Articles related to epidemiology 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.