Effectiveness of personal protective measures in reducing pandemic influenza transmission: A systematic review and meta-analysis

Factors affecting hand hygiene practice during the COVID-19 pandemic in the Zimbabwean population: a qualitative study

BACKGROUND

Practicing hand hygiene is recommended as one of the key preventive measures for reducing the transmission of COVID-19 and other infectious agents. However, it is often not practiced frequently enough or correctly by the public. We aimed to identify barriers to and facilitators of hand hygiene in the Zimbabwean population during the COVID-19 pandemic.

METHODS

A qualitative study was conducted with a purposive sample of health workers, village health workers, church leaders, traditional healers, teachers, youth leaders and the general population selected from ten districts across the country from September to October 2022. Semistructured interviews were conducted with 3 key informant interviews per site. In addition, one homogenous focus group discussion was also conducted per site using a focus group discussion guide. The data were recorded on audiotapes, transcribed verbatim, and translated into English. All the analyses were performed manually using thematic analysis.

RESULTS

Two themes were identified as facilitators of hand hygiene. These include individual factors (knowledge of hand hygiene practices and how they are performed) and access-related factors (access to hand washing infrastructure, soap, and sanitizers). Among the barriers to hand hygiene, four themes were identified: individual factors (knowledge gaps in proper hand washing, lack of conviction about hand hygiene, and habitual behaviour), access-related factors (lack of access to hand washing infrastructure, soap, and sanitizers), safety concerns (concern about the side effects of sanitizers), and sociocultural and religious factors (social customs, cultural beliefs, values, and religious practices).

CONCLUSION

During public health emergencies, there is a need for people to access uninterrupted, on-premises water supplies to promote compliance with hand hygiene. The provision of clean water and hand washing facilities is critical for vulnerable communities to afford them the opportunity to improve quality of life and facilitate resilience in the event of future pandemics. Community engagement is important for identifying vulnerability factors to provide appropriate mitigatory measures.

Preparing schools for future pandemics: Insights on water, sanitation and hygiene solutions from the Brazilian school reopening policies

Post-COVID-19, schools urgently need to enhance infection control and prevention (IPC) measures, including water, sanitation, and hygiene (WASH), to prepare for future outbreaks and pandemics. Particularly in Brazil, that is of particular concern, as students are still recovering from the 20th longest school closure in the world. Hence, the current study had two goals: (i) to describe WASH solutions outlined in policies released at the federal, state, and capital city levels in Brazil during the COVID-19 pandemic for the safe reopening of schools and (ii) to discuss their potential to enhance school's capacity to remain operational during a new pandemic or outbreak. With a qualitative exploratory approach, we performed content analysis to discuss the direction (what, where, how and for whom?) of 66 public policies by integrating four frameworks. Solutions were discussed in the light of the principles of human rights and the human rights to water and sanitation, international guidelines for WASH and IPC in schools and the Sphere minimum standards for humanitarian aid. One hundred and fifty-nine solutions, spanning five thematic areas and five population groups, including software and hardware interventions, were compiled for potential use in Brazil and beyond. While suggested solutions have the potential to provide a cleaner and safer learning environment, it is essential to exercise caution when implementing these measures and adapt them to the specific circumstances of each school.

Estimating spatially disaggregated probability of severe COVID-19 and the impact of handwashing interventions: The case of Zimbabwe

INTRODUCTION

The severity of COVID-19 disease varies substantially between individuals, with some infections being asymptomatic while others are fatal. Several risk factors have been identified that affect the progression of SARS-CoV-2 to severe COVID-19. They include age, smoking and presence of underlying comorbidities such as respiratory illness, HIV, anemia and obesity. Given that respiratory illness is one such comorbidity and is affected by hand hygiene, it is plausible that improving access to handwashing could lower the risk of severe COVID-19 among a population. In this paper, we estimate the potential impact of improved access to handwashing on the risk of respiratory illness and its knock-on impact on the risk of developing severe COVID-19 disease across Zimbabwe.

METHODS

Spatial generalized additive models were applied to cluster level data from the 2015 Demographic and Health Survey. These models were used to generate continuous (1km resolution) estimates of risk factors for severe COVID-19, including prevalence of major comorbidities (respiratory illness, HIV without viral load suppression, anemia and obesity) and prevalence of smoking, which were aggregated to district level alongside estimates of the proportion of the population under 50 from Worldpop data. The risk of severe COVID-19 was then calculated for each district using published estimates of the relationship between comorbidities, smoking and age (under 50) and severe COVID-19. Two scenarios were then simulated to see how changing access to handwashing facilities could have knock on implications for the prevalence of severe COVID-19 in the population.

RESULTS

This modeling conducted in this study shows that (1) current risk of severe disease is heterogeneous across the country, due to differences in individual characteristics and household conditions and (2) that if the quantifiable estimates on the importance of handwashing for transmission are sound, then improvements in handwashing access could lead to reductions in the risk of severe COVID-19 of up to 16% from the estimated current levels across all districts.

CONCLUSIONS

Taken alongside the likely impact on transmission of SARS-CoV-2 itself, as well as countless other pathogens, this result adds further support for the expansion of access to handwashing across the country. It also highlights the spatial differences in risk of severe COVID-19, and thus the opportunity for better planning to focus limited resources in high-risk areas in order to potentially reduce the number of severe cases.

Trajectories of health behaviors during the COVID-19 pandemic: a longitudinal analysis of handwashing, mask wearing, social contact limitations, and physical distancing

AIM

This study aimed to investigate the associations between health behavior adherence and psychological factors during the COVID-19 pandemic, with a particular focus on identifying trajectories of handwashing, mask wearing, social contact limitations, and physical distancing.

METHODS

We employed a multi-trajectory group-based approach to analyze data from 6026 Belgian residents, including 60% women, with an average age of 52.65. Data were collected over six waves spanning from April 2021 to December 2021.

RESULTS

Participants were categorized into trajectory groups based on persistently low (11.9%), moderate-low (20.9%), moderate-high (39.1%), and high (28.1%) levels of adherence to the specified health behaviors. Our findings indicate a declining trend in health behavior adherence over the study period. Additionally, we observed that females, older individuals, and those with prior COVID-19 infection had a higher likelihood of belonging to trajectory groups characterized by the highest levels of health behavior adherence. Similarly, individuals with positive vaccination intentions, a heightened perception of consequences, and increased health anxiety demonstrated greater adherence to health behaviors over time. Furthermore, our investigation into the relationship between health behaviors and mental health revealed that participants in trajectory groups with higher levels of adherence to social contact limitations and physical distancing reported increased feelings of loneliness and decreased life satisfaction.

CONCLUSIONS

The COVID-19 pandemic has reshaped our lives, and while vaccines have marked progress, maintaining health behaviors is crucial for virus prevention. To address potential mental health challenges from sanitary measures, policies and communication should promote health behaviors while acknowledging their psychological impact.

Evaluating the effectiveness of applying aroma seals to masks in reducing stress caused by wearing masks: A randomized controlled trial

During the COVID-19 pandemic, face masks on patients and healthy people have been recommended to prevent airborne transmission of the virus. This increased the number of people who felt stressed while wearing masks. In this study, we investigated the stress-relieving effects of attaching aroma seals to masks. A double-blind, randomized controlled trial was conducted involving 62 university students. The participants were randomly assigned to two groups and instructed to apply a seal to their masks once a day throughout the study period. The primary measure used was the Depression, Anxiety, and Stress Scale-21 (DASS-21), while the secondary measures included the assessment of breathlessness associated with mask-wearing and the World Health Organization Five Well-Being Index (WHO-5). The intervention group, referred to as the aroma-seal use group, utilized aroma seals infused with orange-lime essential oil with the expectation of experiencing the healing effects of citrus. On the other hand, the non-intervention group, known as the placebo-seal use group, utilized identical seals without any aroma. Results indicated that the aroma-seal use group exhibited significant improvements in both the total DASS-21 scores and depression scores compared to their baseline values by the second week of the intervention. Furthermore, the aroma-seal use group demonstrated a reduced occurrence of breathlessness while wearing masks compared to the placebo-seal group. Additionally, when assessing the item "I have felt calm and relaxed" from the WHO-5 questionnaire, the aroma-seal use group displayed significantly higher scores than the placebo group. Therefore, using aroma seals containing orange-lime essential oil could be beneficial in relieving mental stress and reducing breathlessness while wearing a mask, thus improving mental health.

Levels of handwashing and vaccine uptake in Kenya, Uganda, and Tanzania to prevent and control COVID-19: a systematic review and meta-analysis

Introduction

Coronavirus Disease 2019 (COVID-19) presents a massive challenge in Africa due to overwhelmed and underresourced health systems, as well as the existing burden of communicable and non- communicable diseases. Self-inoculation may occur when an individual touches their mucous membrane following direct contact between their hands and severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2)-contaminated surfaces. Therefore, handwashing can be used along with COVID-19 vaccines to reduce the spread of SARS-CoV-2 and the burden of COVID-19. We were interested in investigating the levels of handwashing and vaccine uptake to control and prevent COVID-19 in Kenya, Uganda and Tanzania using a systematic review and meta-analysis.

Methods

We searched PubMed, African Index Medicus and African Journals Online for studies published since inception to 31st January 2023. We included all studies that assessed: the levels of COVID-19 vaccine acceptance and hesitance as indicators of vaccine uptake; and studies on the levels of handwashing to prevent and control COVID-19 in Kenya, Uganda and Tanzania. Study findings were synthesized by meta-analysis to get the pooled effect measure. Three studies were synthesized qualitatively due to high level of heterogeneity in effect measure precluding a quantitative meta-analysis.

Results

Our search identified 128 articles of which 17 studies with 18,305 participants and 622 vaccination sites were reviewed with 14 of them being meta-analyzed. This systematic review and meta-analysis reports high levels of COVID-19 vaccine acceptance and handwashing in Kenya, Uganda and Tanzania at 67% (95% CI: 55, 78) and 88% (95% CI: 73, 97), respectively. Vaccine hesitance among the participants was low at 31% (95% CI: 15, 49).

Discussion

Despite their importance in the control and prevention of COVID-19, some countries do not implement handwashing and vaccination effectively. There is a need for public health strategies to raise awareness about the importance of handwashing and the uptake of the COVID-19 vaccine.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/, PROSPERO ID CRD42023394698.

Policies to prevent zoonotic spillover: a systematic scoping review of evaluative evidence

BACKGROUND

Emerging infectious diseases of zoonotic origin present a critical threat to global population health. As accelerating globalisation makes epidemics and pandemics more difficult to contain, there is a need for effective preventive interventions that reduce the risk of zoonotic spillover events. Public policies can play a key role in preventing spillover events. The aim of this review is to identify and describe evaluations of public policies that target the determinants of zoonotic spillover. Our approach is informed by a One Health perspective, acknowledging the inter-connectedness of human, animal and environmental health.

METHODS

In this systematic scoping review, we searched Medline, SCOPUS, Web of Science and Global Health in May 2021 using search terms combining animal health and the animal-human interface, public policy, prevention and zoonoses. We screened titles and abstracts, extracted data and reported our process in line with PRISMA-ScR guidelines. We also searched relevant organisations' websites for evaluations published in the grey literature. All evaluations of public policies aiming to prevent zoonotic spillover events were eligible for inclusion. We summarised key data from each study, mapping policies along the spillover pathway.

RESULTS

Our review found 95 publications evaluating 111 policies. We identified 27 unique policy options including habitat protection; trade regulations; border control and quarantine procedures; farm and market biosecurity measures; public information campaigns; and vaccination programmes, as well as multi-component programmes. These were implemented by many sectors, highlighting the cross-sectoral nature of zoonotic spillover prevention. Reports emphasised the importance of surveillance data in both guiding prevention efforts and enabling policy evaluation, as well as the importance of industry and private sector actors in implementing many of these policies. Thoughtful engagement with stakeholders ranging from subsistence hunters and farmers to industrial animal agriculture operations is key for policy success in this area.

CONCLUSION

This review outlines the state of the evaluative evidence around policies to prevent zoonotic spillover in order to guide policy decision-making and focus research efforts. Since we found that most of the existing policy evaluations target 'downstream' determinants, additional research could focus on evaluating policies targeting 'upstream' determinants of zoonotic spillover, such as land use change, and policies impacting infection intensity and pathogen shedding in animal populations, such as those targeting animal welfare.

Threat of Antimicrobial Resistance among Pilgrims with Infectious Diseases during Hajj: Lessons Learnt from COVID-19 Pandemic

Hajj pilgrimage is a large mass gathering global event that may facilitate the spread and emergence of various infectious diseases as well as antimicrobial resistance (AMR) in a local and global scenario. Planning and preparing for these public health issues is a challenging and complex process for the Kingdom of Saudi Arabia (KSA) health authorities. Despite multiple efforts for the prevention and treatment of infectious diseases through longtime funding in education and medical care, the prevalence of infectious disease is still high among Hajj pilgrims. The commonly observed infectious diseases during Hajj include respiratory tract infections (influenza and pneumonia), urinary tract infections and skin infections that may necessitate the use of antimicrobials. Beta-lactams are used as a first-line treatment for hospital acquired infections as well as community acquired infections due to their broad-spectrum activity. However, most of the bacterial isolates such as Staphylococcus spp., Pseudomonas spp. and E. coli are resistant to beta-lactams. Irrational use of antimicrobials, lack of infection prevention practices and suboptimal healthcare access further exacerbate the risk of spreading AMR among Hajj pilgrims. Enhanced collaboration between countries, sharing of best practices and international cooperation are crucial in addressing AMR threats among pilgrims. Consequently, robust surveillance systems for early detection and monitoring of AMR, collaboration with national as well as international healthcare agencies, effective infection prevention and control measures, public awareness and rational use of antimicrobials via antimicrobial stewardship programs are required to mitigate the risk of AMR and ensure the health and well-being of pilgrims during Hajj.

A systematic review of nudges on hand hygiene against the spread of COVID-19

The COVID-19 pandemic has posed the greatest threat to global health over the last three years. Due to the temporary shortage of appropriate vaccines, a systematic change in human behaviour is necessary to keep the spread of the virus under control, increasing the quality of basic hygiene practices, such as systematic hand hygiene. Nudges are increasingly used in public health interventions to promote critical preventive hygiene behaviours. This review aimed to investigate the effect and the characteristics of nudges on hand hygiene, as a COVID-19 preventive measure. We systematically reviewed the relevant literature from January 2008 to November 2020. A total of 15 articles met the inclusion criteria. The findings of this review showed that most of the nudging interventions had a positive effect on hand hygiene. Nudges should be included in the existing and future public health interventions to prevent the spread of COVID-19 and future pandemics, rather than being an alternative and unconventional tool for public health policies.

Global variability of influenza activity and virus subtype circulation from 2011 to 2023

BACKGROUND

Although decreased influenza activity has been reported in many countries during the COVID-19 pandemic, it remains unknown how global influenza activity has changed. We described the global variability of influenza activity and virus subtype circulation from 2011 to 2023 to prepare for the potential influenza outbreak with the control of the COVID-19 pandemic.

METHODS

Influenza virological surveillance data between 2011 and 2023 were obtained from the WHO-FluNet database. We first calculated and compared the influenza activity before and during the COVID-19 pandemic. For countries whose influenza activity has recovered, we also described changes in the duration of influenza epidemics. We then determined the proportion of influenza cases caused by the different influenza virus types.

RESULTS

In total, 73 countries with 2.17 million influenza cases were included. In the early stage of the COVID-19 pandemic, decreased influenza activity was observed in all WHO regions. In 2022 and 2023, rebound in influenza activity was observed in all WHO regions, especially in Western Pacific Region. At the same time, a change in the duration of the influenza epidemic was observed in several Southern Hemisphere countries. Moreover, in all WHO regions, few B/Yamagata viruses were detected during the COVID-19 pandemic.

CONCLUSIONS

Lack of exposure to influenza will diminish population immunity and increase the severity of large epidemics on a future global resurgence. Ongoing monitoring of the changes in the duration of the influenza epidemic and circulation subtypes should be the focus of future work.

Knowledge, attitudes, and practices related to COVID-19 in Indonesia: A post delta variant wave cross-sectional study

Introduction

Public information and regulations related to the coronavirus disease 2019 (COVID-19) have been widely published and continuously changed. The Indonesian government has responded to the emerging evidence by regularly updating its unprecedented and preventive measures against the transmission of COVID-19 to the public. It is important to understand how the public responded to these updates. This study aimed to investigate the knowledge, attitudes, and practices of Indonesians toward COVID-19 after the emergence of the delta variant wave.

Methods

A cross-sectional study was conducted among the adult population of non-healthcare workers in Indonesia through an online questionnaire using the SurveyMonkey platform. A total of 1,859 respondents completed this survey from September to October 2021. The knowledge, attitudes, and practices data were analyzed descriptively to find their frequency and percentage. A multivariate analysis was conducted to confirm the factors affecting the respondents' knowledge, attitudes, and practices with a p-value of <0.05 set as significant.

Results

Being female, having a higher education level, and having a higher frequency of access to COVID-19 news showed significant impacts on knowledge, attitudes, and practices (p<0.001). Older age stratification influenced the knowledge level (p<0.05) but had no significant effect on people's attitudes and practices toward COVID-19. Respondents' perceived probability of being exposed to COVID-19 (p < 0.05) and their COVID-19 infection frequency (p < 0.001) significantly influenced their knowledge. Household income and respondents' knowledge significantly affected their attitudes toward COVID-19. Furthermore, only their attitudes had a significant impact on the respondents' practices. Perceived severity, perceived susceptibility, and vaccination status did not significantly influence their knowledge, attitudes, and practices (p > 0.05).

Conclusion

After more than a year of the COVID-19 pandemic, Indonesians maintain their high level of knowledge, attitudes, and practices. COVID-19 disinformation must be combatted by strengthening authorized media, empowering communities, and improving governance among institutions during and post-pandemic.

Conservation Practices for Personal Protective Equipment: A Systematic Review with Focus on Lower-Income Countries

During the start of the COVID-19 pandemic, shortages of personal protective equipment (PPE) necessitated unprecedented and non-validated approaches to conserve PPE at healthcare facilities, especially in high income countries where single-use disposable PPE was ubiquitous. Our team conducted a systematic literature review to evaluate historic approaches for conserving single-use PPE, expecting that lower-income countries or developing contexts may already be uniquely conserving PPE. However, of the 50 included studies, only 3 originated from middle-income countries and none originated from low-income countries. Data from the included studies suggest PPE remained effective with extended use and with multiple or repeated use in clinical settings, as long as donning and doffing were performed in a standard manner. Multiple decontamination techniques were effective in disinfecting single use PPE for repeated use. These findings can inform healthcare facilities and providers in establishing protocols for safe conservation of PPE supplies and updating existing protocols to improve sustainability and overall resilience. Future studies should evaluate conservation practices in low-resource settings during non-pandemic times to develop strategies for more sustainable and resilient healthcare worldwide.

Physical interventions to interrupt or reduce the spread of respiratory viruses

BACKGROUND

Viral epidemics or pandemics of acute respiratory infections (ARIs) pose a global threat. Examples are influenza (H1N1) caused by the H1N1pdm09 virus in 2009, severe acute respiratory syndrome (SARS) in 2003, and coronavirus disease 2019 (COVID-19) caused by SARS-CoV-2 in 2019. Antiviral drugs and vaccines may be insufficient to prevent their spread. This is an update of a Cochrane Review last published in 2020. We include results from studies from the current COVID-19 pandemic.

OBJECTIVES

To assess the effectiveness of physical interventions to interrupt or reduce the spread of acute respiratory viruses.

SEARCH METHODS

We searched CENTRAL, PubMed, Embase, CINAHL, and two trials registers in October 2022, with backwards and forwards citation analysis on the new studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and cluster-RCTs investigating physical interventions (screening at entry ports, isolation, quarantine, physical distancing, personal protection, hand hygiene, face masks, glasses, and gargling) to prevent respiratory virus transmission.  DATA COLLECTION AND ANALYSIS: We used standard Cochrane methodological procedures.

MAIN RESULTS

We included 11 new RCTs and cluster-RCTs (610,872 participants) in this update, bringing the total number of RCTs to 78. Six of the new trials were conducted during the COVID-19 pandemic; two from Mexico, and one each from Denmark, Bangladesh, England, and Norway. We identified four ongoing studies, of which one is completed, but unreported, evaluating masks concurrent with the COVID-19 pandemic. Many studies were conducted during non-epidemic influenza periods. Several were conducted during the 2009 H1N1 influenza pandemic, and others in epidemic influenza seasons up to 2016. Therefore, many studies were conducted in the context of lower respiratory viral circulation and transmission compared to COVID-19. The included studies were conducted in heterogeneous settings, ranging from suburban schools to hospital wards in high-income countries; crowded inner city settings in low-income countries; and an immigrant neighbourhood in a high-income country. Adherence with interventions was low in many studies. The risk of bias for the RCTs and cluster-RCTs was mostly high or unclear. Medical/surgical masks compared to no masks We included 12 trials (10 cluster-RCTs) comparing medical/surgical masks versus no masks to prevent the spread of viral respiratory illness (two trials with healthcare workers and 10 in the community). Wearing masks in the community probably makes little or no difference to the outcome of influenza-like illness (ILI)/COVID-19 like illness compared to not wearing masks (risk ratio (RR) 0.95, 95% confidence interval (CI) 0.84 to 1.09; 9 trials, 276,917 participants; moderate-certainty evidence. Wearing masks in the community probably makes little or no difference to the outcome of laboratory-confirmed influenza/SARS-CoV-2 compared to not wearing masks (RR 1.01, 95% CI 0.72 to 1.42; 6 trials, 13,919 participants; moderate-certainty evidence). Harms were rarely measured and poorly reported (very low-certainty evidence). N95/P2 respirators compared to medical/surgical masks We pooled trials comparing N95/P2 respirators with medical/surgical masks (four in healthcare settings and one in a household setting). We are very uncertain on the effects of N95/P2 respirators compared with medical/surgical masks on the outcome of clinical respiratory illness (RR 0.70, 95% CI 0.45 to 1.10; 3 trials, 7779 participants; very low-certainty evidence). N95/P2 respirators compared with medical/surgical masks may be effective for ILI (RR 0.82, 95% CI 0.66 to 1.03; 5 trials, 8407 participants; low-certainty evidence). Evidence is limited by imprecision and heterogeneity for these subjective outcomes. The use of a N95/P2 respirators compared to medical/surgical masks probably makes little or no difference for the objective and more precise outcome of laboratory-confirmed influenza infection (RR 1.10, 95% CI 0.90 to 1.34; 5 trials, 8407 participants; moderate-certainty evidence). Restricting pooling to healthcare workers made no difference to the overall findings. Harms were poorly measured and reported, but discomfort wearing medical/surgical masks or N95/P2 respirators was mentioned in several studies (very low-certainty evidence).  One previously reported ongoing RCT has now been published and observed that medical/surgical masks were non-inferior to N95 respirators in a large study of 1009 healthcare workers in four countries providing direct care to COVID-19 patients.  Hand hygiene compared to control Nineteen trials compared hand hygiene interventions with controls with sufficient data to include in meta-analyses. Settings included schools, childcare centres and homes. Comparing hand hygiene interventions with controls (i.e. no intervention), there was a 14% relative reduction in the number of people with ARIs in the hand hygiene group (RR 0.86, 95% CI 0.81 to 0.90; 9 trials, 52,105 participants; moderate-certainty evidence), suggesting a probable benefit. In absolute terms this benefit would result in a reduction from 380 events per 1000 people to 327 per 1000 people (95% CI 308 to 342). When considering the more strictly defined outcomes of ILI and laboratory-confirmed influenza, the estimates of effect for ILI (RR 0.94, 95% CI 0.81 to 1.09; 11 trials, 34,503 participants; low-certainty evidence), and laboratory-confirmed influenza (RR 0.91, 95% CI 0.63 to 1.30; 8 trials, 8332 participants; low-certainty evidence), suggest the intervention made little or no difference. We pooled 19 trials (71, 210 participants) for the composite outcome of ARI or ILI or influenza, with each study only contributing once and the most comprehensive outcome reported. Pooled data showed that hand hygiene may be beneficial with an 11% relative reduction of respiratory illness (RR 0.89, 95% CI 0.83 to 0.94; low-certainty evidence), but with high heterogeneity. In absolute terms this benefit would result in a reduction from 200 events per 1000 people to 178 per 1000 people (95% CI 166 to 188). Few trials measured and reported harms (very low-certainty evidence). We found no RCTs on gowns and gloves, face shields, or screening at entry ports.

AUTHORS' CONCLUSIONS

The high risk of bias in the trials, variation in outcome measurement, and relatively low adherence with the interventions during the studies hampers drawing firm conclusions. There were additional RCTs during the pandemic related to physical interventions but a relative paucity given the importance of the question of masking and its relative effectiveness and the concomitant measures of mask adherence which would be highly relevant to the measurement of effectiveness, especially in the elderly and in young children. There is uncertainty about the effects of face masks. The low to moderate certainty of evidence means our confidence in the effect estimate is limited, and that the true effect may be different from the observed estimate of the effect. The pooled results of RCTs did not show a clear reduction in respiratory viral infection with the use of medical/surgical masks. There were no clear differences between the use of medical/surgical masks compared with N95/P2 respirators in healthcare workers when used in routine care to reduce respiratory viral infection. Hand hygiene is likely to modestly reduce the burden of respiratory illness, and although this effect was also present when ILI and laboratory-confirmed influenza were analysed separately, it was not found to be a significant difference for the latter two outcomes. Harms associated with physical interventions were under-investigated. There is a need for large, well-designed RCTs addressing the effectiveness of many of these interventions in multiple settings and populations, as well as the impact of adherence on effectiveness, especially in those most at risk of ARIs.

Actualidad en corioamnionitis

La corioamnionitis se ha relacionados con desenlaces desfavorables en el período prenatal y neonatal (abortos, parto pretérmino, sepsis neonatal, entre otros), además de implicaciones a largo plazo en la infancia, tales como alteraciones en el coeficiente intelectual. Por esta razón es de vital importancia el diagnóstico histopatológico oportuno. En este artículo se revisará el abordaje histopatológico de la corioamnionitis, su estadificación e implicaciones clínicas.

Policies to prevent zoonotic spillover: protocol for a systematic scoping review of evaluative evidence

INTRODUCTION

The increasing incidence of pathogen transmission from animals to humans (zoonotic spillover events) has been attributed to behavioural practices and ecological and socioeconomic change. As these events sometimes involve pathogens with epidemic or pandemic potential, they pose a serious threat to population health. Public policies may play a key role in preventing these events. The aim of this review is to identify evaluations of public policies that target the determinants of zoonotic spillover, examining approaches taken to evaluation, choice of outcomes measures and evidence of effectiveness. Our approach to identifying and analysing this literature will be informed by a One Health lens, acknowledging the interconnectedness of human, animal and environmental health.

METHODS AND ANALYSIS

A systematic scoping review methodology will be used. To identify articles, we will search Medline, SCOPUS, Web of Science and Global Health in May 2021 using search terms combining animal health and the animal-human interface, public policy, prevention and zoonoses. We will screen titles and abstracts and extract data according to published guidelines for scoping reviews. All evaluations of public policies aiming to prevent zoonotic spillover events will be eligible for inclusion. We will summarise key data from each study, mapping policies along the spillover pathway and outlining the range of policies, approaches to evaluation and outcome measures. Review findings will provide a useful reference for researchers and practitioners, outlining the state of the evaluative evidence around policies to prevent zoonotic spillover.

ETHICS AND DISSEMINATION

Formal ethical approval is not required, because the study does not involve primary data collection. The findings of this study will be disseminated through a peer-reviewed publication, presentations and summaries for key stakeholders.

A cross-national and longitudinal analysis of handwashing and its predictors during the COVID-19 pandemic in France and Belgium

BACKGROUND

Using a longitudinal design, we investigate how the adherence to handwashing and its underlying socio-psychological predictors evolved over time during the COVID-19 pandemic and under distinct circumstances (e.g. when the crisis was more acute or chronic).

METHOD

We collected data (N = 753) in Belgium and France at the onset of the COVID-19 pandemic when the crisis was at its peak (April 2020), and almost a year later (February 2021), when the outbreak was more manageable.

RESULTS

Regression models suggest that the compliance with handwashing and its pattern of underlying predictors remained remarkably stable over time despite the variations in contextual factors such as the severity of the health crisis and the stringency of health measures. As such, the findings also highlight the robustness of the models that predict it, namely the Theory of Planned Behavior. The intentions to perform the behavior, the perceived control over it, and being part of the (para)medical field were among the strongest predictors.

CONCLUSIONS

In practice, the stability of the underlying factors suggests a set of action levers that can be used in communication campaigns aimed at fostering its adherence throughout the pandemic.

Effects of classroom cleaning on student health: a longitudinal study

BACKGROUND

School districts across the world have been grappling with how to keep their schools open, students healthy, and prevent the spread of viruses in their communities.

OBJECTIVE

The aims of this study included assessing both (1) the effectiveness of enhanced classroom cleaning and disinfecting protocol on surface biocontamination and (2) the associations between surface biocontamination and student absence due to illnesses.

METHODS

Cleaning effectiveness was assessed using quantitative adenosine triphosphate (ATP) measurements during a 10-week study period in a sample of 34 public schools (15,814 students), of a district located in the Western US. The schools were randomly assigned to 17 intervention schools implementing enhanced cleaning and disinfecting protocol and 17 control schools cleaning as usual. General estimating equations (GEEs) were used for modeling associations between ATP levels and weekly aggregates of student absences due to respiratory and gastrointestinal illnesses, which were recorded by the schools according to district wide protocol.

RESULTS

The weekly average ATP levels on logarithmic scale were 5.02 (SD 0.53) and 5.26 (SD 0.48) in the intervention and control schools, respectively, where the difference is statistically significant (p < 0.001). The probability of weekly absence due to gastrointestinal illness was significantly associated with ATP levels (parameter estimate 1.16, 95% CI 1.01-1.34, per unit (log) increase of weekly average ATP), where the model accounts for student level, gender, ethnic group, and socioeconomic status as well as for school level attendance, total absence ratio, and ventilation adequacy in classrooms. Associations were not found between ATP levels and weekly probability of any absence, or absence due to respiratory illness.

SIGNIFICANCE

Enhanced cleaning resulted in a significantly lower level of biocontamination on desktops in the intervention group. In addition, a statistically significant association was established between ATP levels on classroom desks and probability of absence due to gastrointestinal illness.

IMPACT

We found that enhanced cleaning protocol, including bi-weekly cleaning of classroom desks, as well as training of custodians and teachers, monitoring of effectiveness, and feedback, yielded a moderate but statistically significantly lower level of biocontamination on desktops, indicated by quantitative ATP monitoring. Within the range of weekly average desktop ATP levels observed, the probability of reported absence due to gastrointestinal illness is estimated to increase from 0.021 to 0.026. Based on the results, enhanced surface cleaning and monitoring its effectiveness is a possible district, state, or even national level policy to support healthy school environments.

Practice of non-pharmaceutical interventions against COVID-19 and reduction of the risk of influenza-like illness: a cross-sectional population-based study

Introduction

While the widespread implementation of the non-pharmaceutical interventions was intended to contain the COVID-19 pandemic, such measures could be also effective in limiting the spread of other respiratory infections. This study aimed to examine the association between the implementation of personal protective measures and the occurrence of influenza-like illnesses (ILI) in the general population.

Methods

An online retrospective cross-sectional observational study was conducted in April 2021 to assess cases of ILI among Lebanese adults aged 18 years and above, from all Lebanese governorates during the 2020–2021 flu season. Data were collected using a convenience sampling method. In addition to their socio-demographic information, participants were asked about their frequency of implementing personal protective measures and if they have experienced symptoms of ILI in the previous 6 months. The overall score of the personal protective measures was computed. Multivariable logistic regression was performed to examine the association between participants’ level of adoption of personal protective measures against COVID-19 and the occurrence of ILI.

Results

Among the 1019 Lebanese adults participating in this study, 352 (34.54%) of them reported symptoms of ILI between October 2020 and March 2021. Lebanese adults who wore their facemasks frequently or always were less likely to suffer from symptoms of ILI than others who did not wear the mask (aOR = 0.452, 95% CI = 0.349–0.693, p < 0.001). Similarly, adults who adopt the following protective measures washing hands (aOR = 0.608, 95% CI = 0.524–0.922, p < 0.001), respecting cough etiquette (aOR = 0.763, 95% CI = 0.598–0.918, p < 0.001), disinfecting surface (aOR = 0.892, 95% CI = 0.632–0.911, p = 0.012), avoiding crowded places (aOR = 0.739, 95% CI = 0.688–0.903, p = 0.049), respecting physical distancing (aOR = 0.646, 95% CI = 0.482–0.833, p = 0.031) on a regular basis (frequently/always) were less likely to report symptoms of influenza-like illnesses when compared with those who did not adhere at all to these measures.

Conclusion

Our study highlighted the potential of personal protective measures against COVID-19 in reducing the transmission of respiratory infections such as ILI. Such findings might be invested during influenza season, particularly among groups at high risk of developing severe complications. Exploring trends detected by the national severe acute respiratory infection surveillance system is recommended to confirm the utility of these measures.

Using nasal sprays to prevent respiratory tract infections: a qualitative study of online consumer reviews and primary care patient interviews

OBJECTIVES

Nasal sprays could be a promising approach to preventing respiratory tract infections (RTIs). This study explored lay people's perceptions and experiences of using nasal sprays to prevent RTIs to identify barriers and facilitators to their adoption and continued use.

DESIGN

Qualitative research. Study 1 thematically analysed online consumer reviews of an RTI prevention nasal spray. Study 2 interviewed patients about their reactions to and experiences of a digital intervention that promotes and supports nasal spray use for RTI prevention (reactively: at 'first signs' of infection and preventatively: following possible/probable exposure to infection). Interview transcripts were analysed using thematic analysis.

SETTING

Primary care, UK.

PARTICIPANTS

407 online customer reviews. 13 purposively recruited primary care patients who had experienced recurrent infections and/or had risk factors for severe infections.

RESULTS

Both studies identified various factors that might influence nasal spray use including: high motivation to avoid RTIs, particularly during the COVID-19 pandemic; fatalistic views about RTIs; beliefs about alternative prevention methods; the importance of personal recommendation; perceived complexity and familiarity of nasal sprays; personal experiences of spray success or failure; tolerable and off-putting side effects; concerns about medicines; and the nose as unpleasant and unhygienic.

CONCLUSIONS

People who suffer disruptive, frequent or severe RTIs or who are vulnerable to RTIs are interested in using a nasal spray for prevention. They also have doubts and concerns and may encounter problems. Some of these may be reduced or eliminated by providing nasal spray users with information and advice that addresses these concerns or helps people overcome difficulties.

Was the Reduction in Seasonal Influenza Transmission during 2020 Attributable to Non-Pharmaceutical Interventions to Contain Coronavirus Disease 2019 (COVID-19) in Japan?

We quantified the effects of adherence to various non-pharmaceutical interventions (NPIs) on the seasonal influenza epidemic dynamics in Japan during 2020. The total monthly number of seasonal influenza cases per sentinel site (seasonal influenza activity) reported to the National Epidemiological Surveillance of Infectious Diseases and alternative NPI indicators (retail sales of hand hygiene products and number of airline passenger arrivals) from 2014−2020 were collected. The average number of monthly seasonal influenza cases in 2020 had decreased by approximately 66.0% (p < 0.001) compared to those in the preceding six years. An increase in retail sales of hand hygiene products of ¥1 billion over a 3-month period led to a 15.5% (95% confidence interval [CI]: 10.9−20.0%; p < 0.001) reduction in seasonal influenza activity. An increase in the average of one million domestic and international airline passenger arrivals had a significant association with seasonal influenza activity by 11.6% at lag 0−2 months (95% CI: 6.70−16.5%; p < 0.001) and 30.9% at lag 0−2 months (95% CI: 20.9−40.9%; p < 0.001). NPI adherence was associated with decreased seasonal influenza activity during the COVID-19 pandemic in Japan, which has crucial implications for planning public health interventions to minimize the health consequences of adverse seasonal influenza epidemics.

Impact of urbanisation and environmental factors on spatial distribution of COVID-19 cases during the early phase of epidemic in Singapore

Geographical weighted regression (GWR) can be used to explore the COVID-19 transmission pattern between cases. This study aimed to explore the influence from environmental and urbanisation factors, and the spatial relationship between epidemiologically-linked, unlinked and imported cases during the early phase of the epidemic in Singapore. Spatial relationships were evaluated with GWR modelling. Community COVID-19 cases with residential location reported from 21st January 2020 till 17th March 2020 were considered for analyses. Temperature, relative humidity, population density and urbanisation are the variables used as exploratory variables for analysis. ArcGIS was used to process the data and perform geospatial analyses. During the early phase of COVID-19 epidemic in Singapore, significant but weak correlation of temperature with COVID-19 incidence (significance 0.5-1.5) was observed in several sub-zones of Singapore. Correlations between humidity and incidence could not be established. Across sub-zones, high residential population density and high levels of urbanisation were associated with COVID-19 incidence. The incidence of COVID-19 case types (linked, unlinked and imported) within sub-zones varied differently, especially those in the western and north-eastern regions of Singapore. Areas with both high residential population density and high levels of urbanisation are potential risk factors for COVID-19 transmission. These findings provide further insights for directing appropriate resources to enhance infection prevention and control strategies to contain COVID-19 transmission.

Synchronized spread of COVID-19 in the cities of Bahia, Brazil

The COVID-19 pandemic, caused by the highly transmissible SARS-CoV-2 virus, has overloaded health systems in many contexts Conant and Wolfe (2008). Brazil has experienced more than 345,000 deaths, as of April/2021 Conant and Wolfe (2008), with dire consequences for the country’s public and private health systems. This paper aims to estimate the synchronization graph between the cities’ contagion waves from public COVID-19 data records. For this purpose, the Motif–Synchronization method Magwire et al. (2011) was applied to publicly available COVID-19 data records to determine the sequential relationship of occurrence of the waves among Bahia’s cities. We find synchronization between waves of infection between cities, suggesting diffusion of the disease in Bahia and a potential role for inter-city transportation Saba et al. (2018), Saba et al. (2014), Araújo et al. (2018) in the dynamics of this phenomenon McKee and Stuckler (2020), Chinazzi et al. (2020), Tizzoni et al. (2014). Our main contribution lies in the use of the Motif–Synchronization method applied to COVID-19 data records, with the results revealing a pattern of disease spread that extends beyond city boundaries.

Lessons from past pandemics: a systematic review of evidence-based, cost-effective interventions to suppress COVID-19

BACKGROUND

In an unparalleled global response, during the COVID-19 pandemic, 90 countries asked 3.9 billion people to stay home. Yet other countries avoided lockdowns and focused on other strategies, like contact tracing. How effective and cost-effective are these strategies? We aimed to provide a comprehensive summary of the evidence on past pandemic controls, with a focus on cost-effectiveness.

METHODS

Following PRISMA guidelines, MEDLINE (1946 to April week 2, 2020) and EMBASE (1974 to April 17, 2020) were searched using a range of terms related to pandemic control. Articles reporting on the effectiveness or cost-effectiveness of at least one intervention were included.

RESULTS

We found 1653 papers; 62 were included. The effectiveness of hand-washing and face masks was supported by randomized trials. These measures were highly cost-effective. For other interventions, only observational and modelling studies were found. They suggested that (1) the most cost-effective interventions are swift contact tracing and case isolation, surveillance networks, protective equipment for healthcare workers, and early vaccination (when available); (2) home quarantines and stockpiling antivirals are less cost-effective; (3) social distancing measures like workplace and school closures are effective but costly, making them the least cost-effective options; (4) combinations are more cost-effective than single interventions; and (5) interventions are more cost-effective when adopted early. For 2009 H1N1 influenza, contact tracing was estimated to be 4363 times more cost-effective than school closure ($2260 vs. $9,860,000 per death prevented).

CONCLUSIONS AND CONTRIBUTIONS

For COVID-19, a cautious interpretation suggests that (1) workplace and school closures are effective but costly, especially when adopted late, and (2) scaling up as early as possible a combination of interventions that includes hand-washing, face masks, ample protective equipment for healthcare workers, and swift contact tracing and case isolation is likely to be the most cost-effective strategy.

A Retrospective Global Assessment of Factors Associated With COVID-19 Policies and Health Outcomes

Background

The 2019 Global Health Security (GHS) Index measured the capacities of countries to prepare for and respond to epidemics and pandemics. However, the COVID-19 pandemic revealed that GHS Index scores were poorly correlated with ability to respond to infectious disease threats. It is critical to understand how public health policies may reduce the negative impacts of pandemics.

Objective

To identify non-pharmaceutical interventions (NPIs) that can minimize morbidity and mortality during the COVID-19 and future pandemics, this study examined associations between country characteristics, NPI public health policies, and COVID-19 outcomes during the first year of the pandemic, prior to the introduction of the COVID-19 vaccine. This global analysis describes worldwide trends in policy implementation and generates a stronger understanding of how NPIs contributed to improved health outcomes.

Design

This cross-sectional, retrospective study relied on information drawn from publicly available datasets through December 31, 2020.

Primary and Secondary Outcome Measures

We conducted multivariate regressions to examine associations between country characteristics and policies, and policies and health outcomes.

Results

Countries with higher health service coverage prior to the pandemic implemented more policies and types of policies. Countries with more bordering countries implemented more border control policies (0.78**), and countries with denser populations implemented more masking policies (0.24*). Across all countries, fewer COVID-19 cases and deaths per million were associated with masking (-496.10*, -7.57), testing and tracing (-108.50**, -2.47**), and restriction of movement (-102.30*, -2.10*) policies, with stronger associations when these policies were mandatory rather than voluntary.

Conclusions

Country characteristics, including health service coverage, number of bordering countries, and population density, may predict the frequency and nature of public health interventions. Countries with higher health service coverage may have the infrastructure to react more efficiently to a pandemic, leading them to implement a greater number of policies. Mandatory masking, testing and tracing, and restriction of movement policies were associated with more favorable COVID-19 population health outcomes. While these results are consistent with existing COVID-19 mathematical models, policy effectiveness depends on how well they are implemented. Our results suggest that social distancing policies were less effective in reducing infectious disease risk, which may reflect difficulties with enforcement and monitoring.

Patient perceptions of vulnerability to recurrent respiratory tract infections and prevention strategies: a qualitative study

OBJECTIVES

Respiratory tract infections (RTIs) are extremely common, usually self-limiting, but responsible for considerable work sickness absence, reduced quality of life, inappropriate antibiotic prescribing and healthcare costs. Patients who experience recurrent RTIs and those with certain comorbid conditions have higher personal impact and healthcare costs and may be more likely to suffer disease exacerbations, hospitalisation and death. We explored how these patients experience and perceive their RTIs to understand how best to engage them in prevention behaviours.

DESIGN

A qualitative interview study.

SETTING

Primary care, UK.

METHODS

23 participants who reported recurrent RTIs and/or had relevant comorbid health conditions were interviewed about their experiences of RTIs. Interviews took place as the COVID-19 pandemic began. Data were analysed using inductive thematic analysis.

RESULTS

Three themes were developed: Understanding causes and vulnerability, Attempting to prevent RTIs, Uncertainty and ambivalence about prevention, along with an overarching theme; Changing experiences because of COVID-19. Participants' understandings of their susceptibility to RTIs were multifactorial and included both transmission via others and personal vulnerabilities. They engaged in various approaches to try to prevent infections or alter their progression yet perceived they had limited personal control. The COVID-19 pandemic had improved their understanding of transmission, heightened their concern and motivation to avoid RTIs and extended their repertoire of protective behaviours.

CONCLUSIONS

Patients who experience frequent or severe RTIs are likely to welcome and benefit from advice and support regarding RTI prevention. To engage people effectively, those developing interventions or delivering health services must consider their beliefs and concerns about susceptibility and prevention.

Forecasting for COVID-19 has failed

Epidemic forecasting has a dubious track-record, and its failures became more prominent with COVID-19. Poor data input, wrong modeling assumptions, high sensitivity of estimates, lack of incorporation of epidemiological features, poor past evidence on effects of available interventions, lack of transparency, errors, lack of determinacy, consideration of only one or a few dimensions of the problem at hand, lack of expertise in crucial disciplines, groupthink and bandwagon effects, and selective reporting are some of the causes of these failures. Nevertheless, epidemic forecasting is unlikely to be abandoned. Some (but not all) of these problems can be fixed. Careful modeling of predictive distributions rather than focusing on point estimates, considering multiple dimensions of impact, and continuously reappraising models based on their validated performance may help. If extreme values are considered, extremes should be considered for the consequences of multiple dimensions of impact so as to continuously calibrate predictive insights and decision-making. When major decisions (e.g. draconian lockdowns) are based on forecasts, the harms (in terms of health, economy, and society at large) and the asymmetry of risks need to be approached in a holistic fashion, considering the totality of the evidence.

Planning as Inference in Epidemiological Dynamics Models

In this work we demonstrate how to automate parts of the infectious disease-control policy-making process via performing inference in existing epidemiological models. The kind of inference tasks undertaken include computing the posterior distribution over controllable, via direct policy-making choices, simulation model parameters that give rise to acceptable disease progression outcomes. Among other things, we illustrate the use of a probabilistic programming language that automates inference in existing simulators. Neither the full capabilities of this tool for automating inference nor its utility for planning is widely disseminated at the current time. Timely gains in understanding about how such simulation-based models and inference automation tools applied in support of policy-making could lead to less economically damaging policy prescriptions, particularly during the current COVID-19 pandemic.

Effectiveness of Mask-Wearing on Respiratory Illness Transmission in Community Settings: A Rapid Review

OBJECTIVE

Respiratory illnesses, including coronavirus disease 2019 (COVID-19), have resulted in millions of deaths globally. Guidance on mask-wearing in community settings has been inconsistent. This review examined the effectiveness of mask-wearing on respiratory virus transmission in community settings.

METHODS

A search was conducted for English language reports of randomized controlled trials of mask-wearing in the community and effect on laboratory-confirmed respiratory infections or influenza-like illness. Investigators abstracted study characteristics and assessed bias. Meta-analysis was conducted to calculate pooled risk estimates.

RESULTS

Eleven studies were included. In 7 studies that evaluated influenza-like illness symptoms as an outcome (3029 participants), this study found mask-wearing associated with a decreased risk of influenza-like illness (overall risk ratio [RR], 0.83; 95% confidence interval [CI], 0.71 to 0.96). Studies examining laboratory-confirmed respiratory infections as an outcome (10,531 participants) showed no statistically significant association between mask-wearing and infections (RR, 1.04; 95% CI, 0.60-1.80). However, masking combined with enhanced hand hygiene was associated with a decreased risk for both influenza-like illness symptoms (RR, 0.88; 95% CI, 0.51-1.51) and laboratory-confirmed respiratory infection (RR, 0.79; 95% CI, 0.52-1.18).

CONCLUSIONS

Masking in community settings decreases transmission of influenza-like illness. Mask-wearing combined with enhanced hand hygiene reduces transmission of influenza-like illness and laboratory-confirmed respiratory infection.

Feasibility, acceptability, and effectiveness of non-pharmaceutical interventions against infectious diseases among crisis-affected populations: a scoping review

Background

Non-pharmaceutical interventions (NPIs) are a crucial suite of measures to prevent and control infectious disease outbreaks. Despite being particularly important for crisis-affected populations and those living in informal settlements, who typically reside in overcrowded and resource limited settings with inadequate access to healthcare, guidance on NPI implementation rarely takes the specific needs of such populations into account. We therefore conducted a systematic scoping review of the published evidence to describe the landscape of research and identify evidence gaps concerning the acceptability, feasibility, and effectiveness of NPIs among crisis-affected populations and informal settlements.

Methods

We systematically reviewed peer-reviewed articles published between 1970 and 2020 to collate available evidence on the feasibility, acceptability, and effectiveness of NPIs in crisis-affected populations and informal settlements. We performed quality assessments of each study using a standardised questionnaire. We analysed the data to produce descriptive summaries according to a number of categories: date of publication; geographical region of intervention; typology of crisis, shelter, modes of transmission, NPI, research design; study design; and study quality.

Results

Our review included 158 studies published in 85 peer-reviewed articles. Most research used low quality study designs. The acceptability, feasibility, and effectiveness of NPIs was highly context dependent. In general, simple and cost-effective interventions such as community-level environmental cleaning and provision of water, sanitation and hygiene services, and distribution of items for personal protection such as insecticide-treated nets, were both highly feasible and acceptable. Logistical, financial, and human resource constraints affected both the implementation and sustainability of measures. Community engagement emerged as a strong factor contributing to the effectiveness of NPIs. Conversely, measures that involve potential restriction on personal liberty such as case isolation and patient care and burial restrictions were found to be less acceptable, despite apparent effectiveness.

Conclusions

Overall, the evidence base was variable, with substantial knowledge gaps which varied between settings and pathogens. Based on the current landscape, robust evidence-based guidance is not possible, and a research agenda is urgently required that focusses on these specific vulnerable populations. Although implementation of NPIs presents unique practical challenges in these settings, it is critical that such an agenda is put in place, and that the lessons learned from historical and present experiences are documented to build a firm evidence base.

Graphical Abstract

Supplementary Information

The online version contains supplementary material available at 10.1186/s40249-022-00935-7.

Introducing the Disease Outbreak Resilience Index (DORI) Using the Demographic and Health Surveys Data from sub-Saharan Africa

Although most studies on disease emergencies underscore the need for household readiness for shocks associated with disease outbreaks, no study to date has provided a holistic measure for profiling households based on their readiness toward disease outbreaks. This paper introduces a novel Disease Outbreak Resilience Index (DORI) using a multidimensional approach that draws on the Alkire-Foster methodology. DORI measures disease outbreak resilience in four dimensions: (a) water and hygiene, (b) physical distancing, (c) energy and communication, and (d) economic security and resilience. The paper details the development of DORI and its use by presenting findings from ten countries in sub-Saharan Africa using data from the Demographic and Health Surveys (DHS) program. In addition to serving as a resilience index, we illustrate how DORI can be used to produce a disease outbreak vulnerability index (DOVI). As a versatile index, the indicators under each dimension can be tailored to meet country- and region-specific contexts based on indicators appropriate to each context.

Selected Livestock-Associated Zoonoses as a Growing Challenge for Public Health

The aim of this paper is to review the most significant livestock-associated zoonoses. Human and animal health are intimately connected. This idea has been known for more than a century but now it has gained special importance because of the increasing threat from zoonoses. Zoonosis is defined as any infection naturally transmissible from vertebrate animals to humans. As the frequency and prevalence of zoonotic diseases increase worldwide, they become a real threat to public health. In addition, many of the newly discovered diseases have a zoonotic origin. Due to globalization and urbanization, some of these diseases have already spread all over the world, caused by the international flow of goods, people, and animals. However, special attention should be paid to farm animals since, apart from the direct contact, humans consume their products, such as meat, eggs, and milk. Therefore, zoonoses such as salmonellosis, campylobacteriosis, tuberculosis, swine and avian influenza, Q fever, brucellosis, STEC infections, and listeriosis are crucial for both veterinary and human medicine. Consequently, in the suspicion of any zoonoses outbreak, the medical and veterinary services should closely cooperate to protect the public health.

Combating the Current Pandemic and Preparing for the Next: Lessons Learned From the COVID-19 Pandemic From the Perspective of Deployed Special Operations Forces

The coronavirus 2019 (COVID-19) pandemic continues to be a threat to global health, including the health of deployed armed forces. Servicemembers had to adjust to the “new normal” while maintaining the interests of the nation’s security as well as that of our host nation partners. This commentary examines how Special Operations Forces operating within four different regions worldwide leveraged the challenges presented by the onset of this pandemic in maintaining stability, sustaining a ready force, and operating forward deployed. Deployed forces face constant difficulties with logistical support, varied medical resources access and a medical system predominantly focused on trauma care. At the onset of the COVID-19 pandemic there was little guidance specific to these circumstances which required an improvised adaptation of the recommendations set by national and Department of Defense medical authorities. Plans were constantly revised to match the ever changing medical and operational environment. Strategies such as the “Bubble Philosophy” and tiered force protection measures helped our units to maintain a rigorous training cycle. New methods of communication and training with our host nation partners such as the use of Unmanned Aerial Systems (UAS) platforms to survey host nation training became standard. Through these measures all of our forces were able to maintain operational capacity, protect the force, and maintain rapport with the host nations. We hope these experiences will provide a rough framework for future forces faced with a similar struggle. We also want to stress that challenges vary depending on the area of operations and the pathogen responsible for the pandemic. Any feedback and collaboration that may come from this work is appreciated and encouraged.

Cost-Effectiveness of Public Health Measures to Control COVID-19 in China: A Microsimulation Modeling Study

This study aimed to assess the cost-effectiveness of various public health measures in dealing with coronavirus disease 2019 (COVID-19) in China. A stochastic agent-based model was used to simulate the progress of the COVID-19 outbreak in scenario I (imported one case) and scenario II (imported four cases) with a series of public health measures. The main outcomes included the avoided infections and incremental cost-effectiveness ratios (ICERs). Sensitivity analyses were performed to assess uncertainty. The results indicated that isolation-and-quarantine averted the COVID-19 outbreak at the lowest ICERs. The joint strategy of personal protection and isolation-and-quarantine averted one more case than only isolation-and-quarantine with additional costs. The effectiveness of isolation-and-quarantine decreased with lowering quarantine probability and increasing delay time. The strategy that included community containment would be cost-effective when the number of imported cases was >65, or the delay time of the quarantine was more than 5 days, or the quarantine probability was below 25%, based on current assumptions. In conclusion, isolation-and-quarantine was the most cost-effective intervention. However, personal protection combined with isolation-and-quarantine was the optimal strategy for averting more cases. The community containment could be more cost-effective as the efficiency of isolation-and-quarantine drops and the imported cases increases.

Modes de transmission du SARS-CoV-2 : que sait-on actuellement ?

Des progrès remarquables ont été obtenus dans notre compréhension de la transmission du SARS-CoV-2 et la réduction de sa propagation. La prise en compte du risque majeur des formes asymptomatiques par le port universel du masque est une de ces avancées. Les données épidémiologiques (taux d'attaque et R₀) ainsi que l'accumulation de données en contexte clinique suggèrent une similitude de transmission du SARS-CoV-2 avec celle des autres virus respiratoires comme la grippe ou le SARS-CoV-1, un mode de transmission principal direct de personne à personne, à courte distance par les gouttelettes. La transmission aéroportée est possible mais rare, et ne semble se produire que dans des circonstances opportunistes, notamment lors de procédures médicales sur la sphère respiratoire de patients infectés, ou dans des conditions d'excrétion virale élevée en zone confinée mal ventilée. L'hygiène des mains et le port du masque sont les deux armes essentielles de prévention dans le contexte de la COVID-19.

Effectiveness of Infection Preventive Behaviors on COVID-19-Like Illness Symptoms During the Winter Third Wave of the Epidemic in Japan: A 2-Month Follow-up Nationwide Cohort Study

Although multilayered strategies including preventive behaviors should be adopted to mitigate coronavirus disease 2019 (COVID-19) transmission, evidence on the effectiveness of preventive behaviors against COVID-19 remains limited. This Internet-based prospective cohort study collected baseline data in November 2020 and follow-up data in February 2021, during the third wave of the epidemic in Japan. Among the 19 941 included participants, the percentages reporting that they always used a face mask, practiced hand washing/disinfection, gargling, and ensuring proper room ventilation were 85.4%, 36.0%, 51.1%, and 44.6%, respectively. Multiple logistic regression analyses revealed that less frequently practicing hand washing/disinfection (odds ratio [OR] = 1.20, 95% confidence interval [CI]: 1.10-1.32), gargling (OR = 1.20, 95% CI: 1.10-1.30), and ensuring proper room ventilation (OR = 1.38, 95% CI: 1.26-1.52) were significantly associated with self-reported COVID-19-like illness (CLI). These results suggest that personal preventive behaviors may be effective in reducing CLI, even when universal masking is practiced.

Face masks increase compliance with physical distancing recommendations during the COVID-19 pandemic

Governments across the world have implemented restrictive policies to slow the spread of COVID-19. Recommended face mask use has been a controversially discussed policy, among others, due to potential adverse effects on physical distancing. Using a randomized field experiment (N = 300), we show that individuals kept a significantly larger distance from someone wearing a face mask than from an unmasked person during the early days of the pandemic. According to an additional survey experiment (N = 456) conducted at the time, masked individuals were not perceived as being more infectious than unmasked ones, but they were believed to prefer more distancing. This result suggests that wearing a mask served as a social signal that led others to increase the distance they kept. Our findings provide evidence against the claim that mask use creates a false sense of security that would negatively affect physical distancing. Furthermore, our results suggest that behavior has informational content that may be affected by policies.

Face mask use and physical distancing before and after mandatory masking: No evidence on risk compensation in public waiting lines

During the COVID-19 pandemic, the introduction of mandatory face mask usage triggered a heated debate. A major point of controversy is whether community use of masks creates a false sense of security that would diminish physical distancing, counteracting any potential direct benefit from masking. We conducted a randomized field experiment in Berlin, Germany, to investigate how masks affect distancing and whether the mask effect interacts with the introduction of an indoor mask mandate. Joining waiting lines in front of stores, we measured distances kept from the experimenter in two treatment conditions - the experimenter wore a mask in one and no face covering in the other - in two time spans - before and after mask use becoming mandatory in stores. We find no evidence that mandatory masking has a negative effect on distance kept toward a masked person. To the contrary, masks significantly increase distancing and the effect does not differ between the two periods. However, we show that after the mandate distances are shorter in locations where more non-essential stores, which were closed before the mandate, had reopened. We argue that the relaxations in general restrictions that coincided with the mask mandate led individuals to reduce other precautions, like keeping a safe distance.

The Theory of Planned Behavior during the COVID-19 pandemic: A comparison of health behaviors between Belgian and French residents

The COVID-19 pandemic presents a global crisis and authorities have encouraged the population to promote preventive health behaviors to slow the spread of the virus. While the literature on psychological factors influencing health behaviors during the COVID-19 is flourishing, there is a lack of cross-national research focusing on multiple health behaviors. The present study overcomes this limitation and affords a validation of the Theory of Planned Behavior (TPB) as a conceptual framework for explaining the adoption of handwashing and limitation of social contacts, two health behaviors that highly differ in their nature. Specifically, we compare TPB model on these two protective behaviors among people living in Belgium (N = 3744) and France (N = 1060) during the COVID-19 sanitary crisis. Data were collected from March 18 until April 19, 2020, which corresponds to the spring lockdown and the first peak of the pandemic in these countries. Results indicated that more positive attitudes, greater social norms, increased perceived control and higher intentions were related to higher adherence to handwashing and limitation of social contacts, for both Belgian and French residents. Ultimately, we argued that the TPB model tends to manifest similarly across countries in explaining health behaviors, when comparing handwashing and limitation of social contacts among individuals living in different national contexts.

Analysis of the effectiveness of face-coverings on the death ratio of COVID-19 using machine learning

The recent outbreak of the COVID-19 led to death of millions of people worldwide. To stave off the spread of the virus, the authorities in the US employed different strategies, including the mask mandate order issued by the states' governors. In the current work, we defined a parameter called average death ratio as the monthly average of the number of daily deaths to the monthly average number of daily cases. We utilized survey data to quantify people's abidance by the mask mandate order. Additionally, we implicitly addressed the extent to which people abide by the mask mandate order, which may depend on some parameters such as population, income, and education level. Using different machine learning classification algorithms, we investigated how the decrease or increase in death ratio for the counties in the US West Coast correlates with the input parameters. The results showed that for the majority of counties, the mask mandate order decreased the death ratio, reflecting the effectiveness of such a preventive measure on the West Coast. Additionally, the changes in the death ratio demonstrated a noticeable correlation with the socio-economic condition of each county. Moreover, the results showed a promising classification accuracy score as high as 90%.

The use of masks to protect against respiratory infections: An umbrella review

INTRODUCTION

The global health emergency caused by the current COVID-19 pandemic is resulting in a huge challenge at all levels. The use of masks may reduce the spread of the infection by minimising the excretion of Flügge droplets. The objective of this study was to compile the evidence available on the use of masks in relation to respiratory infections.

METHODOLOGY

An umbrella review (review of systematic reviews) was conducted. Two reviewers independently carried out the screening process, data extraction and data analysis. Discrepancies were resolved with a third reviewer, and the assessment of the risk of bias of the studies was carried out using the AMSTAR 2 tool. The Rayyan QCRI program was used for the screening process.

RESULTS

A total of eight systematic reviews were included. The studies analysed the use of masks in the general population, in long-term care facilities, in hospitals and at mass gatherings, and compared the effectiveness thereof in preventing infection. The results of this review revealed that the use of masks is associated with a protective effect against respiratory infections in healthcare facilities, in long-term care facilities and at mass gatherings.

CONCLUSIONS

In light of the results, it seems reasonable to recommend the use of masks to the general population, but this use should be accompanied by a training programme to improve compliance, as not using them properly may increase the risk of infection.

COVID-19 and handwashing: Implications for water use in Sub-Saharan Africa

Because the main modes of transmission of the COVID-19 virus are respiration and contact, WHO recommends frequent washing of hands with soap under running water for at least 20 s. This article investigates how the level of concern about COVID-19 affects the likelihood of washing hands frequently in sub-Saharan Africa. We discuss the implication of the findings for water-scarce environment. The study makes use of a unique survey dataset from 12 sub-Saharan African countries collected in April 2020 (first round) and May 2020 (second round) and employs an extended ordered probit model with endogenous covariate. The results show that the level of concern about the spread of the virus increases the likelihood of washing hands with soap under running water for a minimum of 20 s at least five times a day. The increase in the probability of handwashing due to concern about COVID-19, ranges from 3% for Benin to 6.3% for South Africa. The results also show heterogeneous effects across gender- and age-groups, locality and various water sources. However, in Africa, the sustainability of the handwashing protocol could be threatened by the severe water scarcity that exists in the region. To sustain frequent handwashing, sub-Saharan Africa needs an effective strategy for water management and supply.

Preventive effects of tea and tea catechins against influenza and acute upper respiratory tract infections: a systematic review and meta-analysis

Purpose

Gargling with tea has protective effects against influenza infection and upper respiratory tract infection (URTI). To evaluate if tea and tea catechin consumption has the same protective effects as gargling with tea, we performed a systematic review and meta-analysis.

Methods

We performed a comprehensive literature search using the PubMed, Cochrane Library, Web of Science, and Ichu-shi Web databases. The search provided six randomized controlled trials (RCTs) and four prospective cohort studies (n = 3748). The quality of each trial or study was evaluated according to the Cochrane risk-of-bias tool or Newcastle–Ottawa Scale. We collected data from publications meeting the search criteria and conducted a meta-analysis of the effect of tea gargling and tea catechin consumption for preventing URTI using a random effects model.

Results

Tea gargling and tea catechin consumption had significant preventive effects against URTI (risk ratio [RR] = 0.74, 95% confidence interval [CI] 0.64–0.87). In sub-analyses, a significant preventive effect was observed by study type (prospective cohort study: RR = 0.67, 95% CI 0.50–0.91; RCT: RR = 0.79, 95% CI 0.66–0.94) and disease type (influenza: RR = 0.69, 95% CI 0.58–0.84; acute URTI: RR = 0.78, 95% CI 0.62–0.98). Both gargling with tea and consuming tea catechins effectively protected against URTI (tea and tea catechins consumption: RR = 0.68, 95% CI 0.52–0.87; tea gargling: RR = 0.83, 95% CI 0.72–0.96).

Conclusion

Our findings suggest that tea gargling and tea catechin consumption may have preventive effects against influenza infection and URTI. The potential effectiveness of these actions as non-pharmaceutical interventions, however, requires further investigation.

A Review of Research on Tourism Industry, Economic Crisis and Mitigation Process of the Loss: Analysis on Pre, During and Post Pandemic Situation

Throughout time, the global tourism industry and economy have been significantly affected by disasters and crises. At present, COVID-19 represents one of these disasters as it has been causing a serious economic downturn with huge implications in tourism. In this review paper, we have analysed more than 100 papers regarding the effect and consequences of a pandemic on tourism and related industries, the economic situation in countries and areas, and mitigation of the loss incurred due to pandemic situations. The article (1) is based on past research on tourism and economy, (2) examines the effects of a pandemic on listed sectors and mitigation processes, and (3) suggests future research and approaches to help progress the field. We have gathered and categorised the literature reviews into several parts. In addition, we have listed the name of authors, journal names, books, websites, and relevant data.

A Proposed Functional Analysis of Transmission Prevention Behaviors for a Respiratory Virus (SARS-CoV-2)

The coronavirus (SARS-CoV-2) pandemic has had a global impact on lives everywhere and has led to the disruption of, and interference with, virtually every aspect of life. In response, leading experts, political leaders, doctors, and scientists have released guidelines that attempt to prevent and mitigate the exponential rate of infection. The response to these safety recommendations has produced tremendous behavior variability as a society. Although a plethora of factors are likely relevant, a more complete analysis of human behavior during this time might help explain this disparity. The principles of applied behavior analysis allow for a functional analysis of an individual's use of transmission prevention behaviors (TPBs) during the SARS-CoV-2 pandemic. Thus, the purpose of this discussion is to provide a conceptual analysis for some possible explanations for why individuals might or might not engage in virus TPBs, as well as some recommendations to help combat the current pandemic, as well as those in the future.

The high level of adherence to personal protective equipment in health care workers efficiently protects them from COVID-19 infection

BACKGROUND

The first case of coronavirus disease 2019 (COVID-19) was reported in December 2019 in Wuhan, China. Healthcare workers (HCWs) are at high risk of acquiring and spreading the COVID-19 infection; using personal protective equipment (PPE) reduces the risk of COVID-19 infection in HCWs.

OBJECTIVE

Our study aimed to investigate the seroprevalence of COVID-19 IgG, IgM antibodies among HCWs as well as identifying the factors associated with this seroprevalence.

METHODS

This cross-sectional study was performed from July to August 2020 on healthcare workers at two COVID-19 referral hospitals of Birjand University of Medical Sciences. The level of COVID-19 IgG and IgM antibodies in sera was measured by commercial qualitative ELISA kits.

RESULTS

In total, 192 individuals participated in the study: physicians (31.25%), nurses (30.2%). 84.2% of participants had contact with confirmed COVID-19 cases and among them 42.9 % of had close contact with COVID-19 patients for more than 3 months, and 31% reported close contact with more than 50 confirmed COVID-19 cases. Mask and gloves were the most frequently used personal protective equipment (PPE) with 92.4% and 77.2% of usage.

CONCLUSIONS

The results of the current study showed high level of adherence to the use of PPE among HCWs as well as very low prevalence of seropositivity for of COVID-19 antibodies, hence confirming the effectiveness of PPE in protecting HCWs among COVVID-19 and possibly any other similar infections.

Adherence to COVID-19 Appropriate Behavior Among Respiratory Therapists: A Cross-Sectional Study in the Kingdom of Saudi Arabia

Background: Adherence to novel coronavirus disease 2019 (COVID-19) appropriate behavior plays a crucial element in the management of the infections of COVID-19. Despite the importance of transmission-reducing behaviors among healthcare professionals, there is a lack of literature in this area of research explicitly relating to respiratory therapists (RTs). Therefore, it is essential to assess the adherence level to COVID-19 transmission-reducing behaviors among the RTs in Saudi Arabia. Methods: A web-based online survey was conducted using questions based on the risk assessment guidelines of WHO. A random representative sample of RTs (N = 215) residing in Saudi Arabia was recruited for the study. Descriptive and inferential statistics were computed using STATA software. Logistic regression analysis was used to identify key factors that are associated with adherence to COVID-19 appropriate behavior among the study participants. Results: Of the 215 participants, 59.5% were aged between 26 and 35 years, and 40.9% were women. Most (85.5%) participants had a bachelor's degree while 12.0% had a master's degree. About 56.2% of RTs provided direct care to a confirmed patient of COVID-19 during the study periods. The study showed 80.9% of RTs in Saudi Arabia adhered to personal protective equipment (PPE) at the workplace and 65.0% at home. Moreover, the findings of the study indicated that senior RTs (with >5 years of experience) demonstrated a higher adherence level to the guidelines than RTs with <5 years of experience. High-risk perception [aOR:2.32; 95% CI: 1.09-3.27], and work history of <5 years [aOR:2.00; 95% CI: 1.14-3.15], were found to be the strongest predictors in explaining the adherence to appropriate behavior among the RTs at the workplace. Whereas the high-risk perception [aOR:2.32; 95% CI: 1.09-3.27] and being married [aOR:1.85; 95% CI: 1.08-3.82] were found to be the strongest predictors at home. Conclusion: Adherence ("Always" or "Most times") to COVID-19 appropriate behavior was found to be high at hospital settings among the study participants. However, the same practice was found to be inconsistence in non-healthcare settings among the RTs. Considering the paramount role of COVID-19 appropriate behavior in reducing the transmissions the policy focus, therefore, needs to be on creating a well-spread behavior change communication that is curtailing the adoption of appropriate behavior in the non-healthcare settings.

Transmissibility and transmission of respiratory viruses

Human respiratory virus infections lead to a spectrum of respiratory symptoms and disease severity, contributing to substantial morbidity, mortality and economic losses worldwide, as seen in the COVID-19 pandemic. Belonging to diverse families, respiratory viruses differ in how easy they spread (transmissibility) and the mechanism (modes) of transmission. Transmissibility as estimated by the basic reproduction number (R0) or secondary attack rate is heterogeneous for the same virus. Respiratory viruses can be transmitted via four major modes of transmission: direct (physical) contact, indirect contact (fomite), (large) droplets and (fine) aerosols. We know little about the relative contribution of each mode to the transmission of a particular virus in different settings, and how its variation affects transmissibility and transmission dynamics. Discussion on the particle size threshold between droplets and aerosols and the importance of aerosol transmission for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and influenza virus is ongoing. Mechanistic evidence supports the efficacies of non-pharmaceutical interventions with regard to virus reduction; however, more data are needed on their effectiveness in reducing transmission. Understanding the relative contribution of different modes to transmission is crucial to inform the effectiveness of non-pharmaceutical interventions in the population. Intervening against multiple modes of transmission should be more effective than acting on a single mode.

Expiratory aerosol particle escape from surgical masks due to imperfect sealing

Wearing surgical masks or other similar face coverings can reduce the emission of expiratory particles produced via breathing, talking, coughing, or sneezing. Although it is well established that some fraction of the expiratory airflow leaks around the edges of the mask, it is unclear how these leakage airflows affect the overall efficiency with which masks block emission of expiratory aerosol particles. Here, we show experimentally that the aerosol particle concentrations in the leakage airflows around a surgical mask are reduced compared to no mask wearing, with the magnitude of reduction dependent on the direction of escape (out the top, the sides, or the bottom). Because the actual leakage flowrate in each direction is difficult to measure, we use a Monte Carlo approach to estimate flow-corrected particle emission rates for particles having diameters in the range 0.5-20 μm. in all orientations. From these, we derive a flow-weighted overall number-based particle removal efficiency for the mask. The overall mask efficiency, accounting both for air that passes through the mask and for leakage flows, is reduced compared to the through-mask filtration efficiency, from 93 to 70% for talking, but from only 94-90% for coughing. These results demonstrate that leakage flows due to imperfect sealing do decrease mask efficiencies for reducing emission of expiratory particles, but even with such leakage surgical masks provide substantial control.

Effects of the filter microstructure and ambient air condition on the aerodynamic dispersion of sneezing droplets: A multiscale and multiphysics simulation study

Concerns have been ramping up with regard to the propagation of infectious droplets due to the recent COVID-19 pandemic. The effects of filter microstructures and ambient air flows on droplet dispersion by sneezing are investigated by a fully coupled Eulerian-Lagrangian computational modeling with a micro-to-macroscale bridging approach. Materials that are commonly applied to face masks are modeled to generate two different virtual masks with various levels of filtration efficiency, and the leakage percentages through the unsealed nose and cheek areas were set to 11% and 25%, respectively. The droplet propagation distance was simulated with and without mask wearing in still and windy conditions involving head wind, tail wind, and side wind. The results demonstrate that wearing a face mask reduces the transmittance distance of droplets by about 90%-95% depending on the mask type; nonetheless, the droplets can be transmitted to distances of 20-25 cm in the forward direction even with mask-wearing. Thus, a social distance of at least 20 cm between people would help to prevent them from becoming exposed to ejected droplets. This study is significant in that important aspects of mask materials, in this case the porous microstructure-dependent filtration efficiency and permeability under varied ambient flow conditions, were considered for the first time in an evaluation of the barrier performance against droplet transmittance through a multiphase computational fluid dynamics simulation of air-droplet interaction and turbulence flow dynamics.

Face masks against COVID-19: Standards, efficacy, testing and decontamination methods

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus responsible for the novel coronavirus disease 2019 (COVID-19), has caused a global pandemic on a scale not seen for over a century. Increasing evidence suggests that respiratory droplets and aerosols are likely the most common route of transmission for SARS-CoV-2. Since the virus can be spread by presymptomatic and asymptomatic individuals, universal face masking has been recommended as a straightforward and low-cost strategy to mitigate virus transmission. Numerous governments and public health agencies around the world have advocated for or mandated the wearing of masks in public settings, especially in situations where social distancing is not possible. However, the efficacy of wearing a mask remains controversial. This interdisciplinary review summarizes the current, state-of-the-art understanding of mask usage against COVID-19. It covers three main aspects of mask usage amid the pandemic: quality standards for various face masks and their fundamental filtration mechanisms, empirical methods for quantitatively determining mask integrity and particle filtration efficiency, and decontamination methods that allow for the reuse of traditionally disposable N95 and surgical masks. The focus is given to the fundamental physicochemical and engineering sciences behind each aspect covered in this review, providing novel insights into the current understanding of mask usage to curb COVID-19 spread.