Excess all-cause mortality during the COVID-19 pandemic in Europe - preliminary pooled estimates from the EuroMOMO network, March to April 2020

Health and Healthcare Variables Associated with Italy's Excess Mortality during the First Wave of the COVID-19 pandemic: An Ecological Study

Background

Healthcare factors have strongly influenced the propagation of COVID-19. This study aims to examine whether excess mortality during the first phase of the COVID-19 outbreak in Italy was associated with health, healthcare, demographic, and socioeconomic, provincial-level indicators.

Methods

This ecological study concerns the raw number of deaths reported from February 1 to April 30, 2020 and the mean number of deaths occurred during the same months from 2015 to 2019, per province. Information on socioeconomic factors and healthcare settings was extracted from updated databases on the Italian National Institute of Statistics (ISTAT) website. A multivariate model and four multilevel models were constructed to test the association between excess mortality and the analysed indicators across 107 Italian provinces.

Results

The hospitalization rate in long-term care wards and the cardiovascular disease mortality rate correlate positively with excess mortality (p <0.05), while higher densities of licensed physicians and of general practitioners are associated with lower excess mortality (p <0.05). After controlling for the COVID-19 cumulative incidence in each province, only the density of licensed physicians remains negatively associated with excess mortality (p <0.01).

Conclusion

Some health and healthcare variables (in particular, the density of physicians) are strongly associated with excess mortality during the first wave of the COVID-19 pandemic in Italy and should be targeted to increase the resilience of health systems.

On assessing excess mortality in Germany during the COVID-19 pandemic

Coronavirus disease 2019 (COVID-19) is associated with a very high number of casualties in the general population. Assessing the exact magnitude of this number is a non-trivial problem, as relying only on officially reported COVID-19 associated fatalities runs the risk of incurring in several kinds of biases. One of the ways to approach the issue is to compare overall mortality during the pandemic with expected mortality computed using the observed mortality figures of previous years. In this paper, we build on existing methodology and propose two ways to compute expected as well as excess mortality, namely at the weekly and at the yearly level. Particular focus is put on the role of age, which plays a central part in both COVID-19-associated and overall mortality. We illustrate our methods by making use of age-stratified mortality data from the years 2016 to 2020 in Germany to compute age group-specific excess mortality during the COVID-19 pandemic in 2020.

[The SARS-CoV-2 Pandemic in Long-Term Care Facilities for the Elderly: Analysis of Data from Frankfurt am Main, Germany, March 2020 - September 2021]

BACKGROUND

Residents in long-term care facilities (LTCF) are particularly vulnerable during the SARS-CoV-2 pandemic. In the first wave of the pandemic in many countries, 30-70% of all deaths from or with SARS-CoV-2 were LTCF residents, although their proportion in the population is typically less than 1%. Findings from LTCFs in Frankfurt am Main (March 2020-September 2021) are presented below and discussed in terms of necessary improvements.

MATERIAL AND METHODS

The reports of positive PCR tests for SARS-CoV-2 in residents and staff of the LTCF in Frankfurt am Main and their symptoms were descriptively evaluated. In addition, the total deaths in nursing homes from 2018 to June 2021 were surveyed per quarter.

RESULTS

In the first pandemic wave (March-May 2020), 111 SARS-CoV-2-positive LTCF residents were reported to the Public Health Department in Frankfurt am Main, of whom 40% were asymptomatic, 48% were hospitalized, and 23% died. In the subsequent pandemic phases through September 30, 2021, additional 1196 residents infected with SARS-CoV-2 were reported, with most of them being asymptomatic (70%); they were hospitalized less frequently (27%). Mortality was also lower (17.6%). Overall mortality in LTCF was 7.6% higher in 2020 than in 2019 and 1.1% higher than in the "flu year" of 2018.

DISCUSSION

In contrast to the first wave, when only a few LTCF residents contracted COVID-19, in the second pandemic wave in autumn/winter 2020/21, with high incidences in the general population, SARS-CoV-2 outbreaks in LTCF in Frankfurt could not be prevented, despite extensive hygiene, infection prevention, and contact mitigation measures (including visitor restrictions) that massively limited residents' quality of life and their personal rights. Only when vaccination rates increased among residents and staff from April 2021 onwards, there were no massive outbreaks. To better protect LTCF residents, an appropriate balance was called for between protecting against infection and avoiding collateral damage by maintaining the freedom and quality of life of nursing home residents as best as possible.

The cost of lost productivity due to premature mortality associated with COVID-19: a Pan-European study

BACKGROUND

Economic cost estimates have the potential to provide a valuable alternative perspective on the COVID-19 burden. We estimate the premature mortality productivity costs associated with COVID-19 across Europe.

METHODS

We calculated excess deaths between the date the cumulative total of COVID-19 deaths reached 10 in a country to 15th May 2020 for nine countries (Belgium, France, Germany, Italy, The Netherlands, Portugal, Spain, Sweden and Switzerland). Gender- and age-specific excess deaths and Years of Potential Productive Life Lost (YPPLL) between 30 and 74 years were calculated and converted into premature mortality productivity costs €2020 for paid and unpaid work using the Human Capital and the Proxy Good Approaches. Costs were discounted at 3.5%.

RESULTS

Total estimated excess deaths across the nine countries were 18,614 (77% in men) and YPPLL were 134,190 (77% male). Total paid premature mortality costs were €1.07 billion (87% male) with Spain (€0.35 billion, 33.0% of total), Italy (€0.22 billion; 20.6%) and The Netherlands (€0.19 billion; 17.5%) ranking highest. Total paid and unpaid premature mortality costs were €2.89 billion (77% male). Premature mortality costs per death ranged between €40,382 (France) and €350,325 (Switzerland). Spain experienced the highest premature mortality cost as a proportion of Gross Domestic Product (0.11%).

CONCLUSION

Even in the initial period of the pandemic in Europe, COVID-19-related premature mortality costs were significant across Europe. We provide policy makers and researchers with a valuable alternative perspective on the burden of the virus and highlight potential economic savings that may be accrued by applying timely public health measures.

The association of intensity and duration of non-pharmacological interventions and implementation of vaccination with COVID-19 infection, death, and excess mortality: natural experiment in 22 European countries

Background

Critical questions remain regarding the need for intensity to continue NPIs as the public was vaccinated. We evaluated the association of intensity and duration of non-pharmaceutical interventions (NPIs) and vaccines with COVID-19 infection, death, and excess mortality in Europe.

Methods

Data comes from Our Word in Data. We included 22 European countries from January 20, 2020, to May 30, 2021. The time-varying constrained distribution lag model was used in each country to estimate the impact of different intensities and duration of NPIs on COVID-19 control, considering vaccination coverage. Country-specific effects were pooled through meta-analysis.

Results

This study found that high-intensity and long-duration of NPIs showed a positive main effect on reducing infection in the absence of vaccines, especially in the intensity above the 80th percentile and lasted for 7 days (RR = 0.93, 95% CI: 0.89–0.98). However, the adverse effect on excess mortality also increased with the duration and intensity. Specifically, it was associated with an increase of 44.16% (RR = 1.44, 95% CI: 1.27–1.64) in the excess mortality under the strict intervention (the intensity above the 80th percentile and lasted for 21 days). As the vaccine rollouts, the inhibition of the strict intervention on cases growth rate was increased (RR dropped from 0.95 to 0.87). Simultaneously, vaccination also alleviated the negative impact of the strict intervention on excess mortality (RR decreased from 1.44 to 1.25).

Besides, maintaining the strict intervention appeared to more reduce the cases, as well as avoids more overall burden of death compared with weak intervention.

Conclusions

Our study highlights the importance of continued high-intensity NPIs in low vaccine coverage. Lifting of NPIs in insufficient vaccination coverage may cause increased infections and death burden. Policymakers should coordinate the intensity and duration of NPIs and allocate medical resources reasonably with widespread vaccination.

Paediatric pneumonia research priorities in the context of COVID-19: A eDelphi study

Background

Pneumonia remains the leading cause of infectious deaths in children under-five globally. We update the research priorities for childhood pneumonia in the context of the COVID-19 pandemic and explore whether previous priorities have been addressed.

Methods

We conducted an eDelphi study from November 2019 to June 2021. Experts were invited to take part, targeting balance by: gender, profession, and high (HIC) and low- and middle-income countries (LMIC). We followed a three-stage approach: 1. Collating questions, using a list published in 2011 and adding newly posed topics; 2. Narrowing down, through participant scoring on importance and whether they had been answered; 3. Ranking of retained topics. Topics were categorized into: prevent and protect, diagnosis, treatment and cross-cutting.

Results

Overall 379 experts were identified, and 108 took part. We started with 83 topics, and 81 further general and 40 COVID-19 specific topics were proposed. In the final ranking 101 topics were retained, and the highest ranked was to "explore interventions to prevent neonatal pneumonia". Among the top 20 topics, epidemiological research and intervention evaluation was commonly prioritized, followed by the operational and implementation research. Two COVID-19 related questions were ranked within the top 20. There were clear differences in priorities between HIC and LMIC respondents, and academics vs non-academics.

Conclusions

Operational research on health system capacities, and evaluating optimized delivery of existing treatments, diagnostics and case management approaches are needed. This list should act as a catalyst for collaborative research, especially to meet the top priority in preventing neonatal pneumonia, and encourage multi-disciplinary partnerships.

The Use of Cremation Data for Timely Mortality Surveillance During the COVID-19 Pandemic in Ontario, Canada: Validation Study

BACKGROUND

Early estimates of excess mortality are crucial for understanding the impact of COVID-19. However, there is a lag of several months in the reporting of vital statistics mortality data for many jurisdictions, including across Canada. In Ontario, a Canadian province, certification by a coroner is required before cremation can occur, creating real-time mortality data that encompasses the majority of deaths within the province.

OBJECTIVE

This study aimed to validate the use of cremation data as a timely surveillance tool for all-cause mortality during a public health emergency in a jurisdiction with delays in vital statistics data. Specifically, this study aimed to validate this surveillance tool by determining the stability, timeliness, and robustness of its real-time estimation of all-cause mortality.

METHODS

Cremation records from January 2020 until April 2021 were compared to the historical records from 2017 to 2019, grouped according to week, age, sex, and whether COVID-19 was the cause of death. Cremation data were compared to Ontario's provisional vital statistics mortality data released by Statistics Canada. The 2020 and 2021 records were then compared to previous years (2017-2019) to determine whether there was excess mortality within various age groups and whether deaths attributed to COVID-19 accounted for the entirety of the excess mortality.

RESULTS

Between 2017 and 2019, cremations were performed for 67.4% (95% CI 67.3%-67.5%) of deaths. The proportion of cremated deaths remained stable throughout 2020, even within age and sex categories. Cremation records are 99% complete within 3 weeks of the date of death, which precedes the compilation of vital statistics data by several months. Consequently, during the first wave (from April to June 2020), cremation records detected a 16.9% increase (95% CI 14.6%-19.3%) in all-cause mortality, a finding that was confirmed several months later with cremation data.

CONCLUSIONS

The percentage of Ontarians cremated and the completion of cremation data several months before vital statistics did not change meaningfully during the COVID-19 pandemic period, establishing that the pandemic did not significantly alter cremation practices. Cremation data can be used to accurately estimate all-cause mortality in near real-time, particularly when real-time mortality estimates are needed to inform policy decisions for public health measures. The accuracy of this excess mortality estimation was confirmed by comparing it with official vital statistics data. These findings demonstrate the utility of cremation data as a complementary data source for timely mortality information during public health emergencies.

Social disparities in the first wave of COVID-19 incidence rates in Germany: a county-scale explainable machine learning approach

OBJECTIVES

Knowledge about the socioeconomic spread of the first wave of COVID-19 infections in Germany is scattered across different studies. We explored whether COVID-19 incidence rates differed between counties according to their socioeconomic characteristics using a wide range of indicators.

DATA AND METHOD

We used data from the Robert Koch-Institute (RKI) on 204 217 COVID-19 diagnoses in the total German population of 83.1 million, distinguishing five distinct periods between 1 January and 23 July 2020. For each period, we calculated age-standardised incidence rates of COVID-19 diagnoses on the county level and characterised the counties by 166 macro variables. We trained gradient boosting models to predict the age-standardised incidence rates with the macrostructures of the counties and used SHapley Additive exPlanations (SHAP) values to characterise the 20 most prominent features in terms of negative/positive correlations with the outcome variable.

RESULTS

The first COVID-19 wave started as a disease in wealthy rural counties in southern Germany and ventured into poorer urban and agricultural counties during the course of the first wave. High age-standardised incidence in low socioeconomic status (SES) counties became more pronounced from the second lockdown period onwards, when wealthy counties appeared to be better protected. Features related to economic and educational characteristics of the young population in a county played an important role at the beginning of the pandemic up to the second lockdown phase, as did features related to the population living in nursing homes; those related to international migration and a large proportion of foreigners living in a county became important in the postlockdown period.

CONCLUSION

High mobility of high SES groups may drive the pandemic at the beginning of waves, while mitigation measures and beliefs about the seriousness of the pandemic as well as the compliance with mitigation measures may put lower SES groups at higher risks later on.

Factors Affecting Young Adults' Decision Making to Undergo COVID-19 Vaccination: A Patient Preference Study

Young adults are a substantial driver of lagging vaccination against COVID-19 worldwide. We aimed to understand what vaccine or vaccination environment attributes may affect young adults' vaccine inclination. We contacted a convenience sample of 1415 students to recruit a minimum of 150 individuals for a web-based discrete choice experiment. The respondents were asked to choose one of two hypothetical vaccines, defined by six attributes-vaccine efficacy, risk of mild side effects, protection duration, administration route, recommender, and travel time to the vaccination site. Individual preferences were calculated with the Markov chain Monte Carlo hierarchical Bayes estimation. A total of 445 individuals (mean age 24.4 years, 272 (61.1%) women) completed the survey between 22 March and 3 May 2021. Vaccine protection duration (28.3 (95% CI, 27.0-29.6)) and vaccine efficacy in preventing COVID-19 (27.5 (95% CI, 26.3-28.8)) were the most important, followed by the risk of vaccine side effects (17.3 (95% CI, 16.2-18.4)). Individuals reluctant or unsure about vaccination (21.1%) prioritized the potential for mild side effects higher and vaccine efficacy lower than the vaccine-inclined individuals. New vaccination programs that target young adults should emphasize the protection duration, low risk of vaccine side effects, and high efficacy.

HIV and SARS-CoV-2 Co-infection: Epidemiological, Clinical Features, and Future Implications for Clinical Care and Public Health for People Living with HIV (PLWH) and HIV Most-at-Risk Groups

PURPOSE OF REVIEW

The purpose of this review is to use the currently available clinical and epidemiological data, to identify key aspects to improve both the clinical management and public health response to SARS-CoV-2/HIV co-infection among HIV vulnerable populations and people living with HIV (PLWH).

RECENT FINDINGS

While at the beginning of the COVID-19 pandemic, the lack of robust information on SARS-CoV-2/HIV co-infection, prevented a clear picture of the synergies between them, currently available data strongly support the importance of common structural factors on both the acquisition and clinical impact of these infections and the relevance of age, comorbidities, and detectable HIV viral load as associated worse prognostic factors among PLWH. Although more information is needed to better understand the biological, clinical, and epidemiological relationship between both infections, a syndemic approach to prevent SARS-CoV-2 among HIV high-risk groups and PLWH, targeting these populations for SARS-CoV-2 vaccines and protocolizing early identification of PLWH with worse COVID-19 prognosis factors, is crucial strategies to decrease the overall impact of SARS-CoV-2 /HIV co-infection.

A Comparative Analysis of In-Hospital Mortality per Disease Groups in Germany Before and During the COVID-19 Pandemic From 2016 to 2020

IMPORTANCE

Throughout the ongoing SARS-CoV-2 pandemic, it has been critical to understand not only the viral disease itself but also its implications for the overall health care system. Reports about excess mortality in this regard have mostly focused on overall death counts during specific pandemic phases.

OBJECTIVE

To investigate hospitalization rates and compare in-hospital mortality rates with absolute mortality incidences across a broad spectrum of diseases, comparing 2020 data with those of prepandemic years.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective, cross-sectional, multicentric analysis of administrative data from 5 821 757 inpatients admitted from January 1, 2016, to December 31, 2020, to 87 German Helios primary to tertiary care hospitals.

EXPOSURES

Exposure to SARS-CoV-2.

MAIN OUTCOMES AND MEASURES

Administrative data were analyzed from January 1, 2016, to March 31, 2021, as a consecutive sample for all inpatients. Disease groups were defined according to International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10; German modification) encoded main discharge diagnoses. Incidence rate ratios (IRRs) for hospital admissions and hospital mortality counts, as well as relative mortality risks (RMRs) comparing 2016-2019 with 2020 (exposure to the SARS-CoV-2 pandemic), were calculated with Poisson regression with log-link function.

RESULTS

Data were examined for 5 821 757 inpatients (mean [SD] age, 56.4 [25.3] years; 51.5% women), including 125 807 in-hospital deaths. Incidence rate ratios for hospital admissions were associated with a significant reduction for all investigated disease groups (IRR, 0.82; 95% CI, 0.79-0.86; P < .001). After adjusting for age, sex, the Elixhauser Comorbidity Index score, and SARS-CoV-2 infections, RMRs were associated with an increase in infectious diseases (RMR, 1.28; 95% CI, 1.21-1.34; P < .001), musculoskeletal diseases (RMR, 1.19; 95% CI, 1.04-1.36; P = .009), and respiratory diseases (RMR, 1.09; 95% CI, 1.05-1.14; P < .001) but not for the total cohort (RMR, 1.00; 95% CI, 0.99-1.02; P = .66). Regarding in-hospital mortality, IRR was associated with an increase within the ICD-10 chapter of respiratory diseases (IRR, 1.28; 95% CI, 1.13-1.46; P < .001) in comparing 2020 with 2016-2019, in contrast to being associated with a reduction in IRRs for the overall cohort and several other subgroups. After exclusion of patients with SARS-CoV-2 infections, IRRs were associated with a reduction in absolute in-hospital mortality for the overall cohort (IRR, 0.78; 95% CI, 0.72-0.84; P < .001) and the subgroup of respiratory diseases (IRR, 0.83; 95% CI, 0.74-0.92; P < .001).

CONCLUSIONS AND RELEVANCE

This cross-sectional study of inpatients from a multicentric German database suggests that absolute in-hospital mortality for 2020 across disease groups was not higher compared with previous years. Higher IRRs of in-hospital deaths observed in patients with respiratory diseases were likely associated with individuals with SARS-CoV-2 infections.

Mortality in Norway and Sweden during the COVID-19 pandemic

Background: Norway and Sweden are similar countries in terms of socioeconomics and health care. Norway implemented extensive COVID-19 measures, such as school closures and lockdowns, whereas Sweden did not. Aims: To compare mortality in Norway and Sweden, two similar countries with very different mitigation measures against COVID-19. Methods: Using real-world data from national registries, we compared all-cause and COVID-19-related mortality rates with 95% confidence intervals (CI) per 100,000 person-weeks and mortality rate ratios (MRR) comparing the five preceding years (2015-2019) with the pandemic year (2020) in Norway and Sweden. Results: In Norway, all-cause mortality was stable from 2015 to 2019 (mortality rate 14.6-15.1 per 100,000 person-weeks; mean mortality rate 14.9) and was lower in 2020 than from 2015 to 2019 (mortality rate 14.4; MRR 0.97; 95% CI 0.96-0.98). In Sweden, all-cause mortality was stable from 2015 to 2018 (mortality rate 17.0-17.8; mean mortality rate 17.1) and similar to that in 2020 (mortality rate 17.6), but lower in 2019 (mortality rate 16.2). Compared with the years 2015-2019, all-cause mortality in the pandemic year was 3% higher due to the lower rate in 2019 (MRR 1.03; 95% CI 1.02-1.04). Excess mortality was confined to people aged ⩾70 years in Sweden compared with previous years. The COVID-19-associated mortality rates per 100,000 person-weeks during the first wave of the pandemic were 0.3 in Norway and 2.9 in Sweden. Conclusions: All-cause mortality in 2020 decreased in Norway and increased in Sweden compared with previous years. The observed excess deaths in Sweden during the pandemic may, in part, be explained by mortality displacement due to the low all-cause mortality in the previous year.

Premature mortality attributable to COVID-19: potential years of life lost in 17 countries around the world, January-August 2020

BACKGROUND

Understanding the impact of the burden of COVID-19 is key to successfully navigating the COVID-19 pandemic. As part of a larger investigation on COVID-19 mortality impact, this study aims to estimate the Potential Years of Life Lost (PYLL) in 17 countries and territories across the world (Australia, Brazil, Cape Verde, Colombia, Cyprus, France, Georgia, Israel, Kazakhstan, Peru, Norway, England & Wales, Scotland, Slovenia, Sweden, Ukraine, and the United States [USA]).

METHODS

Age- and sex-specific COVID-19 death numbers from primary national sources were collected by an international research consortium. The study period was established based on the availability of data from the inception of the pandemic to the end of August 2020. The PYLL for each country were computed using 80 years as the maximum life expectancy.

RESULTS

As of August 2020, 442,677 (range: 18-185,083) deaths attributed to COVID-19 were recorded in 17 countries which translated to 4,210,654 (range: 112-1,554,225) PYLL. The average PYLL per death was 8.7 years, with substantial variation ranging from 2.7 years in Australia to 19.3 PYLL in Ukraine. North and South American countries as well as England & Wales, Scotland and Sweden experienced the highest PYLL per 100,000 population; whereas Australia, Slovenia and Georgia experienced the lowest. Overall, males experienced higher PYLL rate and higher PYLL per death than females. In most countries, most of the PYLL were observed for people aged over 60 or 65 years, irrespective of sex. Yet, Brazil, Cape Verde, Colombia, Israel, Peru, Scotland, Ukraine, and the USA concentrated most PYLL in younger age groups.

CONCLUSIONS

Our results highlight the role of PYLL as a tool to understand the impact of COVID-19 on demographic groups within and across countries, guiding preventive measures to protect these groups under the ongoing pandemic. Continuous monitoring of PYLL is therefore needed to better understand the burden of COVID-19 in terms of premature mortality.

High Infection Secondary Attack Rates of Severe Acute Respiratory Syndrome Coronavirus 2 in Dutch Households Revealed by Dense Sampling

BACKGROUND

Indoor environments are considered one of the main settings for transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Households in particular represent a close-contact environment with high probability of transmission between persons of different ages and roles in society.

METHODS

Households with a laboratory-confirmed SARS-CoV-2 positive case in the Netherlands (March-May 2020) were included. At least 3 home visits were performed during 4-6 weeks of follow-up, collecting naso- and oropharyngeal swabs, oral fluid, feces and blood samples from all household members for molecular and serological analyses. Symptoms were recorded from 2 weeks before the first visit through to the final visit. Infection secondary attack rates (SAR) were estimated with logistic regression. A transmission model was used to assess household transmission routes.

RESULTS

A total of 55 households with 187 household contacts were included. In 17 households no transmission took place; in 11 households all persons were infected. Estimated infection SARs were high, ranging from 35% (95% confidence interval [CI], 24%-46%) in children to 51% (95% CI, 39%-63%) in adults. Estimated transmission rates in the household were high, with reduced susceptibility of children compared with adolescents and adults (0.67; 95% CI, .40-1.1).

CONCLUSION

Estimated infection SARs were higher than reported in earlier household studies, presumably owing to our dense sampling protocol. Children were shown to be less susceptible than adults, but the estimated infection SAR in children was still high. Our results reinforce the role of households as one of the main multipliers of SARS-CoV-2 infection in the population.

The acid sphingomyelinase/ceramide system in COVID-19

Acid sphingomyelinase (ASM) cleaves sphingomyelin into the highly lipophilic ceramide, which forms large gel-like rafts/platforms in the plasma membrane. We showed that SARS-CoV-2 uses these platforms for cell entry. Lowering the amount of ceramide or ceramide blockade due to inhibitors of ASM, genetic downregulation of ASM, anti-ceramide antibodies or degradation by neutral ceramidase protected against infection with SARS-CoV-2. The addition of ceramide restored infection with SARS-CoV-2. Many clinically approved medications functionally inhibit ASM and are called FIASMAs (functional inhibitors of acid sphingomyelinase). The FIASMA fluvoxamine showed beneficial effects on COVID-19 in a randomized prospective study and a prospective open-label real-world study. Retrospective and observational studies showed favorable effects of FIASMA antidepressants including fluoxetine, and the FIASMA hydroxyzine on the course of COVID-19. The ASM/ceramide system provides a framework for a better understanding of the infection of cells by SARS-CoV-2 and the clinical, antiviral, and anti-inflammatory effects of functional inhibitors of ASM. This framework also supports the development of new drugs or the repurposing of "old" drugs against COVID-19.

Inequalities in excess premature mortality in England during the COVID-19 pandemic: a cross-sectional analysis of cumulative excess mortality by area deprivation and ethnicity

OBJECTIVES

To examine magnitude of the impact of the COVID-19 pandemic on inequalities in premature mortality in England by deprivation and ethnicity.

DESIGN

A statistical model to estimate increased mortality in population subgroups during the COVID-19 pandemic by comparing observed with expected mortality in each group based on trends over the previous 5 years.

SETTING

Information on deaths registered in England since 2015 was used, including age, sex, area of residence and cause of death. Ethnicity was obtained from Hospital Episode Statistics records linked to death data.

PARTICIPANTS

Population study of England, including all 569 824 deaths from all causes registered between 21 March 2020 and 26 February 2021.

MAIN OUTCOME MEASURES

Excess mortality in each subgroup over and above the number expected based on trends in mortality in that group over the previous 5 years.

RESULTS

The gradient in excess mortality by area deprivation was greater in the under 75s (the most deprived areas had 1.25 times as many deaths as expected, least deprived 1.14) than in all ages (most deprived had 1.24 times as many deaths as expected, least deprived 1.20). Among the black and Asian groups, all area deprivation quintiles had significantly larger excesses than white groups in the most deprived quintiles and there were no clear gradients across quintiles. Among the white group, only those in the most deprived quintile had more excess deaths than deaths directly involving COVID-19.

CONCLUSION

The COVID-19 pandemic has widened inequalities in premature mortality by area deprivation. Among those under 75, the direct and indirect effects of the pandemic on deaths have disproportionately impacted ethnic minority groups irrespective of area deprivation, and the white group the most deprived areas. Statistics limited to deaths directly involving COVID-19 understate the pandemic's impact on inequalities by area deprivation and ethnic group at younger ages.

Geographically weighted generalized Farrington algorithm for rapid outbreak detection over short data accumulation periods

The demand for rapid surveillance and early detection of local outbreaks has been growing recently. The rapid surveillance can select timely and appropriate interventions toward controlling the spread of emerging infectious diseases, such as the coronavirus disease 2019 (COVID-19). The Farrington algorithm was originally proposed by Farrington et al (1996), extended by Noufaily et al (2012), and is commonly used to estimate excess death. However, one of the major challenges in implementing this algorithm is the lack of historical information required to train it, especially for emerging diseases. Without sufficient training data the estimation/prediction accuracy of this algorithm can suffer leading to poor outbreak detection. We propose a new statistical algorithm-the geographically weighted generalized Farrington (GWGF) algorithm-by incorporating both geographically varying and geographically invariant covariates, as well as geographical information to analyze time series count data sampled from a spatially correlated process for estimating excess death. The algorithm is a type of local quasi-likelihood-based regression with geographical weights and is designed to achieve a stable detection of outbreaks even when the number of time points is small. We validate the outbreak detection performance by using extensive numerical experiments and real-data analysis in Japan during COVID-19 pandemic. We show that the GWGF algorithm succeeds in improving recall without reducing the level of precision compared with the conventional Farrington algorithm.

The burden of isolation to the individual: a comparison between isolation for COVID-19 and for other influenza-like illnesses in Japan

At present, there is scarce evidence about the burden associated with the isolation of COVID-19 patients. We aimed to assess the differences between COVID-19 and other influenza-like illnesses (ILIs) in disease burden brought by isolation. We conducted an online survey of 302 respondents who had COVID-19 or other ILIs and compared the burden of isolation due to sickness with one-to-one propensity score matching. The primary outcomes are the duration and productivity losses associated with isolation, the secondary outcome is the health-related quality of life (HRQoL) valuation on the day of the survey. Acute symptoms of outpatient COVID-19 and other ILIs lasted 17 (interquartile range (IQR) 9-32) and 7 (IQR 4-10) days, respectively. The length of isolation due to COVID-19 was 18 (IQR 10-33) days and that due to other ILIs was 7 (IQR 4-11) days, respectively. The monetary productivity loss of isolation due to COVID-19 was 1424.3 (IQR 825.6-2545.5) USD and that due to other ILIs was 606.1 (IQR 297.0-1090.9) USD, respectively. HRQoL at the time of the survey was lower in the COVID-19 group than in the 'other ILIs' group (0.89 and 0.96, P = 0.001). COVID-19 infection imposes a substantial disease burden, even in patients with non-severe disease. This burden is larger for COVID-19 than other ILIs, mainly because the required isolation period is longer.

A comparison of coronavirus disease 2019 and seasonal influenza surveillance in five European countries: France, Germany, Italy, Spain and the United Kingdom

Background

In response to the coronavirus disease (COVID‐19) outbreak that unfolded across Europe in 2020, the World Health Organisation (WHO) called for repurposing existing influenza surveillance systems to monitor COVID‐19. This analysis aimed to compare descriptively the extent to which influenza surveillance systems were adapted and enhanced and how COVID‐19 surveillance could ultimately benefit or disrupt routine influenza surveillance.

Methods

We used a previously developed framework in France, Germany, Italy, Spain and the United Kingdom to describe COVID‐19 surveillance and its impact on influenza surveillance. The framework divides surveillance systems into seven subsystems and 20 comparable outcomes of interest and uses five evaluation criteria based on WHO guidance. Information on influenza and COVID‐19 surveillance systems were collected from publicly available resources shared by European and national public health agencies.

Results

Overall, non‐medically attended, virological, primary care and mortality surveillance were adapted in most countries to monitor COVID‐19, although community, outbreak and hospital surveillance were reinforced in all countries. Data granularity improved, with more detailed demographic and medical information recorded. A shift to systematic notification for cases and deaths enhanced both geographic and population representativeness, although the sampling strategy benefited from the roll out of widespread molecular testing. Data communication was greatly enhanced, contributing to improved public awareness.

Conclusions

Well‐established influenza surveillance systems are a key component of pandemic preparedness, and their upgrade allowed European countries to respond to the COVID‐19 pandemic. However, uncertainties remain on how both influenza and COVID‐19 surveillance can be jointly and durably implemented.

Excess deaths from COVID-19 in Japan and 47 prefectures from January through June 2021

Objectives

In Japan, several studies have reported no excess all-cause deaths (the difference between the observed and expected number of deaths) during the coronavirus disease 2019 (COVID-19) pandemic in 2020. This study aimed to estimate the weekly excess deaths in Japan's 47 prefectures for 2021 until June 27.

Study design

Vital statistical data on deaths were obtained from the Ministry of Health, Labour and Welfare of Japan. For this analysis, we used data from January 2012 to June 2021.

Methods

A quasi-Poisson regression was used to estimate the expected weekly number of deaths. Excess deaths were expressed as the range of differences between the observed and expected number of all-cause deaths and the 95% upper bound of the one-sided prediction interval.

Results

Since January 2021, excess deaths were observed for the first time in the week corresponding to April 12–18 and have continued through mid-June, with the highest excess percentage occurring in the week corresponding to May 31–June 6 (excess deaths: 1431–2587; excess percentage: 5.95–10.77%). Similarly, excess deaths were observed in consecutive weeks from April to June 2021 in 18 of 47 prefectures.

Conclusions

For the first time since February 2020, when the first COVID-19 death was reported in Japan, excess deaths possibly related to COVID-19 were observed in April 2021 in Japan, during the fourth wave. This may reflect the deaths of non-infected people owing to the disruption that the pandemic has caused.

The Impact of COVID-19 on Mortality in Spain: Monitoring Excess Mortality (MoMo) and the Surveillance of Confirmed COVID-19 Deaths

Measuring mortality has been a challenge during the COVID-19 pandemic. Here, we compared the results from the Spanish daily mortality surveillance system (MoMo) of excess mortality estimates, using a time series analysis, with those obtained for the confirmed COVID-19 deaths reported to the National Epidemiological Surveillance Network (RENAVE). The excess mortality estimated at the beginning of March 2020 was much greater than what has been observed in previous years, and clustered in a very short time. The cumulated excess mortality increased with age. In the first epidemic wave, the excess mortality estimated by MoMo was 1.5 times higher than the confirmed COVID-19 deaths reported to RENAVE, but both estimates were similar in the following pandemic waves. Estimated excess mortality and confirmed COVID-19 mortality rates were geographically distributed in a very heterogeneous way. The greatest increase in mortality that has taken place in Spain in recent years was detected early by MoMo, coinciding with the spread of the COVID-19 pandemic. MoMo is able to identify risk situations for public health in a timely manner, relying on mortality in general as an indirect indicator of various important public health problems.

CM, A. BG, F. VS, A. SF, V. OQ, A. SC. Analysis of case fatality rate of SARS-CoV-2 infection in the Spanish Autonomous Communities between March and May 2020

OBJECTIVE

The Spanish health system is made up of seventeen regional health systems. Through the official reporting systems, some inconsistencies and differences in case fatality rates between Autonomous Communities (CC.AA.) have been observed. Therefore the objective of this paper is to compare COVID-19 case fatality rates across the Spanish CC.AA.

MATERIAL AND METHODS

Observational descriptive study. The COVID-19 case fatality rate (CFR) was estimated according to the official records (CFR-PCR+), the daily mortality monitory system (MoMo) record (CFR-Mo), and the seroprevalence study ENE-COVID-19 (Estudio Nacional de sero Epidemiologia Covid-19) according to sex, age group and CC.AA. between March and June 2020. The main objective is to detect whether there are any differences in CFR between Spanish Regions using two different register systems, i. e., the official register of the Ministry of Health and the MoMo.

RESULTS

Overall, the CFR-Mo was higher than the CFR-PCR+, 1.59% vs 0.98%. The differences in case fatality rate between both methods were significantly higher in Castilla La Mancha, Castilla y León, Cataluña, and Madrid. The difference between both methods was higher in persons over 74 years of age (CFR-PCR+ 7.5% vs 13.0% for the CFR-Mo) but without statistical significance. There was no correlation of the estimated prevalence of infection with CFR-PCR+, but there was with CFR-Mo (R2 = 0.33). Andalucía presented a SCFR below 1 with both methods, and Asturias had a SCFR higher than 1. Cataluña and Castilla La Mancha presented a SCFR greater than 1 in any scenario of SARS-CoV-2 infection calculated with SCFR-Mo.

CONCLUSIONS

The PCR+ case fatality rate underestimates the case fatality rate of the SARS-CoV- 2 virus pandemic. It is therefore preferable to consider the MoMo case fatality rate. Significant differences have been observed in the information and registration systems and in the severity of the pandemic between the Spanish CC.AA. Although the infection prevalence correlates with case fatality rate, other factors such as age, comorbidities, and the policies adopted to address the pandemic can explain the differences observed between CC.AA.

Impact of COVID-19 pandemic on routine immunization

The current COVID-19 global pandemic continues to impact healthcare services beyond those directly related to the management of SARS-CoV-2 transmission and disease. We reviewed the published literature to assess the pandemic impact on existing global immunization activities and how the impact may be addressed. Widespread global disruption in routine childhood immunization has impacted a majority of regions and countries, especially in the initial pandemic phases. While data indicate subsequent recovery in immunization rates, a substantial number of vulnerable people remain unvaccinated. The downstream impact may be even greater in resource-limited settings and economically poorer populations, and consequently there are growing concerns around the resurgence of vaccine-preventable diseases, particularly measles. Guidance on how to address immunization deficits are available and continue to evolve, emphasizing the importance of maintaining and restoring routine immunization and necessary mass vaccination campaigns during and after pandemics. In this, collaboration between a broad range of stakeholders (governments, industry, healthcare decision-makers and frontline healthcare professionals) and clear communication and engagement with the public can help achieve these goals.Key messagesThe COVID-19 pandemic has a substantial impact on essential immunization activities.Disruption to mass vaccination campaigns increase risk of VPD resurgence.Catch-up campaigns are necessary to limit existing shortfalls in vaccine uptake.Guidance to mitigate these effects continues to evolve.

Tracheal stenosis following mild-to-moderate COVID-19 infection without history of tracheal intubation: a case report

Laryngotracheal stenosis is a major side effect of intubation in patients with Coronavirus 2019 (COVID-19). However, no study has since reported tracheal stenosis in patients with COVID-19 without a history of tracheal intubation. The current study reports a 77-year-old male patient with the COVID-19 infection but without a history of tracheal intubation diagnosed with distal tracheal stenosis. Tracheal stenosis was successfully treated with rigid bronchoscopy. This study reported the first case of tracheal stenosis due to viral tracheitis associated with COVID-19 infection. However, further studies are required to investigate this speculation.

Early warning indicators of COVID-19 burden for a prosilient European pandemic response

BACKGROUND

The European Union has been criticized for responding to the COVID-19 pandemic in a reactive, rather than prosilient manner. For the EU bloc to be prosilient, it needs to have the right early warning indicators to allow short-term healthcare system preparedness and agile planning of the public health response.

METHOD

The association of COVID-19 disease burden, as measured by mortality (COVID-19 and all-cause), hospital and ICU occupancy, with incidence rate (IR), total positivity rate (TPR) and adjusted TPR as proposed by Vong and Kakkar, was investigated using Poisson regression analysis. This was carried out using both real-time data and time lags of up to 8 weeks to identify potential for early warning of spikes in disease burden. ECDC weekly figures for these indicators were used, and the analysis was repeated for the subset of data after Week 42  of 2020, when the EU Council introduced minimum COVID-19 testing rates.

RESULTS

TPR and IR were noted to be the most predictive of COVID-19 disease burden whilst adjusted TPR applied on weekly data was not associated. TPR behaved better at predicting all-cause mortality in both analyses. The TPR and IR were both best associated with hospital and ICU occupancy and COVID-19 mortality with a short time lag (2-3 weeks in the case of TPR with hospital occupancy and COVID-19 mortality).

CONCLUSIONS

Monitoring TPR can provide a 2-3-week warning of a spike in hospital occupancy and COVID-19 mortality. This time, if well utilized, could help health systems save countless lives by mobilising resources.

Methods for modelling excess mortality across England during the COVID-19 pandemic

Excess mortality is an important measure of the scale of the coronavirus-2019 pandemic. It includes both deaths caused directly by the pandemic, and deaths caused by the unintended consequences of containment such as delays to accessing care or postponements of healthcare provision in the population. In 2020 and 2021, in England, multiple groups have produced measures of excess mortality during the pandemic. This paper describes the data and methods used in five different approaches to estimating excess mortality and compares their estimates.

The fundamental principles of estimating excess mortality are described, as well as the key commonalities and differences between five approaches. Two of these are based on the date of registration: a quasi-Poisson model with offset and a 5-year average; and three are based on date of occurrence: a Poisson model without offset, the European monitoring of excess mortality model and a synthetic controls model. Comparisons between estimates of excess mortality are made for the period March 2020 through March 2021 and for the two waves of the pandemic that occur within that time-period.

Model estimates are strikingly similar during the first wave of the pandemic though larger differences are observed during the second wave. Models that adjusted for reduced circulation of winter infection produced higher estimates of excess compared with those that did not. Models that do not adjust for reduced circulation of winter infection captured the effect of reduced winter illness as a result of mobility restrictions during the period. None of the estimates captured mortality displacement and therefore may underestimate excess at the current time, though the extent to which this has occurred is not yet identified. Models use different approaches to address variation in data availability and stakeholder requirements of the measure. Variation between estimates reflects differences in the date of interest, population denominators and parameters in the model relating to seasonality and trend.

A rapid test recognizing mucosal SARS-CoV-2-specific antibodies distinguishes prodromal from convalescent COVID-19

The COVID-19 pandemic poses enormous challenges to global healthcare sectors. To prevent the overburden of medical systems, it is crucial to distinguish individuals approaching the most infectious early phase from those in the declining non-infectious phase. However, a large fraction of transmission events occur during pre- or asymptomatic phases. Especially in the absence of symptoms, it is difficult to distinguish prodromal from late phases of infection just by RT-PCR since both phases are characterized by low viral loads and corresponding high Ct values (>30).

We evaluated a new rapid test detecting IgG antibodies recognizing SARS-CoV-2 nucleocapsid protein using two commercial antibody assays and an in-house neutralization test before determining suitability for testing clinical swab material. Our analyses revealed the combination of the well-known RT-PCR and the new rapid antibody test using one single clinical nasopharyngeal swab specimen as a fast, cost-effective, and reliable way to discriminate prodromal from subsiding phases of COVID-19.

•

A novel rapid antibody test for SARS-CoV-2 N-specific IgG was established

•

The rapid antibody testing is fast, cost-effective, and reliable

•

N-specific IgG is detectable in swab specimens during the late phase of infection

•

Testing of swab specimens discriminates prodromal from declining phases of COVID-19

Sex-differences in COVID-19 associated excess mortality is not exceptional for the COVID-19 pandemic

Europe experienced excess mortality from February through June, 2020 due to the COVID-19 pandemic, with more COVID-19-associated deaths in males compared to females. However, a difference in excess mortality among females compared to among males may be a more general phenomenon, and should be investigated in none-COVID-19 situations as well. Based on death counts from Eurostat, separate excess mortalities were estimated for each of the sexes using the EuroMOMO model. Sex-differential excess mortality were expressed as differences in excess mortality incidence rates between the sexes. A general relation between sex-differential and overall excess mortality both during the COVID-19 pandemic and in preceding seasons were investigated. Data from 27 European countries were included, covering the seasons 2016/17 to 2019/20. In periods with increased excess mortality, excess was consistently highest among males. From February through May 2020 male excess mortality was 52.7 (95% PI: 56.29; 49.05) deaths per 100,000 person years higher than for females. Increased male excess mortality compared to female was also observed in the seasons 2016/17 to 2018/19. We found a linear relation between sex-differences in excess mortality and overall excess mortality, i.e., 40 additional deaths among males per 100 excess deaths per 100,000 population. This corresponds to an overall female/male mortality incidence ratio of 0.7. In situations with overall excess mortality, excess mortality increases more for males than females. We suggest that the sex-differences observed during the COVID-19 pandemic reflects a general sex-disparity in excess mortality.

Sex-differences in COVID-19 associated excess mortality is not exceptional for the COVID-19 pandemic

Europe experienced excess mortality from February through June, 2020 due to the COVID-19 pandemic, with more COVID-19-associated deaths in males compared to females. However, a difference in excess mortality among females compared to among males may be a more general phenomenon, and should be investigated in none-COVID-19 situations as well. Based on death counts from Eurostat, separate excess mortalities were estimated for each of the sexes using the EuroMOMO model. Sex-differential excess mortality were expressed as differences in excess mortality incidence rates between the sexes. A general relation between sex-differential and overall excess mortality both during the COVID-19 pandemic and in preceding seasons were investigated. Data from 27 European countries were included, covering the seasons 2016/17 to 2019/20. In periods with increased excess mortality, excess was consistently highest among males. From February through May 2020 male excess mortality was 52.7 (95% PI: 56.29; 49.05) deaths per 100,000 person years higher than for females. Increased male excess mortality compared to female was also observed in the seasons 2016/17 to 2018/19. We found a linear relation between sex-differences in excess mortality and overall excess mortality, i.e., 40 additional deaths among males per 100 excess deaths per 100,000 population. This corresponds to an overall female/male mortality incidence ratio of 0.7. In situations with overall excess mortality, excess mortality increases more for males than females. We suggest that the sex-differences observed during the COVID-19 pandemic reflects a general sex-disparity in excess mortality.

Epidemiological findings on interventional cardiology procedures during the COVID-19 pandemic: A multi-center study

BACKGROUND

The rates of in-hospital mortality following percutaneous interventional procedures (PIP) during the COVID-19 pandemic period compared to the non-pandemic period has not been reported so far.

METHODS

We retrospectively enrolled all consecutive patients admitted for PIP across five centers from February 2020 to May 2020.

RESULTS

A total of 4092 PIP were performed during the reference periods. The total number of procedures dropped from 2380 to 1712 (28.0% reduction). Overall in-hospital mortality increased from 1.1% in 2019, to 2.6% in 2020 (63% relative increase).

CONCLUSION

During the COVID-19 pandemic, in-hospital all-cause mortality significantly increased in patients admitted for cardiological PIP.

COVID-19 Case Age Distribution: Correction for Differential Testing by Age

BACKGROUND

Despite expected initial universal susceptibility to a novel pandemic pathogen like SARS-CoV-2, the pandemic has been characterized by higher observed incidence in older persons and lower incidence in children and adolescents.

OBJECTIVE

To determine whether differential testing by age group explains observed variation in incidence.

DESIGN

Population-based cohort study.

SETTING

Ontario, Canada.

PARTICIPANTS

Persons diagnosed with SARS-CoV-2 and those tested for SARS-CoV-2.

MEASUREMENTS

Test volumes from the Ontario Laboratories Information System, number of laboratory-confirmed SARS-CoV-2 cases from the Integrated Public Health Information System, and population figures from Statistics Canada. Demographic and temporal patterns in incidence, testing rates, and test positivity were explored using negative binomial regression models and standardization. Sources of variation in standardized ratios were identified and test-adjusted standardized infection ratios (SIRs) were estimated by metaregression.

RESULTS

Observed disease incidence and testing rates were highest in the oldest age group and markedly lower in those younger than 20 years; no differences in incidence were seen by sex. After adjustment for testing frequency, SIRs were lowest in children and in adults aged 70 years or older and markedly higher in adolescents and in males aged 20 to 49 years compared with the overall population. Test-adjusted SIRs were highly correlated with standardized positivity ratios (Pearson correlation coefficient, 0.87 [95% CI, 0.68 to 0.95]; P < 0.001) and provided a case identification fraction similar to that estimated with serologic testing (26.7% vs. 17.2%).

LIMITATIONS

The novel methodology requires external validation. Case and testing data were not linkable at the individual level.

CONCLUSION

Adjustment for testing frequency provides a different picture of SARS-CoV-2 infection risk by age, suggesting that younger males are an underrecognized group at high risk for SARS-CoV-2 infection.

PRIMARY FUNDING SOURCE

Canadian Institutes of Health Research.

Excess Mortality Among Patients Hospitalized During the COVID-19 Pandemic

BACKGROUND

The extent to which the COVID-19 pandemic has affected outcomes for patients with unplanned hospitalizations is unclear.

OBJECTIVE

To examine changes in in-hospital mortality for patients without COVID-19 during the first 10 months of the pandemic (March 4, 2020 to December 31, 2020).

DESIGN, SETTING, AND PARTICIPANTS

Observational study of adults with unplanned hospitalizations at 51 hospitals across 6 Western states.

EXPOSURES

Unplanned hospitalizations occurring during the spring COVID-19 surge (March 4 to May 13, 2020; Period 1), an intervening period (May 14 to October 19, 2020; Period 2), and the fall COVID-19 surge (October 20 to December 31, 2020; Period 3) were compared with a pre-COVID-19 baseline period from January 1, 2019, to March 3, 2020.

MAIN OUTCOMES AND MEASURES

We examined daily hospital admissions and in-hospital mortality overall and in 30 conditions.

RESULTS

Unplanned hospitalizations declined steeply during Periods 1 and 3 (by 47.5% and 25% compared with baseline, respectively). Although volumes declined, adjusted in-hospital mortality rose from 2.9% in the pre-pandemic period to 3.5% in Period 1 (20.7% relative increase), returning to baseline in Period 2, and rose again to 3.4% in Period 3. Elevated mortality was seen for nearly all conditions studied during the pandemic surge periods.

CONCLUSION

Pandemic COVID-19 surges were associated with higher rates of in-hospital mortality among patients without COVID-19, suggesting disruptions in care patterns for patients with many common acute and chronic illnesses.

Excess Mortality During the COVID-19 Pandemic in Guatemala

Objectives. To describe excess mortality during the COVID-19 pandemic in Guatemala during 2020 by week, age, sex, and place of death. Methods. We used mortality data from 2015 to 2020, gathered through the vital registration system of Guatemala. We calculated weekly mortality rates, overall and stratified by age, sex, and place of death. We fitted a generalized additive model to calculate excess deaths, adjusting for seasonality and secular trends and compared excess deaths to the official COVID-19 mortality count. Results. We found an initial decline of 26% in mortality rates during the first weeks of the pandemic in 2020, compared with 2015 to 2019. These declines were sustained through October 2020 for the population younger than 20 years and for deaths in public spaces and returned to normal from July onward in the population aged 20 to 39 years. We found a peak of 73% excess mortality in mid-July, especially in the population aged 40 years or older. We estimated a total of 8036 excess deaths (95% confidence interval = 7935, 8137) in 2020, 46% higher than the official COVID-19 mortality count. Conclusions. The extent of this health crisis is underestimated when COVID-19 confirmed death counts are used. (Am J Public Health. 2021;111(10): 1839-1846. https://doi.org/10.2105/AJPH.2021.306452).

Estimation of all-cause excess mortality by age-specific mortality patterns for countries with incomplete vital statistics: a population-based study of the case of Peru during the first wave of the COVID-19 pandemic

BACKGROUND

All-cause excess mortality is a comprehensive measure of the combined direct and indirect effects of COVID-19 on mortality. Estimates are usually derived from Civil Registration and Vital Statistics (CRVS) systems, but these do not include non-registered deaths, which may be affected by changes in vital registration coverage over time.

METHODS

Our analytical framework and empirical strategy account for registered mortality and under-registration. This provides a better estimate of the actual mortality impact of the first wave of the COVID-19 pandemic in Peru. We use population and crude mortality rate projections from Peru's National Institute of Statistics and Information (INEI, in Spanish), individual-level registered COVID-19 deaths from the Ministry of Health (MoH), and individual-level registered deaths by region and age since 2017 from the National Electronic Deaths Register (SINADEF, in Spanish).We develop a novel framework combining different estimates and using quasi-Poisson models to estimate total excess mortality across regions and age groups. Also, we use logistic mixed-effects models to estimate the coverage of the new SINADEF system.

FINDINGS

We estimate that registered mortality underestimates national mortality by 37•1% (95% CI 23% - 48•5%) across 26 regions and nine age groups. We estimate total all-cause excess mortality during the period of analysis at 173,099 (95% CI 153,669 - 187,488) of which 108,943 (95% CI 96,507 - 118,261) were captured by the vital registration system. Deaths at age 60 and over accounted for 74•1% (95% CI 73•9% - 74•7%) of total excess deaths, and there were fewer deaths than expected in younger age groups. Lima region, on the Pacific coast and including the national capital, accounts for the highest share of excess deaths, 87,781 (95% CI 82,294 - 92,504), while in the opposite side regions of Apurimac and Huancavelica account for less than 300 excess deaths.

INTERPRETATION

Estimating excess mortality in low- and middle-income countries (LMICs) such as Peru must take under-registration of mortality into account. Combining demographic trends with data from administrative registries reduces uncertainty and measurement errors. In countries like Peru, this is likely to produce significantly higher estimates of excess mortality than studies that do not take these effects into account.

FUNDING

None.

Outbreaks of COVID-19 in Nursing Homes: A Cross-Sectional Survey of 74 Nursing Homes in a French Area

In this multi-centric cross-sectional survey conducted in nursing homes of the French Alps, from 1 March to 31 May 2020, we analyze the relationship between the occurrence of an outbreak of COVID 19 among residents and staff members. Out of 225 eligible nursing homes, 74 (32.8%) completed the survey. Among 5891 residents, the incidence of confirmed or probable COVID-19 was 8.2% (95CI, 7.5% to 8.9%), and 22 (29.7%) facilities had an outbreak with at least 3 cases. Among the 4652 staff members, the incidence of confirmed or probable COVID-19 was 6.3% (95CI, 5.6% to 7.1%). A strong positive correlation existed between residents and staff members for both numbers of cases (r² = 0.77, p < 0.001) and the incidence (r² = 0.76, p < 0.001). In univariate analyses, cases among the staff were the only factor associated with the occurrence of an outbreak among residents (OR = 11.2 (95CI, 2.25 to 53.6)). In bivariate analysis, this relationship was not influenced by any nursing home characteristics, nor the action they implemented to mitigate the COVID-19 crisis. Staff members were, therefore, likely to be a source of contamination and spread of COVID-19 among nursing home residents during the first wave of the pandemic.

Counting the Dead: COVID-19 and Mortality in Quebec and British Columbia During the First Wave

The first wave of the COVID-19 pandemic has led to excess mortality across the globe, and Canada has been no exception. Nonetheless, the pandemic experience has been very different across provinces, and the objective of this paper is to investigate these differences focusing on two extreme cases. We contrast the mortality experience of British Columbia with that of Québec to understand how large differences in mortality during the first wave of the pandemic emerged across these two provinces. We find that most of the differences can be found in excess mortality in institutions (nursing homes) and that travel restrictions, differences in how deaths are recorded, differences in the seasonality of the flu, or differences in how the pandemic spread across different economic segments of the population are unlikely explain these large differences. We document that the reported death toll from COVID-19 is about 30% larger than excess mortality in Quebec due to lower mortality from other causes of death, in particular malignant tumors, heart disease, and respiratory problems. We do not find evidence of an income gradient (measured by postal code level income) in relative excess death for the first wave.

Infection surveillance measures during the COVID-19 pandemic in Germany

Introduction: To address the question as to which infection surveillance measures are used during the ongoing COVID-19 pandemic in Germany and how they differ from pre-existing approaches. Methods: In accordance with the systematic approach of a scoping review, a literature search was conducted in national and international medical literature databases using a search string. The search in the databases was limited to the period from 01.01.2000 to 15.11.2020 and has been subsequently completed by hand search until 08.03.2021. A hand search, even beyond 15.11.2020, seemed necessary and reasonable, since due to the dynamics of the ongoing COVID-19 pandemic, a large number of articles and regulations are being published very quickly at short notice. Results: The literature search resulted in the following number of hits in the databases listed below: PubMed: 165 articlesCochrane: 1 review and 35 studiesWeb of Science: 217 articlesRobert Koch Institute: 49 articles Thus, a total of 467 hits were identified, with a total of 124 hits being duplicates. From these, 138 articles were considered relevant to the COVID-19 infection surveillance situation in Germany based on established criteria. After reading the full texts, 92 articles and websites were ultimately included in the scoping review. Discussion: Many of the lessons learned from previous outbreaks seem to have been implemented in the infection surveillance measures during the ongoing COVID-19 pandemic in Germany. Most of the changes compared with previous measures were based on technological streamlining of existing procedures and changes and more inclusion of the population in different infection surveillance measures.

Estimating under-recognized COVID-19 deaths, United States, march 2020-may 2021 using an excess mortality modelling approach

BACKGROUND

In the United States, Coronavirus Disease 2019 (COVID-19) deaths are captured through the National Notifiable Disease Surveillance System and death certificates reported to the National Vital Statistics System (NVSS). However, not all COVID-19 deaths are recognized and reported because of limitations in testing, exacerbation of chronic health conditions that are listed as the cause of death, or delays in reporting. Estimating deaths may provide a more comprehensive understanding of total COVID-19-attributable deaths.

METHODS

We estimated COVID-19 unrecognized attributable deaths, from March 2020-April 2021, using all-cause deaths reported to NVSS by week and six age groups (0-17, 18-49, 50-64, 65-74, 75-84, and ≥85 years) for 50 states, New York City, and the District of Columbia using a linear time series regression model. Reported COVID-19 deaths were subtracted from all-cause deaths before applying the model. Weekly expected deaths, assuming no SARS-CoV-2 circulation and predicted all-cause deaths using SARS-CoV-2 weekly percent positive as a covariate were modelled by age group and including state as a random intercept. COVID-19-attributable unrecognized deaths were calculated for each state and age group by subtracting the expected all-cause deaths from the predicted deaths.

FINDINGS

We estimated that 766,611 deaths attributable to COVID-19 occurred in the United States from March 8, 2020-May 29, 2021. Of these, 184,477 (24%) deaths were not documented on death certificates. Eighty-two percent of unrecognized deaths were among persons aged ≥65 years; the proportion of unrecognized deaths were 0•24-0•31 times lower among those 0-17 years relative to all other age groups. More COVID-19-attributable deaths were not captured during the early months of the pandemic (March-May 2020) and during increases in SARS-CoV-2 activity (July 2020, November 2020-February 2021).

INTERPRETATION

Estimating COVID-19-attributable unrecognized deaths provides a better understanding of the COVID-19 mortality burden and may better quantify the severity of the COVID-19 pandemic.

FUNDING

None.

Inequalities in the decline and recovery of pathological cancer diagnoses during the first six months of the COVID-19 pandemic: a population-based study

BACKGROUND

The restructuring of healthcare systems to cope with the demands of the COVID-19 pandemic has led to a reduction in clinical services such as cancer screening and diagnostics.

METHODS

Data from the four Northern Ireland pathology laboratories were used to assess trends in pathological cancer diagnoses from 1st March to 12th September 2020 overall and by cancer site, sex and age. These trends were compared to the same timeframe from 2017 to 2019.

RESULTS

Between 1st March and 12th September 2020, there was a 23% reduction in cancer diagnoses compared to the same time period in the preceding 3 years. Although some recovery occurred in August and September 2020, this revealed inequalities across certain patient groups. Pathological diagnoses of lung, prostate and gynaecological malignancies remained well below pre-pandemic levels. Males and younger/middle-aged adults, particularly the 50-59-year-old patient group, also lagged behind other population demographic groups in terms of returning to expected numbers of pathological cancer diagnoses.

CONCLUSIONS

There is a critical need to protect cancer diagnostic services in the ongoing pandemic to facilitate timely investigation of potential cancer cases. Targeted public health campaigns may be needed to reduce emerging inequalities in cancer diagnoses as the COVID-19 pandemic continues.

To Get Vaccinated, or Not to Get Vaccinated, That Is the Question: Illness Representations about COVID-19 and Perceptions about COVID-19 Vaccination as Predictors of COVID-19 Vaccination Willingness among Young Adults in The Netherlands

Mass vaccination is considered necessary to reduce the spread of COVID-19; however, vaccination willingness was found to be especially low among young adults. Therefore, based on the extended Common Sense Model, the unique effects and the interplay of illness representations about COVID-19 and perceptions about COVID-19 vaccination in explaining COVID-19 vaccination willingness was investigated using a cross-sectional design. An online survey measuring the relevant variables was filled in by 584 participants (69.9% female) between 18 and 34 years. Correlation analyses showed that all illness representation dimensions except from timeline and both dimensions of vaccination perceptions were related to vaccination willingness. The mediation analysis revealed that less personal control, more prevention control, more concerns about COVID-19 as well as more perceived necessity of and fewer concerns about the vaccination were directly related to higher vaccination willingness. Additionally, prevention control was indirectly related to higher vaccination willingness through stronger perceptions of necessity of the vaccination. The extended Common Sense Model proved to be useful in the context of illness prevention. Campaigns to improve vaccination rates should aim at increasing the perception that COVID-19 is preventable through vaccination and the personal need of the vaccination as well as at decreasing concerns about the vaccination.

Quantifying and communicating the burden of COVID-19

Background

An essential aspect of preventing further COVID-19 outbreaks and to learn for future pandemics is the evaluation of different political strategies, which aim at reducing transmission of and mortality due to COVID-19. One important aspect in this context is the comparison of attributable mortality.

Methods

We give a comprehensive overview of six epidemiological measures that are used to quantify COVID-19 attributable mortality (p-score, standardized mortality ratio, absolute number of excess deaths, per capita rate, z-score and the population attributable fraction).

Results

By defining the six measures based on observed and expected deaths, we explain their relationship. Moreover, three publicly available data examples serve to illustrate the interpretational strengths and weaknesses of the various measures.

Finally, we give recommendation which measures are suitable for an evaluation of public health strategies against COVID-19. The R code to reproduce the results is available as online supplementary material.

Conclusion

The number of excess deaths should be always reported together with the population attributable fraction, the p-score or the standardized mortality ratio instead of a per capita rate. For a complete picture of COVID-19 attributable mortality, quantifying and communicating its relative burden also to a lay audience is of major importance.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12874-021-01349-z.

Impact of the COVID-19 pandemic on voluntary terminations of pregnancy in an Italian metropolitan area

PURPOSE

The COVID-19 pandemic and national lockdown from 9 March to 4 May 2020 changed social, familial, and sexual relationships, as well as how citizens interact with the health services. How these profound changes have affected sexuality, contraception and voluntary terminations of pregnancy is still largely undescribed. The main objective of this study was therefore to find out whether the COVID-19 pandemic and ensuing lockdown affected the demand for legal abortion.

MATERIAL AND METHODS

The study period was divided into three phases: the pre-pandemic (January and February 2020); lockdown (March and April); and post-lockdown (May and June). The number and characteristics of women requesting pregnancy termination each month during that time were compared with the stats for the same months in the preceding three years (2017-2019).

RESULTS

Immediately after national lockdown, the number of voluntary abortions markedly declined (-40.45%). The effect was more evident in women below 20 years of age (-66.67%), employed versus unemployed women (-42.71% vs. -21.05), and non-Italian versus Italian citizens (-53.01 vs. -32.85). No difference was found in the mean time from request to execution of the procedure, or in the type of the procedure used.

CONCLUSION(S)

National lockdown reduced the number of unwanted pregnancies, especially in younger women. The Italian health service's response to the demand appears to have been unaffected by the pandemic. However, as the demand for abortion is still high, probably due to unplanned pregnancies among cohabitants within a stable relationship, contraception guidance should be improved among women traditionally deemed low-risk in terms of sexual behaviour.

Excess mortality due to Covid-19? A comparison of total mortality in 2020 with total mortality in 2016 to 2019 in Germany, Sweden and Spain

INTRODUCTION

Excess mortality is a suitable indicator of health consequences of COVID-19 because death from any cause is clearly defined contrary to death from Covid-19. We compared the overall mortality in 2020 with the overall mortality in 2016 to 2019 in Germany, Sweden and Spain. Contrary to other studies, we also took the demographic development between 2016 and 2020 and increasing life expectancy into account.

METHODS

Using death and population figures from the EUROSTAT database, we estimated weekly and cumulative Standardized Mortality Ratios (SMR) with 95% confidence intervals (CI) for the year 2020. We applied two approaches to calculate weekly numbers of death expected in 2020: first, we used mean weekly mortality rates from 2016 to 2019 as expected mortality rates for 2020, and, second, to consider increasing life expectancy, we calculated expected mortality rates for 2020 by extrapolation from mortality rates from 2016 to 2019.

RESULTS

In the first approach, the cumulative SMRs show that in Germany and Sweden there was no or little excess mortality in 2020 (SMR = 0.976 (95% CI: 0.974-0.978), and 1.030 (1.023-1.036), respectively), while in Spain the excess mortality was 14.8% (1.148 (1.144-1.151)). In the second approach, the corresponding SMRs for Germany and Sweden increased to 1.009 (1.007-1.011) and 1.083 (1.076-1.090), respectively, whereas results for Spain were virtually unchanged.

CONCLUSION

In 2020, there was barely any excess mortality in Germany for both approaches. In Sweden, excess mortality was 3% without, and 8% with consideration of increasing life expectancy.

Intensive care unit professionals during the COVID-19 pandemic in Spain: social and work-related variables, COVID-19 symptoms, worries, and generalized anxiety levels

BACKGROUND

The severe acute respiratory syndrome coronavirus 2 outbreak has been identified as a pandemic and global health emergency. It presents as a severe acute respiratory disease. The rapid dissemination of the disease created challenges for healthcare systems and forced healthcare workers (HCWs) to deal with many clinical and nonclinical stresses. The aim of our research is to describe work conditions, symptoms experienced by HCWs, worries about contagion, and generalized anxiety symptoms and compare those findings across regions in Spain.

METHODS

This cross-sectional study was conducted using an online survey. Critical care units throughout Spain were included. The sample comprised HCWs working in intensive care units from March to May 2020. We assessed work variables, physical symptoms, worries about contagion, and anxiety (generalized anxiety disorder-7 questionnaire).

RESULTS

The final sample comprised 448 surveys. Among the respondents, 86.9% (n=389) were nursing professionals, and 84.8% (n=380) were women. All participants cared for coronavirus disease 2019 (COVID-19) patients during the study period. Workload during the pandemic in Madrid was judged to be higher than in other regions (P<0.01). The availability of personal protective equipment was found to be higher in Cataluña. The most frequently experienced symptom was headaches (78.1%). Worries about self-infection and the possibility of infecting others received mean scores of 3.11 and 3.75, respectively. Mean scores for generalized anxiety levels were 11.02, with 58.7% of the professionals presenting with generalized anxiety syndrome during the assessment.

CONCLUSIONS

In this study, we found high levels of anxiety among HCWs caring directly for COVID-19 patients, which could produce long-term psychological alterations that still need to be assessed.

Clinical case of Guillain-Barré syndrome associated with COVID-19

Background: The coronavirus infection caused by SARS-Cov-2 is characterized by a damage to many organs and systems of the human body. To date, convincing information has been obtained about the involvement of various parts of the nervous system in the pathological process in patients with COVID-19. Among the most frequently described impairments, there are disorders of smell and taste, common disorders of the central nervous system, characterized by general cerebral symptoms, such as headache, asthenization, psychopathological disorders. One of the rare and severe forms of the peripheral nervous system damage in COVID-19 is Guillain-Barre syndrome (GBS), characterized by acute post-infectious inflammatory polyneuropathy with an autoimmune etiology. Clinical case description. We present a clinical case of GBS associated with COVID-19. The disease debuted as a peripheral tetraparesis with a progredient course of up to 21 days. Systemic administration of immunoglobulin stopped the disease progression. The association of GBS with COVID-19 was clarified a month after the disease onset, when bilateral polysegmental pneumonia was diagnosed, and a high level of IgG to the S-protein of SARS-CoV-2 was found, 3 times higher than the level of IgM, which indicated the duration of the disease was not less than three weeks. Conclusion: The GBS development upon infection with SARS-CoV-2 may precede the lung damage. The debut of GBS during the COVID-19 pandemic requires the exclusion of the SARS-CoV-2 etiological role in each case.

Excess all-cause mortality and COVID-19-related mortality: a temporal analysis in 22 countries, from January until August 2020

Background

This study aimed to investigate overall and sex-specific excess all-cause mortality since the inception of the COVID-19 pandemic until August 2020 among 22 countries.

Methods

Countries reported weekly or monthly all-cause mortality from January 2015 until the end of June or August 2020. Weekly or monthly COVID-19 deaths were reported for 2020. Excess mortality for 2020 was calculated by comparing weekly or monthly 2020 mortality (observed deaths) against a baseline mortality obtained from 2015–2019 data for the same week or month using two methods: (i) difference in observed mortality rates between 2020 and the 2015–2019 average and (ii) difference between observed and expected 2020 deaths.

Results

Brazil, France, Italy, Spain, Sweden, the UK (England, Wales, Northern Ireland and Scotland) and the USA demonstrated excess all-cause mortality, whereas Australia, Denmark and Georgia experienced a decrease in all-cause mortality. Israel, Ukraine and Ireland demonstrated sex-specific changes in all-cause mortality.

Conclusions

All-cause mortality up to August 2020 was higher than in previous years in some, but not all, participating countries. Geographical location and seasonality of each country, as well as the prompt application of high-stringency control measures, may explain the observed variability in mortality changes.

Excess Mortality in Italy During the COVID-19 Pandemic: Assessing the Differences Between the First and the Second Wave, Year 2020

COVID-19 dramatically influenced mortality worldwide, in Italy as well, the first European country to experience the Sars-Cov2 epidemic. Many countries reported a two-wave pattern of COVID-19 deaths; however, studies comparing the two waves are limited. The objective of the study was to compare all-cause excess mortality between the two waves that occurred during the year 2020 using nationwide data. All-cause excess mortalities were estimated using negative binomial models with time modeled by quadratic splines. The models were also applied to estimate all-cause excess deaths “not directly attributable to COVD-19”, i.e., without a previous COVID-19 diagnosis. During the first wave (25th February−31st May), we estimated 52,437 excess deaths (95% CI: 49,213–55,863) and 50,979 (95% CI: 50,333–51,425) during the second phase (10th October−31st December), corresponding to percentage 34.8% (95% CI: 33.8%–35.8%) in the second wave and 31.0% (95%CI: 27.2%–35.4%) in the first. During both waves, all-cause excess deaths percentages were higher in northern regions (59.1% during the first and 42.2% in the second wave), with a significant increase in the rest of Italy (from 6.7% to 27.1%) during the second wave. Males and those aged 80 or over were the most hit groups with an increase in both during the second wave. Excess deaths not directly attributable to COVID-19 decreased during the second phase with respect to the first phase, from 10.8% (95% CI: 9.5%–12.4%) to 7.7% (95% CI: 7.5%–7.9%), respectively. The percentage increase in excess deaths from all causes suggests in Italy a different impact of the SARS-CoV-2 virus during the second wave in 2020. The decrease in excess deaths not directly attributable to COVID-19 may indicate an improvement in the preparedness of the Italian health care services during this second wave, in the detection of COVID-19 diagnoses and/or clinical practice toward the other severe diseases.

Indoor Environmental Quality and Consumption Patterns before and during the COVID-19 Lockdown in Twelve Social Dwellings in Madrid, Spain

This article analyses the situation that prevailed in 12 dwellings located on the outskirts of Madrid during Spain’s state of emergency. How did 24/7 occupation affect the quality of indoor air and power consumption patterns? The mixed method used (surveys and instrumental monitoring) pragmatically detected the variation in consumption, comfort and indoor air quality patterns before and during the COVID-19 pandemic. The characteristics initially in place and household predisposition had a conclusive effect on such variations. The starting conditions, including household composition, habits and the way daily activities were performed, differed widely, logically affecting power consumption: 8/12 case studies increase occupancy density by more than 25 percent; 11/12 improve thermal comfort; 10/12 improve air quality but not necessarily translate in a sufficient ventilation practices; air quality was lower in the bedrooms on the whole; only 4/12 case studies use the potential of passive measures; only one household adopted energy savings strategies; 10/12 case studies increase electric power consumption but none of the dwellings was fitted with a renewable power generation system. The conclusion drawn is that, despite starting conditions differing widely, household composition, habits (including performance of daily activities performance) and power consumption also played an active role in the end result. This approach allowed to integrate qualitative and quantitative findings on indoor environmental quality (IEQ), energy use and households’ behavior. The objective data on the energy situation of the case studies not only is useful for the study, but also for potential enrollment in energy rehabilitation programs, such as the European Regional Development Fund (ERDF).