India: a cross-sectional survey

Authors: Ishaana Sood ,1 Anand Chinnakaran,2 Atanu Majumdar,3 Shalinder Sabherwal 1


Objectives: To assess COVID-19-related awareness and knowledge among truck drivers across India and report prevention practices followed, and challenges faced, by them during the COVID-19 lockdown.

Design: Cross-sectional study.

Setting: Delhi, Kanpur, Kolkata and Bangalore from July to September 2020.

Participants: Data were collected in Hindi using a structured questionnaire via telephonic interviews. Minimum 200 drivers were included from each location.

Outcome measures: Sociodemographic profile, awareness regarding COVID-19, knowledge regarding infection sources, disease spread and vulnerable populations, prevention practices followed and challenges faced. Information sources were also assessed.

Results: Fisher’s exact test and Analysis of variance (ANOVA) test were used to check for significant differences across proportions. P value less than 0.05 was considered significant. Overall, 1246 drivers were included, with 72% response rate. Of 1246 drivers, 65% were 30–50 years of age. A majority correctly answered knowledge questions regarding communicability (95%) and fatality (66%). Fifty per cent drivers were aware of treatability of the disease, while only 43% and 24% correctly reported all signs and symptoms and routes of transmission, respectively. No driver was aware of all high-risk populations. Overall Knowledge Score is significantly associated with region. Mobile phones were the primary source of information across all regions. Over two-third drivers follow all prevention practices regularly, which differed significantly across regions. Following standard prevention practices was positively correlated with higher knowledge scores and was significantly correlated with mask use. Worry about the disease was common. Less than 40% drivers received full payment for work during this period, while 25% drivers were unable to return home due to the pandemic. Seven per cent and 26% drivers had either limited or no access to food and health services, respectively.

Conclusions: Awareness activities and employer provisioned social security/health insurance might safeguard this vulnerable population till the pandemic fully abates as well as in similar situations in the future.

16 epidem.pdf

Educational status and COVID-19 related outcomes in India: hospitalbased cross-sectional study

Authors: Arvind K Sharma,1 Rajeev Gupta ,2,3 Vaseem Naheed Baig,1 Veer Teja Singh,1 Surabhi Chakraborty,1 Jagdish P Sunda,1 Prahalad Dhakar,4 Shiv Prakash Sharma,1 Raja Babu Panwar,2 Vishwa Mohan Katoch5


Objective: Association of educational status, as marker of socioeconomic status, with COVID-19 outcomes has not been well studied. We performed a hospital-based crosssectional study to determine its association with outcomes.

Methods: Successive patients of COVID-19 presenting at government hospital were recruited. Demographic and clinical details were obtained at admission, and in-hospital outcomes were assessed. Cohort was classified according to self-reported educational status into group 1: illiterate or ≤primary; group 2: higher secondary; and group 3: some college. To compare intergroup outcomes, we performed logistic regression.

Results: 4645 patients (men 3386, women 1259) with confirmed COVID-19 were recruited. Mean age was 46±18 years, most lived in large households and 30.5% had low educational status. Smoking or tobacco use was in 29.5%, comorbidities in 28.6% and low oxygen concentration (SPo2 <95%) at admission in 30%. Average length of hospital stay was 6.8±3.7 days, supplemental oxygen was provided in 18.4%, high flow oxygen or non-invasive ventilation 7.1% and mechanical ventilation 3.6%, 340 patients (7.3%) died. Group 1 patients had more tobacco use, hypoxia at admission, lymphocytopaenia, and liver and kidney dysfunction. In group 1 versus groups 2 and 3, requirement of oxygen (21.6% vs 16.7% and 17.0%), non-invasive ventilation (8.0% vs 5.9% and 7.1%), invasive ventilation (4.6% vs 3.5% and 3.1%) and deaths (10.0% vs 6.8% and 5.5%) were significantly greater (p <0.05) OR for deaths were higher in group 1 (1.91, 95% CI 1.46 to 2.51) and group 2 (1.24, 95% CI 0.93 to 1.66) compared with group 3. Adjustment for demographic and comorbidities led to some attenuation in groups 1 (1.44, 95% CI 1.07 to 1.93) and 2 (1.38, 95% CI 1.02 to 1.85); this persisted with adjustments for clinical parameters and oxygen support in groups 1 (1.38, 95% CI 0.99 to 1.93) and 2 (1.52, 95% CI 1.01 to 2.11).

Conclusion: Low educational status patients with COVID-19 in India have significantly greater adverse inhospital outcomes and mortality.

Trial registration number REF/2020/06/034036

15 epidem.pdf

Epidemiology of COVID-19 and effect of public health interventions, Chennai, India, March–October 2020: an analysis of COVID-19 surveillance system

Authors: Jagadeesan M,1 Parasuraman Ganeshkumar,2 Prabhdeep Kaur ,3 Hemalatha Masanam Sriramulu,1 Manikandanesan Sakthivel,4 Polani Rubeshkumar ,4 Mohankumar Raju ,4 Lakshmidevi Murugesan,1 Raajkumar Ganapathi,1 Mahalakshmi Srinivasan,1 Aswini Sukumar,3 Kumaravel Ilangovan ,4 Madhusudhan Reddy,1 Divyadharshini Shanmugam,1 Prakash Govindasamy,1 Manoj Murhekar 2


Objectives To describe the public health strategies and their effect in controlling the COVID-19 pandemic from March to October 2020 in Chennai, India.

Setting: Chennai, a densely populated metropolitan city in Southern India, was one of the five cities which contributed to more than half of the COVID-19 cases in India from March to May 2020. A comprehensive community-centric public health strategy was implemented for controlling COVID-19, including surveillance, testing, contact tracing, isolation and quarantine. In addition, there were different levels of restrictions between March and October 2020.

Participants: We collected the deidentified line list of all the 192 450 COVID-19 cases reported from 17 March to 31 October 2020 in Chennai and their contacts for the analysis. We defined a COVID-19 case based on the realtime reverse transcriptase-PCR (RT-PCR) positive test conducted in one of the government-approved labs.

Outcome measures: The primary outcomes of interest were incidence of COVID-19 per million population, case fatality ratio (CFR), deaths per million, and the effective reproduction number (Rt ). We also analysed the surveillance, testing, contact tracing and isolation indicators.

Results: Of the 192 450 RT-PCR confirmed COVID-19 cases reported in Chennai from 17 March to 31 October 2020, 114 889 (60%) were males. The highest incidence was 41 064 per million population among those 61–80 years. The incidence peaked during June 2020 at 5239 per million and declined to 3627 per million in October 2020. The city reported 3543 deaths, with a case fatality ratio of 1.8%. In March, Rt was 4.2, dropped below one in July and remained so until October, even with the relaxation of restrictions.

Conclusion The combination of public health strategies might have contributed to controlling the COVID-19 epidemic in a large, densely populated city in India. We recommend continuing the test-trace-isolate strategy and appropriate restrictions to prevent resurgence.

14 epidem.pdf

Phylogenetic analysis of 17271 Indian SARSCoV-2 genomes to identify temporal and spatial hotspot mutations

Authors: Nimisha Ghosh, Suman Nandi, Indrajit Saha


The second wave of SARS-CoV-2 has hit India hard and though the vaccination drive has started, moderate number of COVID affected patients is still present in the country, thereby leading to the analysis of the evolving virus strains. In this regard, multiple sequence alignment of 17271 Indian SARS-CoV-2 sequences is performed using MAFFT followed by their phylogenetic analysis using Nextstrain. Subsequently, mutation points as SNPs are identified by Nextstrain. Thereafter, from the aligned sequences temporal and spatial analysis are carried out to identify top 10 hotspot mutations in the coding regions based on entropy. Finally, to judge the functional characteristics of all the non-synonymous hotspot mutations, their changes in proteins are evaluated as biological functions considering the sequences by using PolyPhen-2 while I-Mutant 2.0 evaluates their structural stability. For both temporal and spatial analysis, there are 21 non-synonymous hotspot mutations which are unstable and damaging.

13 epidem.pdf

Deep phylogenetic-based clustering analysis uncovers new and shared mutations in SARSCoV-2 variants as a result of directional and convergent evolution

Authors: Danilo Rosa Nunes , Carla Torres Braconi, Louisa F. Ludwig-Begall , Clarice Weis Arns , Ricardo Durães-Carvalho


Nearly two decades after the last epidemic caused by a severe acute respiratory syndrome coronavirus (SARS-CoV), newly emerged SARS-CoV-2 quickly spread in 2020 and precipitated an ongoing global public health crisis. Both the continuous accumulation of point mutations, owed to the naturally imposed genomic plasticity of SARS-CoV-2 evolutionary processes, as well as viral spread over time, allow this RNA virus to gain new genetic identities, spawn novel variants and enhance its potential for immune evasion. Here, through an in-depth phylogenetic clustering analysis of upwards of 200,000 whole-genome sequences, we reveal the presence of previously unreported and hitherto unidentified mutations and recombination breakpoints in Variants of Concern (VOC) and Variants of Interest (VOI) from Brazil, India (Beta, Eta and Kappa) and the USA (Beta, Eta and Lambda). Additionally, we identify sites with shared mutations under directional evolution in the SARS-CoV-2 Spikeencoding protein of VOC and VOI, tracing a heretofore-undescribed correlation with viral spread in South America, India and the USA. Our evidence-based analysis provides wellsupported evidence of similar pathways of evolution for such mutations in all SARS-CoV-2 variants and sub-lineages. This raises two pivotal points: (i) the co-circulation of variants and sub-lineages in close evolutionary environments, which sheds light onto their trajectories into convergent and directional evolution, and (ii) a linear perspective into the prospective vaccine efficacy against different SARS-CoV-2 strains.

12 epidem.pdf

Corona was scary, lockdown was worse: A mixed-methods study of community perceptions on COVID-19 from urban informal settlements of Mumbai

Authors: Sudha Ramani, Manjula Bahuguna, Apurva Tiwari, Sushma Shende, Anagha Waingankar, Rama Sridhar, Nikhat Shaikh, Sushmita Das, Shanti Pantvaidya, Armida Fernandez, Anuja Jayaraman


The COVID-19 pandemic has magnified the multiple vulnerabilities of people living in urban informal settlements globally. To bring community voices from such settlements to the center of COVID-19 response strategies, we undertook a study in the urban informal settlements of Dharavi, Mumbai, from September 2020-April 2021. In this study, we have examined the awareness, attitudes, reported practices, and some broader experiences of the community in Dharavi with respect to COVID-19. We have used a mixed-methods approach, that included a cross-sectional survey of 468 people, and in-depth interviews and focus group discussions with 49 people living in this area. Data was collected via a mix of phone and face-to-face interviews. We have presented here the descriptive statistics from the survey and the key themes that emerged from our qualitative data. People reported high levels of knowledge about COVID-19, with television (90%), family and friends (56%), and social media (47%) being the main sources of information. The knowledge people had, however, was not free of misconceptions and fear; people were scared of being forcefully quarantined and dying alone during the early days of COVID-19. These fears had negative repercussions in the form of patient-related stigma and hesitancy in seeking healthcare. A year into the pandemic, however, people reported a shift in attitudes from ‘extreme fear to low fear’ (67% reported perceiving low/no COVID risk in October 2020), contributing to a general laxity in following COVID-appropriate behaviors. Currently, the community is immensely concerned about the revival of livelihoods, that have been adversely impacted due to the lockdown in 2020 as well as the continued ‘othering’ of Dharavi for being a COVID hotspot. These findings suggest that urban informal settlements like Dharavi need community-level messaging that counters misinformation and denial of the outbreak; local reinforcement of COVID-appropriate behaviours; and long-term social protection measures.

11 epidem.pdf

Seroprevalence of COVID-19 infection among vaccine naïve population after the second surge (June 2020) in a rural district of South India: A community-based cross-sectional study

Authors: Carolin Elizabeth George , Leeberk Raja Inbaraj, Shon Rajukutty, Roshni Florina Joan, Arun Karthikeyan Suseeladevi, Sangeetha Muthuraj, Sindhulina Chandrasingh


Objective: To determine the seroprevalence of the SARS Cov 2 infection among vaccine naive population in a rural district of South India post-second surge.

Methodology: We conducted a cross-sectional study in the five villages of a randomly chosen sub-district in the Bangalore rural district. We did house to house surveys and recruited 831 vaccine naive adults in July 2021. We tested samples for the presence of antibodies (including IgG & IgM) to SARS CoV-2 using the Roche Elecsys SARS-CoV-2 –S assay that quantifies antibodies against the receptor-binding domain (RBD) of the spike (S) protein.

Results: We estimated an overall prevalence of 62.7% (95% CI: 59.3–66.0) and an age-and genderadjusted seroprevalence of 44.9% (95% CI: 42.5–47.4). When adjusted for test performance, the seroprevalence was 74.64% (95% CI: 70.66–78.47). The case-to-undetectedinfected ratio (CIR) was 1: 8.65 (95% CI 1:8.1–1:9.1), and the Infection Fatality Rate (IFR) was 16.27 per 100,00 infections as of 13 July 2021. A history of at least one symptom suggestive of COVID-19 or a positive COVID-19 test of self or a family member in the past were significantly associated with seropositivity.

Conclusion: We report a high seroprevalence of COVID-19 infection despite the advantages of low population density and well-ventilated landscapes in rural areas. CIR and IFR were higher than the previous serosurvey conducted in the same population during the first surge. The thought of achieving herd immunity comes with relief. However, it’s vital to put efforts into building population health and rural health infrastructure to avert future health catastrophes.

10 epidem.pdf

Impact of COVID-19 on the mobility patterns: An investigation of taxi trips in Chicago

Authors: Satyam Mukherjee, Tarun Jain


The COVID-19 outbreak has impacted urban transportation mobility throughout the world. In this paper, we investigate the impact of COVID-19 on the urban mobility network’s structural characteristics. We contribute to the literature by discussing how various community areas in the city traffic network are impacted by the pandemic. We analyze a large dataset on urban mobility from the city of Chicago and derive various insights. Our analysis of the mobility network structure is important because a better understanding of such networks can help control the spread of the disease by reducing interactions among individuals. We find that the pandemic significantly impacted the structure of the mobility network of taxis in Chicago. Our study reveals some important pointers for policymakers that could potentially aid in developing urban transportation policies during the pandemic.

9 epidem.pdf

Relationship between mobility and road traffic injuries during COVID-19 pandemic— The role of attendant factors

Authors: Kandaswamy Paramasivan, Rahul Subburaj, Venkatesh Mohan Sharma , Nandan Sudarsanam


This study investigates the important role of attendant factors, such as road traffic victims’ access to trauma centres, the robustness of health infrastructure, and the responsiveness of police and emergency services in the incidence of Road Traffic Injuries (RTI) during the pandemic-induced COVID-19 lockdowns. The differential effects of the first and second waves of the pandemic concerning perceived health risk and legal restrictions provide us with a natural experiment that helps us differentiate between the impact of attendant factors and the standard relationship between mobility and Road Traffic Injuries. The authors use the auto-regressive recurrent neural network method on two population levels–Tamil Nadu (TN), a predominantly rural state, and Chennai, the most significant metropolitan city of the state, to draw causal inference through counterfactual predictions on daily counts of road traffic deaths and Road Traffic Injuries. During the first wave of the pandemic, which was less severe than the second wave, the traffic flow was correlated to Road Traffic Death/ Road Traffic Injury. In the second wave’s partial and post lockdown phases, an unprecedented fall of over 70% in Road Traffic Injury—Grievous as against Road Traffic Injury— Minor was recorded. Attendant factors, such as the ability of the victim to approach relief centres, the capability of health and other allied infrastructures, transportation and medical treatment of road traffic crash victims, and minimal access to other emergency services, including police, assumed greater significance than overall traffic flow in the incidence of Road Traffic Injury in the more severe second wave. These findings highlight the significant role these attendant factors play in producing the discrepancy between the actual road traffic incident rate and the officially registered rate. Thus, our study enables practitioners to observe the mobility-adjusted actual incidence rate devoid of factors related to reporting and registration of accidents.

8 epidem.pdf

Impact of quarantine due to COVID-19 pandemic on health and lifestyle conditions in older adults from Centro American countries

Authors: Neyda Ma. Mendoza-Ruvalcaba, Rau´l Gutie´rrez-Herrera , Cecilia Lo´pez , Heike Hesse , Marcio Soto-Añari , Miguel Ramos-Henderson , Juan-Carlos Ca´rdenas-Valverde, Loida Camargo , Nicole Caldichoury , Jorge Herrera-Pino, Jose´ Calizaya-Lo´pez, Cesar Castellanos, Claudia Garcı´a, Marı´a F. Porto, Norman Lo´pez


Background: The impact of quarantine in older adults have been reported in several studies with contradictory results, reporting from negative effects to no significant outcomes or even beneficial consequences. Heterogeneity in aging plays a role in each region, the aim of this study is to analyze the impact of quarantine on health conditions (physical and mental) and lifestyle in older adults in five Centro American countries during COVID-19 pandemic.

Method: In this cross-sectional study, n = 712 older adults 60 years and older from Mexico, Guatemala, El Salvador, Honduras and Costa Rica were assessed by telephone. Sociodemographic data, physical and mental health, lifestyle and quarantine conditions were asked previous informed consent.

Results: In general, mean of days in quarantine at the moment of the study was 142 days (approximately four months and three weeks). In the analysis of the impact of the days in quarantine effects were found on the frequency of falls, functional ability in Activities of Daily Living (ADL), general cognitive function, memory, orientation, language, frequency of drinking alcohol, having a balanced diet, and being active cognitively. Some differences were found between countries.

Conclusions: Effects of quarantine on older adults in Centro America, requires attention of governments and healthcare to prevent long term morbidity and disability, and to promote healthy aging.

7 epidem.pdf

Topical analysis of migration coverage during lockdown in India by mainstream print media

Authors: Swati Agarwal, Sayantani Sarkar


Implementing countrywide lockdown measures in India, from March 2020 to May 2020 was a major step to deal with the COVID -19 pandemic crisis. The decision of country lockdown adversely affected the urban migrant population, and a large section of them was compelled to move out of the urban areas to their native places. The reverse migration garnered widespread media attention and coverage in electronic as well as print media. The present study focuses on the coverage of the issue by print media using descriptive natural language text mining. The study uses topic modelling, clustering, and sentiment analysis to examine the articles on migration issues during the lockdown period published in two leading English newspapers in India- The Times of India and The Hindu. The sentiment analysis results indicate that the majority of articles have neutral sentiment while very few articles show high negative or positive polarity. Descriptive topic modelling results show that transport, food security, special services, and employment with migration and migrants are the majorly covered topics after employing Bag of Words and TF-IDF models. Clustering is performed to group the article titles based on similar traits using agglomerative hierarchical clustering.

6 epidem.pdf

Impact of ‘infodemic in pandemic’ on food and nutrition related perceptions and practices of Indian internet users

Authors: SubbaRao M. Gavaravarapu, Ananya Seal , Paromita Banerjee , Thirupathi Reddy , Naresh Pittla


The uncontrolled spread of (mis)information, news and propaganda related to COVID 19 created an ‘infodemic’ leading to panic and unscientific practices among the mass. With the largest number of internet users in the world, India has witnessed a steep rise in the number of people seeking information on social media related to COVID-19, which reached a staggering 22.3 million by March, 2020. This study aimed to evaluate the trend of COVID-19 associated food and nutrition news search by Indian internet users between 27th January 2020 to 30th June 2021 (time period between the first detected COVID-19 case and the end of the second wave in India) and its impact on their perceptions and practices. The association between the change in Relative Search Volume (RSV) on Google Trends (GT) of 34 popularly searched keywords classified by the researchers under 5 different categories —“Immunity”, “Eating behavior”, “Food safety”, “Food scares and concerns” and “Covid scare” showed a steep rise in search for immunity boosters, vitamin supplement brands “ayush kadha (ayurvedic decoction) during the first wave (April- August 2020). With a brief period of decline in the search trend, it again hiked correspondingly with the growing number of positive cases during the second wave in India. An online survey conducted on adult Indian internet users (n = 572) reported high (71.9%) consumption of Vitamin C rich fruits as well as Vitamin C (68.2%) and Zinc (61.4%) supplements to boost immunity. Traditional Indian spices like ginger and garlic were used by 62.9% and 50.9% respondents respectively. Most respondents reported to rely on social media for gathering COVID-19 associated tips for boosting immunity, however those with history of COVID-19 infection reported to rely more on doctors and health professionals for information. This study highlights the need of media and health literacy to advocate for the use of health information cautiously.

5 epidem.pdf

Predictors of social distancing and hand washing among adults in five countries during COVID-19

Authors: Kaston D. Anderson-Carpenter, Garrett S. Tacy.


The purpose of this cross-sectional study is to examine disparities in hand washing and social distancing among 2,509 adults from the United States, Italy, Spain, the Kingdom of Saudi Arabia, and India. Respondents were recruited via Qualtrics’ participant pool and completed an online survey in the most common language spoken in each country. In hierarchical linear regression models, living in a rural area (β = -0.08, p = .001), older age (β = 0.07, p < .001), identifying as a woman (β = 0.07, p = .001), and greater educational attainment (β = 0.07, p = .017) were significantly associated with hand washing. Similar results were found regarding social distancing, in which living in a rural area (β = -0.10, p < .001), country of residence (β = 0.11, p < .001), older age (β = 0.17, p < .001), identifying as a woman (β = 0.11, p < .001), and greater educational attainment (β = 0.06, p = .019) were significant predictors. Results from the multivariable linear regression models demonstrate more nuanced findings with distinct and significant disparities across the five countries found with respect to hand washing and social distancing. Taken together, the results suggest multiple influencing factors that contribute to existing disparities regarding social distancing and hand washing among adults internationally. As such, more tailored public interventions are needed to promote preventive measures to mitigate existing COVID related disparities.

4 epidem.pdf

A retrospective observational insight into COVID-19 exposures resulting from personal protective equipment (PPE) breaches

Authors: Ujjwala Nitin Gaikwad1‡*, Oshrika Bose1‡, Abhishek Padhi1‡, Atul Jindal2 , Keshao Nagpure3 , Anudita Bhargava1 , Padma Das1 1 Department of Microbiology, All India Institute of Medical Sciences, Raipur, Chhatisgarh, India, 2 Department of Pediatrics, All India Institute of Medical Sciences, Raipur, Chhatisgarh, India, 3 Department of General Medicine, All India Institute of Medical Sciences, Raipur, Chhatisgarh, India ‡


Background: Healthcare workers (HCWs) stand the risk of acquiring infection directly, while attending to patients or indirectly while handling and testing patient specimens. Considering this, the present study was planned to assess Personal Protective Equipment (PPE) breaches and exposures among HCWs working in COVID-19 wards/ screening areas and to evaluate their COVID-19 positivity rates post-exposure concerning the level of exposure, type of PPE breach, and the cadre of HCWs exposed in COVID-19 wards.

Methods: This retrospective cross-sectional study involved the analysis of all instances of PPE breaches which occurred during a period of nine months from June 2020 to February 2021 at a tertiary care level hospital in Central India. The analysis included all exposures involving any cadre of HCWs that occurred while handling the patients or while doffing the contaminated PPE in COVID -19 wards.

Results: A total of 347 PPE breaches were analyzed from the available records of the Hospital Infection Control team repository. Amongst the 347 breaches, 268 (77.2%) were classified as low-risk exposures and 79 (22.8%) as high-risk exposures. Cadre wise distribution of high and low-risk exposures revealed that, PPE breaches occurred most commonly in the category of nursing officers (n = 174, 50.1%). Among all of the breaches, 15.2% of high-risk exposures and 2.6% of low-risk exposures resulted in COVID-19 positivity with a cumulative positivity of 5.4%. Collectively, non-mask related breaches accounted for the majority (63.2%) of the positive COVID-19 cases. Conclusion Appropriate use of PPE by HCWs is vital for their protection. However, breaches in the use of PPE may occur while managing COVID-19 patients due to physical and mental exhaustion among HCWs resulting from work overload. Early identification and appropriate management of HCWs with high-risk exposures can help prevent transmission to other hospital staff and patients, thus preserving resources and workforce.

3 epidem.pdf

Effective interventions to ensure MCH (Maternal and Child Health) services during pandemic related health emergencies (Zika, Ebola, and COVID-19): A systematic review

Authors:Subrata Kumar Palo, Shubhankar Dubey, Sapna Negi, Mili Roopchand Sahay, Kripalini Patel, Swagatika Swain, Bijaya Kumar Mishra, Dinesh Bhuyan, Srikanta Kanungo, Meena Som, Brajesh Raj Merta, Debdutta Bhattacharya, Jaya Singh Kshatri, Sanghamitra Pati.


Introduction: Ensuring accessible and quality health care for women and children is an existing challenge, which is further exacerbated during pandemics. There is a knowledge gap about the effect of pandemics on maternal, newborn, and child well-being. This systematic review was conducted to study maternal and child health (MCH) services utilization during pandemics (Zika, Ebola, and COVID-19) and the effectiveness of various interventions undertaken for ensuring utilization of MCH services.

Methodology: A systematic and comprehensive search was conducted in MEDLINE/PubMed, Cochrane CENTRAL, Embase, Epistemonikos, ScienceDirect, and Google Scholar. Of 5643 citations, 60 potential studies were finally included for analysis. The included studies were appraised using JBI Critical appraisal tools. Study selection and data extraction were done independently and in duplicate. Findings are presented narratively based on the RMNCHA framework by World Health Organization (WHO).

Results: Maternal and child health services such as antenatal care (ANC) visits, institutional deliveries, immunization uptake, were greatly affected during a pandemic situation. Innovative approaches in form of health care services through virtual consultation, patient triaging, developing dedicated COVID maternity centers and maternity schools were implemented in different places for ensuring continuity of MCH care during pandemics. None of the studies reported the effectiveness of these interventions during pandemic-related health emergencies.

Conclusion: The findings suggest that during pandemics, MCH care utilization often gets affected. Many innovative interventions were adopted to ensure MCH services. However, they lack evidence about their effectiveness. It is critically important to implement evidence-based appropriate interventions for better MCH care utilization.

2 epidem.pdf

Contact tracing indicators for COVID-19: Rapid scoping review and conceptual framework

Authors: Florian Vogt, Karishma Krishna Kurup , Paul Mussleman , Caroline Habrun , Madeleine Crowe , Alexandra Woodward , Giovanna Jaramillo-Gutierrez , John Kaldor , Sirenda Vong , Victor del Rio Vilas


Background: Contact tracing is one of the key interventions in response to the COVID-19 pandemic but its implementation varies widely across countries. There is little guidance on how to monitor contact tracing performance, and no systematic overview of indicators to assess contact tracing systems or conceptual framework for such indicators exists to date.

Methods: We conducted a rapid scoping review using a systematic literature search strategy in the peer-reviewed and grey literature as well as open source online documents. We developed a conceptual framework to map indicators by type (input, process, output, outcome, impact) and thematic area (human resources, financial resources, case investigation, contact identification, contact testing, contact follow up, case isolation, contact quarantine, transmission chain interruption, incidence reduction).

Result: We identified a total of 153 contact tracing indicators from 1,555 peer-reviewed studies, 894 studies from grey literature sources, and 15 sources from internet searches. Two-thirds of indicators were process indicators (102; 67%), while 48 (31%) indicators were output indicators. Only three (2%) indicators were input indicators. Indicators covered seven out of ten conceptualized thematic areas, with more than half being related to either case investigation (37; 24%) or contact identification (44; 29%). There were no indicators for the input area “financial resources”, the outcome area “transmission chain interruption”, and the impact area “incidence reduction”.

Conclusions: Almost all identified indicators were either process or output indicators focusing on case investigation, contact identification, case isolation or contact quarantine. We identified important gaps in input, outcome and impact indicators, which constrains evidence-based assessment of contact tracing systems. A universally agreed set of indicators is needed to allow for cross-system comparisons and to improve the performance of contact tracing systems.

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Household COVID-19 secondary attack rate and associated determinants in Pakistan; A retrospective cohort study

Authors: Amjad Khan1, Muhammad Hassan Mushtaq2, Javed Muhammad3, Anupam Sule4, Ali Akbar5, Khunsa Junaid6, Ali Akram Khan6, Taimoor Akram Khan6, Ubaid Khan6, Fatmee Waqar6, Asghar Khan7, Muhammad Akib Warraich8, Abdul Jabbar9 , Abbas Al Mutair10,11,12, Saad Alhumaid13, Maha Al-Mozaini14, Kuldeep Dhama15, Muhammad Fayaz Khan9 , Ali A. Rabaan1,16,17


Background: COVID-19 household transmissibility remains unclear in Pakistan. To understand the dynamics of Severe Acute Respiratory Syndrome Coronavirus disease epidemiology, this study estimated Secondary Attack Rate (SAR) among household and close contacts of index cases in Pakistan using a statistical transmission model.

Methodology: A retrospective cohort study was conducted using an inclusive contact tracing dataset from the provinces of Punjab and Khyber-Pakhtunkhwa to estimate SAR. We considered the probability of an infected person transmitting the infection to close contacts regardless of residential addresses. This means that close contacts were identified irrespective of their relationship with the index case. We assessed demographic determinants of COVID-19 infectivity and transmissibility. For this purpose based on evolving evidence, and as CDC recommends fully vaccinated people get tested 5–7 days after close contact with a personwith suspected or confirmed COVID-19. Therefore we followed the same procedure in the close contacts for secondary infection.

Findings: During the study period from 15th May 2020 to 15th Jan 2021, a total of 339 (33.9%) index cases were studied from 1000 cases initially notified. Among close contact groups (n = 739), households were identified with an assumed mean incubation period of 8.2+4.3 days and a maximum incubation period of 15 days. SAR estimated here is among the household contacts. 117 secondary cases from 739 household contacts, with SAR 11.1% (95% CI 9.0– 13.6). All together (240) SAR achieved was 32.48% (95% CI; 29.12–37.87) for symptomatic and confirmed cases. The potential risk factors for SAR identified here included; old age group (>45 years of age), male (gender), household members >5, and residency in urban areas and for index cases high age group. Overall local reproductive number (R) based on the observed household contact frequencies for index/primary cases was 0.9 (95% CI 0.47– 1.21) in Khyber Pakhtunkhwa and 1.3 (95% CI 0.73–1.56) in Punjab.

Conclusions: SAR estimated here was high especially in the second phase of the COVID-19 pandemic in Pakistan. The results highlight the need to adopt rigorous preventive measures to cut the chain of viral transmission and prevent another wave of COVID-19.


The impact of invisible-spreaders on COVID19 transmission and work resumption

Authors: Chao WuID1,2*, Cong Xu1 , Feng Mao3 *, Xiaolin XuID4,5, Chan Zhang6

1 School of Public Affairs, Zhejiang University, Hangzhou, China, 2 Data Science Institute, Imperial College London, London, United Kingdom, 3 School of Earth and Environmental Sciences Cardiff University, Cardiff, United Kingdom, 4 Center for Biostatistics, Bioinformatics, and Big Data, Second Affiliated Hospital and Department of Big Data in Health Science, School of Public Health, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China, 5 National Institute for Data Science in Health and Medicine, Hangzhou, Zhejiang, China, 6 College of Media and International Culture, Zhejiang University, Hangzhou, China.

Abstract: The global impact of coronavirus disease 2019 (COVID-19) is unprecedented, and many control and prevention measures have been implemented to test for and trace COVID-19. However, invisible-spreaders, who are associated with nucleic acid detection and asymptomatic infections, have received insufficient attention in the current COVID-19 control efforts. In this paper, we analyze the time series infection data for Italy, Germany, Brazil, India and Sweden since the first wave outbreak to address the following issues through a series of experiments. We conclude that: 1) As of June 1, 2020, the proportion of invisible spreaders is close to 0.4% in Sweden, 0.8% in early Italy and Germany, and 0.4% in the middle and late stages. However, in Brazil and India, the proportion still shows a gradual upward trend; 2) During the spread of this pandemic, even a slight increase in the proportion of invisible-spreaders could have large implications for the health of the community; and 3) On resuming work, the pandemic intervention measures will be relaxed, and invisible spreaders will cause a new round of outbreaks.


Deep learning via LSTM models for COVID-19 infection forecasting in India

Authors: Rohitash ChandraID1 *, Ayush Jain2, Divyanshu Singh Chauhan3

Abstract: The COVID-19 pandemic continues to have major impact to health and medical infrastructure, economy, and agriculture. Prominent computational and mathematical models have been unreliable due to the complexity of the spread of infections. Moreover, lack of data collection and reporting makes modelling attempts difficult and unreliable. Hence, we need to re-look at the situation with reliable data sources and innovative forecasting models. Deep learning models such as recurrent neural networks are well suited for modelling spatiotemporal sequences. In this paper, we apply recurrent neural networks such as long short term memory (LSTM), bidirectional LSTM, and encoder-decoder LSTM models for multi-step (short-term) COVID-19 infection forecasting. We select Indian states with COVID-19 hotpots and capture the first (2020) and second (2021) wave of infections and provide two months ahead forecast. Our model predicts that the likelihood of another wave of infections in October and November 2021 is low; however, the authorities need to be vigilant given emerging variants of the virus. The accuracy of the predictions motivate the application of the method in other countries and regions. Nevertheless, the challenges in modelling remain due to the reliability of data and difficulties in capturing factors such as population density, logistics, and social aspects such as culture and lifestyle.

A new generalized family of distributions based on combining Marshal-Olkin transformation with T-X family

Authors: Hadeel Klakattawi1 , Dawlah AlsulamiID1 , Mervat Abd Elaal1 , Sanku Dey2 , Lamya BaharithID1 *

Abstract: Data analysis in real life often relies mainly on statistical probability distributions. However, data arising from different fields such as environmental, financial, biomedical sciences and other areas may not fit the classical distributions. Therefore, the need arises for developing new distributions that would capture high degree of skewness and kurtosis and enhance the goodness-of-fit in empirical distribution. In this paper, we introduce a novel family of distributions which can extend some popular classes of distributions to include different new versions of the baseline distributions. The proposed family of distributions is referred as the Marshall-Olkin Weibull generated family. The proposed family of distributions is a combination of Marshall-Olkin transformation and the Weibull generated family. Two special members of the proposed family are investigated. A variety of shapes for the densities and hazard rate are presented of the considered sub-models. Some of the main mathematical properties of this family are derived. The estimation for the parameters is obtained via the maximum likelihood method. Moreover, the performance of the estimators for the considered members is examined through simulation studies in terms of bias and root mean square error. Besides, based on the new generated family, the log Marshall-Olkin WeibullWeibull regression model for censored data is proposed. Finally, COVID-19 data and three lifetime data sets are used to demonstrate the importance of the newly proposed family. Through such an applications, it is shown that this family of distributions provides a better fit when compared with other competitive distributions.


Governing the Access to COVID-19 Tools Accelerator: towards greater participation, transparency, and accountability

Authors: Suerie Moon, Jana Armstrong, Brian Hutler, Ross Upshur, Rachel Katz, Caesar Atuire, Anant Bhan, Ezekiel Emanuel, Ruth Faden, Prakash Ghimire, Dirceu Greco, Calvin WL Ho, Sonali Kochhar, G Owen Schaefer, Ehsan Shamsi-Gooshki, Jerome Amir Singh, Maxwell J Smith, Jonathan Wolff

Abstract: The Access to COVID-19 Tools Accelerator (ACT-A) is a multistakeholder initiative quickly constructed in the early months of the COVID-19 pandemic to respond to a catastrophic breakdown in global cooperation. ACT-A is now the largest international effort to achieve equitable access to COVID-19 health technologies, and its governance is a matter of broad public importance. We traced the evolution of ACT-A’s governance through publicly available documents and analysed it against three principles embedded in the founding mission statement of ACT-A: participation, transparency, and accountability. We found three challenges to realising these principles. First, the roles of the various organisations in ACT-A decision making are unclear, obscuring who might be accountable to whom and for what. Second, the absence of a clearly defined decision making body; ACT-A instead has multiple centres of legally binding decision making and uneven arrangements for information transparency, inhibiting meaningful participation. Third, the nearly indiscernible role of governments in ACT-A, raising key questions about political legitimacy and channels for public accountability. With global public health and billions in public funding at stake, short-term improvements to governance arrangements can and should now be made. Efforts to strengthen pandemic preparedness for the future require attention to ethical, legitimate arrangements for governance.


Household transmission of COVID-19 cases associated with SARS-CoV-2 delta variant (B.1.617.2): national case-control study

Authors: Hester Allen,$ Amoolya Vusirikala,$ Joe Flannagan, Katherine A. Twohig, Asad Zaidi, Dimple Chudasama, Theresa Lamagni, Natalie Groves, Charlie Turner, Christopher Rawlinson, Jamie Lopez-Bernal, Ross Harris, Andre Charlett, Gavin Dabrera and Meaghan Kall,* the COVID-19 Genomics UK (COG-UK Consortium) # National Infection Service, Public Health England, Colindale, London, NW9 5EQ, UK


Background: The SARS-CoV-2 Delta variant (B.1.617.2), first detected in India, has rapidly become the dominant variant in England. Early reports suggest this variant has an increased growth rate suggesting increased transmissibility. This study indirectly assessed differences in transmissibility between the emergent Delta variant compared to the previously dominant Alpha variant (B.1.1.7). Methods: A matched case-control study was conducted to estimate the odds of household transmission (≥ 2 cases within 14 days) for Delta variant index cases compared with Alpha cases. Cases were derived from national surveillance data (March to June 2021). One-to-two matching was undertaken on geographical location of residence, time period of testing and property type, and a multivariable conditional logistic regression model was used for analysis. Findings: In total 5,976 genomically sequenced index cases in household clusters were matched to 11,952 sporadic index cases (single case within a household). 43.3% (n=2,586) of cases in household clusters were confirmed Delta variant compared to 40.4% (n= 4,824) of sporadic cases. The odds ratio of household transmission was 1.70 among Delta variant cases (95% CI 1.48-1.95, p 0.001) compared to Alpha cases after adjusting for age, sex, ethnicity, index of multiple deprivation (IMD), number of household contacts and vaccination status of index case. Interpretation: We found evidence of increased household transmission of SARS-CoV-2 Delta variant, potentially explaining its success at displacing Alpha variant as the dominant strain in England. With the Delta variant now having been detected in many countries worldwide, the understanding of the transmissibility of this variant is important for informing infection prevention and control policies internationally. Keywords: COVID-19; SARS-CoV-2; variant; Delta, household; transmission; England


Adherence to COVID-19 protective behaviours in India from May to December 2020: evidence from a nationally representative longitudinal survey

Authors: Simone Schaner ,1,2 Natalie Theys,1 Marco Angrisani,1,2 Joyita Banerjee,3 Pranali Yogiraj Khobragade,1 Sarah Petrosyan,1 Arunika Agarwal,4 Sandy Chien,1 Bas Weerman,1 Avinash Chakrawarty,3 Prasun Chatterjee,3 Nirupam Madaan,5 David Bloom,4 Jinkook Lee,1,2 Aparajit Ballav Dey


Objectives: Since the onset of the COVID-19 pandemic, behavioural interventions to reduce disease transmission have been central to public health policy worldwide. Sustaining individual protective behaviour is especially important in low-income and middle-income settings, where health systems have fewer resources and access to vaccination is limited. This study seeks to assess time trends in COVID-19 protective behaviour in India. Design: Nationally representative, panel-based, longitudinal study. Setting: We conducted a panel survey of Indian households to understand how the adoption of COVID-19 protective behaviours has changed over time. Our data span peaks and valleys of disease transmission over May– December 2020. Participants: Respondents included 3719 adults from 1766 Indian households enrolled in the Harmonised Diagnostic Assessment of Dementia for the Longitudinal Ageing Study in India. Analysis: We used ordinary least squares regression analysis to quantify time trends in protective behaviours. Results: We find a 30.6 percentage point (95% CI (26.7 to 34.5); p<0.05) from a high base. Our conclusions are unchanged after adjusting for recorded COVID-19 caseload and nationwide COVID-19 containment policy; we also observe significant declines across socioeconomic strata spanning age, gender, education and urbanicity. Conclusion: We argue that these changes reflect, at least in part, ‘COVID-19 fatigue,’ where adherence to social distancing becomes more difficult over time irrespective of the surrounding disease environment.


Indirect effects of the early phase of the COVID-19 pandemic on the coverage of essential maternal and newborn health services in a rural subdistrict in Bangladesh: results from a crosssectional household survey

Authors: Shema Mhajabin ,1 Aniqa Tasnim Hossain,1 Nowrin Nusrat,1 Sabrina Jabeen,1 Shafiqul Ameen,1 Goutom Banik,1 Tazeen Tahsina,1 Anisuddin Ahmed,1 Qazi Sadeq-ur Rahman,1 Emily S Gurley,2 Sanwarul Bari,1 Atique Iqbal Chowdhury,1 Shams El Arifeen,1 Rajesh Mehta,3 Ahmed Ehsanur Rahman 1,4


Objective: This paper presents the effect of the early phase of COVID-19 on the coverage of essential maternal and newborn health (MNH) services in a rural subdistrict of Bangladesh. Design: Cross-sectional household survey with random sampling. Setting: Baliakandi subdistrict, Rajbari district, Bangladesh. Participants: Data were collected from women who were on the third trimester of pregnancy during the early phase of the pandemic (111) and pre-pandemic periods (115) to measure antenatal care (ANC) service coverage. To measure birth, postnatal care (PNC) and essential newborn care (ENC), data were collected from women who had a history of delivery during the early phase of the pandemic (163) and prepandemic periods (166). Exposure: Early phase of the pandemic included a strict national lockdown between April and June 2020, and prepandemic was defined as August–October 2019. Outcome of interest: Changes in the coverage of selected MNH services (ANC, birth, PNC, ENC) during the early phase of COVID-19 pandemic compared with the pre-pandemic period, estimated by two-sample proportion tests. Findings: Among women who were on the third trimester of pregnancy during the early phase of the pandemic period, 77% (95% CI: 70% to 85%) received at least one ANC from a medically trained provider (MTP) during the third trimester, compared with 83% (95% CI: 76% to 90%) during the prepandemic period (p=0.33). Among women who gave birth during the early phase of the pandemic period, 72% (95% CI: 66% to 79%) were attended by an MTP, compared with 63% (95% CI: 56% to 71%) during the pre-pandemic period (p=0.08). Early initiation of breast feeding was practised among 38% (95% CI: 31% to 46%) of the babies born during the early phase of the pandemic period. It was 37% (95% CI: 29% to 44%) during the pre-pandemic period (p=0.81). The coverage of ANC, birth, PNC and ENC did not differ by months of pandemic and pre-pandemic periods; only the coverage of at least one ANC from an MTP significantly differed among the women who were 7 months pregnant during the early phase of the pandemic (35%,95% CI: 26% to 44%) and prepandemic (49%, 95% CI: 39% to 58%) (p=0.04). Conclusion: The effect of the early phase of the pandemic including lockdown on the selected MNH service coverage was null in the study area. The nature of the lockdown, the availability and accessibility of private sector health services in that area, and the combating strategies at the rural level made it possible for the women to avail the required MNH services.


A vulnerability index for the management of and response to the COVID-19 epidemic in India: an ecological study

Authors: Rajib Acharya, PhDa,* and Akash Porwal, MPSa

Abstract:BackgroundCOVID-19 is spreading rapidly in India and other parts of the world. Despite the Indian Government's efforts to contain the disease in the affected districts, cases have been reported in 627 (98%) of 640 districts. There is a need to devise a tool for district-level planning and prioritisation and effective allocation of resources. Based on publicly available data, this study reports a vulnerability index for identification of vulnerable regions in India on the basis of population and infrastructural characteristics.MethodsWe computed a composite index of vulnerability at the state and district levels based on 15 indicators across the following five domains: socioeconomic, demographic, housing and hygiene, epidemiological, and health system. We used a percentile ranking method to compute both domain-specific and overall vulnerability and presented results spatially with number of positive COVID-19 cases in districts.FindingsA number of districts in nine large states—Bihar, Madhya Pradesh, Telangana, Jharkhand, Uttar Pradesh, Maharashtra, West Bengal, Odisha, and Gujarat—located in every region of the country except the northeast, were found to have high overall vulnerability (index value more than 0·75). These states also had high vulnerability according to most of the five domains. Although our intention was not to predict the risk of infection for a district or a state, we observed similarities between vulnerability and the current concentration of COVID-19 cases at the state level. However, this relationship was not clear at the district level.InterpretationThe vulnerability index presented in this paper identified a number of vulnerable districts in India, which currently do not have large numbers of COVID-19 cases but could be strongly impacted by the epidemic. Our index aims to help planners and policy makers effectively prioritise regions for resource allocation and adopt risk mitigation strategies for better preparedness and responses to the COVID-19 epidemic.FundingNone.

SARS-CoV-2 antibody seroprevalence in India, August–September, 2020: findings from the second nationwide household serosurvey

Authors: Manoj V Murhekar, MD,a,* Tarun Bhatnagar, PhD,a Sriram Selvaraju, MPH,b V Saravanakumar, PhD,a Jeromie Wesley Vivian Thangaraj, MPH,a Naman Shah, PhD,a Muthusamy Santhosh Kumar, MPH,a Kiran Rade, MD,c R Sabarinathan, BE,a Smita Asthana, MD,d,* Rakesh Balachandar, PhD,e,* Sampada Dipak Bangar, MPH,f,* Avi Kumar Bansal, DPH,g,* Jyothi Bhat, MD,h,* Vishal Chopra, MD,i,* Dasarathi Das, PhD,j,* Alok Kumar Deb, PhD,k,* Kangjam Rekha Devi, PhD,l,* Gaurav Raj Dwivedi, PhD,m,* S Muhammad Salim Khan, MD,n,* C P Girish Kumar, PhD,a,* M Sunil Kumar, DTCD,o,* Avula Laxmaiah, PhD,p,* Major Madhukar, DTCD,q,* Amarendra Mahapatra, PhD,j,* Suman Sundar Mohanty, PhD,r,* Chethana Rangaraju, MD,s,* Alka Turuk, MD,t,* Dinesh Kumar Baradwaj, PhD,p,† Ashrafjit S Chahal, MD,i,† Falguni Debnath, MPH,k,† Inaamul Haq, MD,n,† Arshad Kalliath, DTCD,o,† Srikanta Kanungo, MD,j,† Jaya Singh Kshatri, MD,j,† G G J Naga Lakshmi, DTCD,u,† Anindya Mitra, MD,v,† A R Nirmala, MD,w,† Ganta Venkata Prasad, DTCD,u,† Mariya Amin Qurieshi, MD,n,† Seema Sahay, PhD,f,† Ramesh Kumar Sangwan, PhD,r,† Krithikaa Sekar, MD,b,† Vijay Kumar Shukla, MBBS,x,† Prashant Kumar Singh, PhD,d,† Pushpendra Singh, PhD,h,† Rajeev Singh, PhD,m,† Dantuluri Sheethal Varma, MBBS,u,† Ankit Viramgami, MD,e,† Samiran Panda, MD,t D C S Reddy, MD,y Balram Bhargava, DM,t and ICMR Serosurveillance Group



The first national severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) serosurvey in India, done in May–June, 2020, among adults aged 18 years or older from 21 states, found a SARS-CoV-2 IgG antibody seroprevalence of 0·73% (95% CI 0·34–1·13). We aimed to assess the more recent nationwide seroprevalence in the general population in India.


We did a second household serosurvey among individuals aged 10 years or older in the same 700 villages or wards within 70 districts in India that were included in the first serosurvey. Individuals aged younger than 10 years and households that did not respond at the time of survey were excluded. Participants were interviewed to collect information on sociodemographics, symptoms suggestive of COVID-19, exposure history to laboratory-confirmed COVID-19 cases, and history of COVID-19 illness. 3–5 mL of venous blood was collected from each participant and blood samples were tested using the Abbott SARS-CoV-2 IgG assay. Seroprevalence was estimated after applying the sampling weights and adjusting for clustering and assay characteristics. We randomly selected one adult serum sample from each household to compare the seroprevalence among adults between the two serosurveys.


Between Aug 18 and Sept 20, 2020, we enrolled and collected serum samples from 29 082 individuals from 15 613 households. The weighted and adjusted seroprevalence of SARS-CoV-2 IgG antibodies in individuals aged 10 years or older was 6·6% (95% CI 5·8–7·4). Among 15 084 randomly selected adults (one per household), the weighted and adjusted seroprevalence was 7·1% (6·2–8·2). Seroprevalence was similar across age groups, sexes, and occupations. Seroprevalence was highest in urban slum areas followed by urban non-slum and rural areas. We estimated a cumulative 74·3 million infections in the country by Aug 18, 2020, with 26–32 infections for every reported COVID-19 case.


Approximately one in 15 individuals aged 10 years or older in India had SARS-CoV-2 infection by Aug 18, 2020. The adult seroprevalence increased approximately tenfold between May and August, 2020. Lower infection-to-case ratio in August than in May reflects a substantial increase in testing across the country.


Indian Council of Medical Research.


Impact of COVID-19 on cancer care in India: a cohort study

Authors: Priya Ranganathan, Prof, MD,a Manju Sengar, Prof, DM,a Girish Chinnaswamy, Prof, MD,a Gaurav Agrawal, MS,b Rajkumar Arumugham, DM,c Rajiv Bhatt, MS,d Ramesh Bilimagga, MD,e Jayanta Chakrabarti, DNB,f Arun Chandrasekharan, DM,g Harit Kumar Chaturvedi, MCh,h Rajiv Choudhrie, MCh,i Mitali Dandekar, MS,j Ashok Das, MS,k Vineeta Goel, DNB,l Caleb Harris, MCh,m Sujai Kolnadguthu Hegde, MS,n Narendra Hulikal, Prof, MCh,o Deepa Joseph, MD,p Rajesh Kantharia, MS,q Azizullah Khan, DNB,r Rohan Kharde, MD,s Navin Khattry, Prof, DM,a Maqbool M Lone, Prof, MD,t Umesh Mahantshetty, Prof, MD,u Hemant Malhotra, Prof, MD,v Hari Menon, DM,w Deepti Mishra, MCh,x Rekha A Nair, Prof, MD,y Shashank J Pandya, Prof, MCh,z Nidhi Patni, MD,aa Jeremy Pautu, DM,ab Simon Pavamani, Prof, MD,ac Satyajit Pradhan, Prof, MD,ad Subramanyeshwar Rao Thammineedi, MCh,ae G Selvaluxmy, Prof, MD,af Krishna Sharan, Prof, MD,ag B K Sharma, MS,ah Jayesh Sharma, MS,ai Suresh Singh, Prof, MS,aj Gowtham Chandra Srungavarapu, MDS,ak R Subramaniam, MD,al Rajendra Toprani, Prof, MCh,am Ramanan Venkat Raman, MS,an Rajendra Achyut Badwe, Prof, MS,a C S Pramesh, Prof, MS,a,* and National Cancer Grid of India,

AbstractBackgroundThe COVID-19 pandemic has disrupted health-care systems, leading to concerns about its subsequent impact on non-COVID disease conditions. The diagnosis and management of cancer is time sensitive and is likely to be substantially affected by these disruptions. We aimed to assess the impact of the COVID-19 pandemic on cancer care in India.MethodsWe did an ambidirectional cohort study at 41 cancer centres across India that were members of the National Cancer Grid of India to compare provision of oncology services between March 1 and May 31, 2020, with the same time period in 2019. We collected data on new patient registrations, number of patients visiting outpatient clinics, hospital admissions, day care admissions for chemotherapy, minor and major surgeries, patients accessing radiotherapy, diagnostic tests done (pathology reports, CT scans, MRI scans), and palliative care referrals. We also obtained estimates from participating centres on cancer screening, research, and educational activities (teaching of postgraduate students and trainees). We calculated proportional reductions in the provision of oncology services in 2020, compared with 2019.FindingsBetween March 1 and May 31, 2020, the number of new patients registered decreased from 112 270 to 51 760 (54% reduction), patients who had follow-up visits decreased from 634 745 to 340 984 (46% reduction), hospital admissions decreased from 88 801 to 56 885 (36% reduction), outpatient chemotherapy decreased from 173634 to 109 107 (37% reduction), the number of major surgeries decreased from 17 120 to 8677 (49% reduction), minor surgeries from 18 004 to 8630 (52% reduction), patients accessing radiotherapy from 51 142 to 39 365 (23% reduction), pathological diagnostic tests from 398 373 to 246 616 (38% reduction), number of radiological diagnostic tests from 93 449 to 53 560 (43% reduction), and palliative care referrals from 19 474 to 13 890 (29% reduction). These reductions were even more marked between April and May, 2020. Cancer screening was stopped completely or was functioning at less than 25% of usual capacity at more than 70% of centres during these months. Reductions in the provision of oncology services were higher for centres in tier 1 cities (larger cities) than tier 2 and 3 cities (smaller cities).InterpretationThe COVID-19 pandemic has had considerable impact on the delivery of oncology services in India. The long-term impact of cessation of cancer screening and delayed hospital visits on cancer stage migration and outcomes are likely to be substantial.FundingNone.

Neurological associations of COVID-19

Authors: Mark A Ellul, Laura Benjamin, Bhagteshwar Singh, Suzannah Lant, Benedict Daniel Michael, Ava Easton, Rachel Kneen, Sylviane Defres,Jim Sejvar, Tom Solomon



The COVID-19 pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is of a scale not seen since the 1918 influenza pandemic. Although the predominant clinical presentation is with respiratory disease, neurological manifestations are being recognised increasingly. On the basis of knowledge of other coronaviruses, especially those that caused the severe acute respiratory syndrome and Middle East respiratory syndrome epidemics, cases of CNS and peripheral nervous system disease caused by SARS-CoV-2 might be expected to be rare.

Recent developments

A growing number of case reports and series describe a wide array of neurological manifestations in 901 patients, but many have insufficient detail, reflecting the challenge of studying such patients. Encephalopathy has been reported for 93 patients in total, including 16 (7%) of 214 hospitalised patients with COVID-19 in Wuhan, China, and 40 (69%) of 58 patients in intensive care with COVID-19 in France. Encephalitis has been described in eight patients to date, and Guillain-Barré syndrome in 19 patients. SARS-CoV-2 has been detected in the CSF of some patients. Anosmia and ageusia are common, and can occur in the absence of other clinical features. Unexpectedly, acute cerebrovascular disease is also emerging as an important complication, with cohort studies reporting stroke in 2–6% of patients hospitalised with COVID-19. So far, 96 patients with stroke have been described, who frequently had vascular events in the context of a pro-inflammatory hypercoagulable state with elevated C-reactive protein, D-dimer, and ferritin.

Where next?

Careful clinical, diagnostic, and epidemiological studies are needed to help define the manifestations and burden of neurological disease caused by SARS-CoV-2. Precise case definitions must be used to distinguish non-specific complications of severe disease (eg, hypoxic encephalopathy and critical care neuropathy) from those caused directly or indirectly by the virus, including infectious, para-infectious, and post-infectious encephalitis, hypercoagulable states leading to stroke, and acute neuropathies such as Guillain-Barré syndrome. Recognition of neurological disease associated with SARS-CoV-2 in patients whose respiratory infection is mild or asymptomatic might prove challenging, especially if the primary COVID-19 illness occurred weeks earlier. The proportion of infections leading to neurological disease will probably remain small. However, these patients might be left with severe neurological sequelae. With so many people infected, the overall number of neurological patients, and their associated health burden and social and economic costs might be large. Health-care planners and policy makers must prepare for this eventuality, while the many ongoing studies investigating neurological associations increase our knowledge base.


Lessons learnt from easing COVID-19 restrictions: an analysis of countries and regions in Asia Pacific and Europe

Authors: Emeline Han*, Melisa Mei Jin Tan*, Eva Turk, Devi Sridhar, Gabriel M Leung, Kenji Shibuya, Nima Asgari, Juhwan Oh, Alberto L García-Basteiro, Johanna Hanefeld, Alex R Cook, Li Yang Hsu, Yik Ying Teo, David Heymann, Helen Clark, Martin McKee, Helena Legido-Quigley

The COVID-19 pandemic is an unprecedented global crisis. Many countries have implemented restrictions on population movement to slow the spread of severe acute respiratory syndrome coronavirus 2 and prevent health systems from becoming overwhelmed; some have instituted full or partial lockdowns. However, lockdowns and other extreme restrictions cannot be sustained for the long term in the hope that there will be an effective vaccine or treatment for COVID-19. Governments worldwide now face the common challenge of easing lockdowns and restrictions while balancing various health, social, and economic concerns. To facilitate cross-country learning, this Health Policy paper uses an adapted framework to examine the approaches taken by nine high-income countries and regions that have started to ease COVID-19 restrictions: five in the Asia Pacific region (ie, Hong Kong [Special Administrative Region], Japan, New Zealand, Singapore, and South Korea) and four in Europe (ie, Germany, Norway, Spain, and the UK). This comparative analysis presents important lessons to be learnt from the experiences of these countries and regions. Although the future of the virus is unknown at present, countries should continue to share their experiences, shield populations who are at risk, and suppress transmission to save lives.


Institutional and behaviour-change interventions to support COVID-19 public health measures: a review by the Lancet Commission Task Force on public health measures to suppress the pandemic

Authors: Jong-Koo Lee, Chris Bullen, Yanis Ben Amor, Simon R Bush, Francesca Colombo, Alejandro Gaviria, Salim S Abdool Karim, Booyuel Kim, John N Lavis, Jeffrey V Lazarus, Yi-Chun Lo, Susan F Michie, Ole F Norheim, Juhwan Oh, Kolli Srinath Reddy, Mikael Rostila, Rocío Sáenz, Liam D G Smith, John W Thwaites, Miriam K Were, Lan Xue, and (The Lancet COVID-19 Commission Task Force for Public Health Measures to Suppress the Pandemic)


The Lancet COVID-19 Commission Task Force for Public Health Measures to Suppress the Pandemic was launched to identify critical points for consideration by governments on public health interventions to control coronavirus disease 2019 (COVID-19). Drawing on our review of published studies of data analytics and modelling, evidence synthesis and contextualisation, and behavioural science evidence and theory on public health interventions from a range of sources, we outline evidence for a range of institutional measures and behaviour-change measures. We cite examples of measures adopted by a range of countries, but especially jurisdictions that have, thus far, achieved low numbers of COVID-19 deaths and limited community transmission of severe acute respiratory syndrome coronavirus 2. Finally, we highlight gaps in knowledge where research should be undertaken. As countries consider long-term measures, there is an opportunity to learn, improve the response and prepare for future pandemics.

Keywords: behaviour change, COVID-19, pandemic, public health


Global effect of the COVID-19 pandemic on paediatric cancer care: a cross-sectional study

Authors: Dylan Graetz, MD,a Asya Agulnik, MD,a Radhikesh Ranadive, MS,a Yuvanesh Vedaraju, MS,a Yichen Chen, PhD,a Guillermo Chantada, Prof, MD,b,c Monika L Metzger, Prof, MD,a Sheena Mukkada, MD,a Lisa M Force, MD,d,e Paola Friedrich, MD,a Catherine Lam, MD,a Elizabeth Sniderman, MSN,a Nickhill Bhakta, MD,a Laila Hessissen, Prof, MD,f Rashmi Dalvi, Prof, MD,g Meenakshi Devidas, Prof, PhD,a Kathy Pritchard-Jones, Prof, MD,h Carlos Rodriguez-Galindo, Prof, MD,a and Daniel C Moreira, MDa,*



Although mortality due to COVID-19 has been reportedly low among children with cancer, changes in health-care services due to the pandemic have affected cancer care delivery. This study aimed to assess the effect of the COVID-19 pandemic on childhood cancer care worldwide.


A cross-sectional survey was distributed to paediatric oncology providers worldwide from June 22 to Aug 21, 2020, through the St Jude Global Alliance and International Society for Paediatric Oncology listservs and regional networks. The survey included 60 questions to assess institution characteristics, the number of patients diagnosed with COVID-19, disruptions to cancer care (eg, service closures and treatment abandonment), adaptations to care, and resources (including availability of clinical staff and personal protective equipment). Surveys were included for analysis if respondents answered at least two thirds of the items, and the responses were analysed at the institutional level.


Responses from 311 health-care professionals at 213 institutions in 79 countries from all WHO regions were included in the analysis. 187 (88%) of 213 centres had the capacity to test for SARS-CoV-2 and a median of two (range 0–350) infections per institutution were reported in children with cancer. 15 (7%) centres reported complete closure of paediatric haematology-oncology services (median 10 days, range 1–75 days). Overall, 2% (5 of 213) of centres were no longer evaluating new cases of suspected cancer, while 43% (90 of 208) of the remaining centers described a decrease in newly diagnosed paediatric cancer cases. 73 (34%) centres reported increased treatment abandonment (ie, failure to initiate cancer therapy or a delay in care of 4 weeks or longer). Changes to cancer care delivery included: reduced surgical care (153 [72%]), blood product shortages (127 [60%]), chemotherapy modifications (121 [57%]), and interruptions to radiotherapy (43 [28%] of 155 institutions that provided radiotherapy before the pandemic). The decreased number of new cancer diagnoses did not vary based on country income status (p=0·14). However, unavailability of chemotherapy agents (p=0·022), treatment abandonment (p<0·0001), and interruptions in radiotherapy (p<0·0001) were more frequent in low-income and middle-income countries than in high-income countries. These findings did not vary based on institutional or national numbers of COVID-19 cases. Hospitals reported using new or adapted checklists (146 [69%] of 213), processes for communication with patients and families (134 [63%]), and guidelines for essential services (119 [56%]) as a result of the pandemic.


The COVID-19 pandemic has considerably affected paediatric oncology services worldwide, posing substantial disruptions to cancer diagnosis and management, particularly in low-income and middle-income countries. This study emphasises the urgency of an equitably distributed robust global response to support paediatric oncology care during this pandemic and future public health emergencies.


American Lebanese Syrian Associated Charities.


Suicide trends in the early months of the COVID-19 pandemic: an interrupted time-series analysis of preliminary data from 21 countries

Author: Jane Pirkis, Ann John, Sangsoo Shin, Marcos DelPozo-Banos, Vikas Arya, Pablo Analuisa-Aguilar, Louis Appleby, Ella Arensman, Jason Bantjes, Anna Baran, Jose M Bertolote, Guilherme Borges, Petrana Brečić, Eric Caine, Giulio Castelpietra, Shu-Sen Chang, David Colchester, David Crompton, Marko Curkovic, Eberhard A Deisenhammer, Chengan Du, Jeremy Dwyer, Annette Erlangsen, Jeremy S Faust, Sarah Fortune, Andrew Garrett, Devin George, Rebekka Gerstner, Renske Gilissen, Madelyn Gould, Keith Hawton, Joseph Kanter, Navneet Kapur, Murad Khan, Olivia J Kirtley, Duleeka Knipe, Kairi Kolves, Stuart Leske, Kedar Marahatta, Ellenor Mittendorfer-Rutz, Nikolay Neznanov, Thomas Niederkrotenthaler, Emma Nielsen, Merete Nordentoft, Herwig Oberlerchner, Rory C O’Connor, Melissa Pearson, Michael R Phillips, Steve Platt, Paul L Plener, Georg Psota, Ping Qin, Daniel Radeloff, Christa Rados, Andreas Reif, Christine Reif-Leonhard, Vsevolod Rozanov, Christiane Schlang, Barbara Schneider, Natalia Semenova, Mark Sinyor, Ellen Townsend, Michiko Ueda, Lakshmi Vijayakumar, Roger T Webb, Manjula Weerasinghe, Gil Zalsman, David Gunnell*, Matthew J Spittal*



The COVID-19 pandemic is having profound mental health consequences for many people. Concerns have been expressed that, at their most extreme, these consequences could manifest as increased suicide rates. We aimed to assess the early effect of the COVID-19 pandemic on suicide rates around the world.


We sourced real-time suicide data from countries or areas within countries through a systematic internet search and recourse to our networks and the published literature. Between Sept 1 and Nov 1, 2020, we searched the official websites of these countries’ ministries of health, police agencies, and government-run statistics agencies or equivalents, using the translated search terms “suicide” and “cause of death”, before broadening the search in an attempt to identify data through other public sources. Data were included from a given country or area if they came from an official government source and were available at a monthly level from at least Jan 1, 2019, to July 31, 2020. Our internet searches were restricted to countries with more than 3 million residents for pragmatic reasons, but we relaxed this rule for countries identified through the literature and our networks. Areas within countries could also be included with populations of less than 3 million. We used an interrupted time-series analysis to model the trend in monthly suicides before COVID-19 (from at least Jan 1, 2019, to March 31, 2020) in each country or area within a country, comparing the expected number of suicides derived from the model with the observed number of suicides in the early months of the pandemic (from April 1 to July 31, 2020, in the primary analysis).


We sourced data from 21 countries (16 high-income and five upper-middle-income countries), including whole-country data in ten countries and data for various areas in 11 countries). Rate ratios (RRs) and 95% CIs based on the observed versus expected numbers of suicides showed no evidence of a significant increase in risk of suicide since the pandemic began in any country or area. There was statistical evidence of a decrease in suicide compared with the expected number in 12 countries or areas: New South Wales, Australia (RR 0·81 [95% CI 0·72–0·91]); Alberta, Canada (0·80 [0·68–0·93]); British Columbia, Canada (0·76 [0·66–0·87]); Chile (0·85 [0·78–0·94]); Leipzig, Germany (0·49 [0·32–0·74]); Japan (0·94 [0·91–0·96]); New Zealand (0·79 [0·68–0·91]); South Korea (0·94 [0·92–0·97]); California, USA (0·90 [0·85–0·95]); Illinois (Cook County), USA (0·79 [0·67–0·93]); Texas (four counties), USA (0·82 [0·68–0·98]); and Ecuador (0·74 [0·67–0·82]).


This is the first study to examine suicides occurring in the context of the COVID-19 pandemic in multiple countries. In high-income and upper-middle-income countries, suicide numbers have remained largely unchanged or declined in the early months of the pandemic compared with the expected levels based on the pre-pandemic period. We need to remain vigilant and be poised to respond if the situation changes as the longer-term mental health and economic effects of the pandemic unfold.



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