The indirect impact of COVID-19 large-scale containment measures on the incidence of community-acquired pneumonia in older people: a region-wide population-based study in Tuscany, Italy

Effects of coronavirus disease 2019 on the spread of respiratory-transmitted human-to-human bacteria

OBJECTIVES

The coronavirus disease 2019 (COVID-19) pandemic has necessitated significant changes in medical systems, social behaviours, and non-pharmaceutical interventions (NPIs). We aimed to determine the effect of the COVID-19 pandemic on changes in the epidemiology of respiratory-transmitted bacteria that have been unexplored.

METHODS

We utilised a comprehensive national surveillance database from 2018 to 2021 to compare monthly number of patients with four respiratory -transmitted human-to-human bacteria (Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, and Streptococcus pyogenes) before and after the COVID-19 pandemic, stratified by specimen sources and age groups.

RESULTS

The incidence of detected patients with S. pneumoniae, H. influenzae, and S. pyogenes from both respiratory and blood cultures significantly decreased from 2019 to 2020. In 2021, the incidence of detected patients with the respiratory-transmitted bacterial species, except for S. pyogenes, from respiratory cultures increased again from April to July, primarily affecting the 0-4-year age group.

CONCLUSIONS

Our comprehensive national surveillance data analysis demonstrates the dynamic changes and effects of NPIs on respiratory-transmitted bacteria during the COVID-19 pandemic, with variations observed among species, specimen sources, and age groups.

Reduction in the incidence of invasive infections caused by encapsulated bacteria after the onset of the COVID-19 pandemic

Interaction between severe acute respiratory coronavirus 2 (SARS-CoV-2) and IIEB remains under investigation. Objective: to compare IIEB incidence before and during COVID-19 pandemic, and assess incidence of coinfection with COVID-19 and case fatality. A cross-sectional study was performed on data from a centralized microbiology laboratory serving a network of healthcare centers comprising 713 pediatric and adult inpatient beds, expanded by 20% during the pandemic. Three periods were evaluated: (1) pre-pandemic: March 1, 2019-February 29, 2020; (2) pandemic year 1: March 1, 2020-February 28, 2021; (3) pandemic year 2: March 1, 2021-July 31, 2021. Descriptive statistical analysis was performed. 56 502 samples (96% blood cultures) from 27224 patients were analyzed. Of these, 54 samples (from 54 patients) were positive for encapsulated bacteria. IIEB incidence was: 167.4, 32.6, and 50.4 per 100000 samples for periods 1, 2, and 3, respectively. Twelve IIEB episodes occurred during the pandemic period: 10 Streptococcus pneumoniae, and 2 Haemophilus influenzae, of which 7 were SARS-CoV-2/S. pneumoniae coinfections, with an incidence of 5.68 per 10000 COVID-19-related hospitalizations (0.056%). IIEB case fatality was 31%, 29%, and 60% for each period, respectively, 3/7 patients with coinfection died (43%). Case fatality for invasive pneumococcal disease (IPD) in patients without COVID-19, was 32.5%. Significant reduction in IIEB incidence was observed during the pandemic, coinciding with implementation of containment measures. The incidence of SARS-CoV-2/S. pneumoniae coinfection was low, with higher case fatality than IPD patients without COVID-19.

A Profile of Adult Severe Acute Respiratory Syndrome Coronavirus 2 Pneumonia Patients According to Pneumococcal Vaccination Status

Certain patient profile characteristics, such as preexisting medical conditions, can modify the risk of developing SARS-CoV-2 pneumonia among adults vaccinated and not vaccinated against pneumococcal disease. This retrospective cohort study aimed to quantify the risk of pneumonia caused by SARS-CoV-2 among individuals from 15 to 64 years old with and without pneumococcal vaccination in Spain during the 2020-2021 influenza season and establish a risk profile of patients more likely to develop SARS-CoV-2 pneumonia. Data (demographic information, patient medical history, and lifestyle habits) were gathered both directly from the patient via personal interview and by reviewing electronic medical records. In an adjusted analysis for pneumococcal vaccinated patients, visits to hospital outpatient clinics were protective while visits to primary health care services, being widowed, obese, and not using masks in outdoor open spaces were identified as risk factors. For patients who had not received a pneumococcal vaccine, visits to hospital outpatient clinics were protective, while being overweight or obese, alcohol consumption, and not using masks in outdoor open spaces were identified as risk factors. Concerning comorbidities, in the pneumococcal vaccinated group none were found to be protective but having diabetes or other respiratory diseases were identified as risk factors. In the unvaccinated group, undergoing immunosuppressive treatment and having metastatic tumors were protective factors, while cerebrovascular disease and obesity with a BMI ≥ 40 were risk factors. A similar risk profile for developing SARS-CoV-2 pneumonia in pneumococcal vaccinated and non-vaccinated individuals was found. Generally, vaccinated individuals had a lower risk of developing SARS-CoV-2. The findings suggest that vaccination against S. pneumoniae could prevent and reduce SARS-CoV-2 pneumonia. Additionally, this study has identified individuals with other medical conditions, such as obesity, underweight, diabetes, and a history of respiratory diseases, who are at an increased risk of developing SARS-CoV-2 pneumonia and could benefit from vaccination and supervision.

Impact of the COVID-19 pandemic on severe non-SARS-CoV-2 community-acquired pneumonia in Reunion Island: a multicenter retrospective observational study, 2016-2021

The Coronavirus 2019 (COVID-19) pandemic has had a considerable impact on the incidence of severe community-acquired pneumonia (CAP) worldwide. The aim of this study was to assess the early impact of the COVID-19 pandemic in the Reunion Island. This multicenter retrospective observational study was conducted from 2016 to 2021 in the hospitals of Reunion Island. The incidence of severe non-SARS-CoV-2 CAP, microorganisms, characteristics and outcomes of patients hospitalized in intensive care unit were compared between the pre-COVID-19 period (January 1, 2016 to February 29, 2020) and the early COVID-19 period (March 1, 2020 to October 31, 2021). Over the study period, 389 patients developed severe non-SARS-CoV-2 CAP. The incidence of severe non-SARS-CoV-2 CAP significantly decreased between the two periods (9.16 vs. 4.13 cases per 100,000 person-years). The influenza virus was isolated in 43.5% patients with severe non-SARS-CoV-2 CAP in the pre-COVID-19 period and in none of the 60 patients in the early COVID-19 period (P < 0.0001). The only virus that did not decrease was rhinovirus. Streptococcus pneumoniae was the most frequently isolated bacterial microorganism, with no significant difference between the two periods. In Reunion Island, the COVID-19 pandemic led to a significant decrease in the incidence of influenza, which likely explains the observed decrease in the incidence of severe non-SARS-CoV-2 CAP. The pandemic had no impact on the incidence of other viral and bacterial severe non-SARS-CoV-2 CAP. Monitoring influenza incidence is crucial now that COVID-19 control measures have been removed.

Decreased community-acquired pneumonia coincided with rising awareness of precautions before governmental containment policy in Japan

The effectiveness of population-wide compliance to personal precautions (mask-wearing and hand hygiene) in preventing community-acquired pneumonia has been unknown. In Japan, different types of nonpharmaceutical interventions from personal precautions to containment and closure policies (CACPs, e.g. stay-at-home requests) were sequentially introduced from late January to April 2020, allowing for separate analysis of the effects of personal precautions from other more stringent interventions. We quantified the reduction in community-acquired pneumonia hospitalizations and deaths and assessed if it coincided with the timing of increased public awareness of personal precautions before CACPs were implemented. A quasi-experimental interrupted time-series design was applied to non-COVID-19 pneumonia hospitalization and 30-day death data from April 2015 to August 2020 across Japan to identify any trend changes between February and April 2020. We also performed a comparative analysis of pyelonephritis and biliary tract infections to account for possible changes in the baseline medical attendance. These trend changes were then compared with multiple indicators of public awareness and behaviors related to personal precautions, including keyword usage in mass media coverage and sales of masks and hand hygiene products. Hospitalizations and 30-day deaths from non-COVID-19 pneumonia dropped by 24.3% (95% CI 14.8-32.8) and 16.1% (5.5-25.5), respectively, in February 2020, before the implementation of CACPs, whereas pyelonephritis and biliary tract infections did not suggest a detectable change. These changes coincided with increases in indicators related to personal precautions rather than those related to contact behavior changes. Community-acquired pneumonia could be reduced by population-wide compliance to moderate precautionary measures.

The effects of the COVID-19 pandemic on community respiratory virus activity

The emergence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) caused substantial global morbidity and deaths, leading governments to turn to non-pharmaceutical interventions to slow down the spread of infection and lessen the burden on health care systems. These policies have evolved over the course of the COVID-19 pandemic, including after the availability of COVID-19 vaccines, with regional and country-level differences in their ongoing use. The COVID-19 pandemic has been associated with changes in respiratory virus infections worldwide, which have differed between virus types. Reductions in respiratory virus infections, including by influenza virus and respiratory syncytial virus, were most notable at the onset of the COVID-19 pandemic and continued in varying degrees through subsequent waves of SARS-CoV-2 infections. The decreases in community infection burden have resulted in reduced hospitalizations and deaths associated with non-SARS-CoV-2 respiratory infections. Respiratory virus evolution relies on the maintaining of a diverse genetic pool, but evidence of genetic bottlenecking brought on by case reduction during the COVID-19 pandemic has resulted in reduced genetic diversity of some respiratory viruses, including influenza virus. By describing the differences in these changes between viral species across different geographies over the course of the COVID-19 pandemic, we may better understand the complex factors involved in community co-circulation of respiratory viruses.

Impact of the early phase of COVID-19 on the trends of isolated bacteria in the national database of Japan: an interrupted time-series analysis

OBJECTIVES

During the coronavirus disease 2019 (COVID-19) pandemic, a change in the trend of infections was observed. However, there are few reports comprehensively assessing the impact of the early phase of COVID-19 on the trend of bacteria isolated.

METHODS

We extracted the number of positive cultures of hospitalized patients for approximately 200 institutions using the Japanese national database. The outcome was the ratio of 10 species isolated in comparison to the total isolates for each month. Interrupted time-series analyses were conducted between 13 (from Jan-2019 to Jan-2020) and 8 (from May-2020 to Dec-2020) monthly data points.

RESULTS

A total of 369,210 isolates were involved. Differences in the level change for Streptococcus pneumoniae, Haemophilus influenzae, and Streptococcus pyogenes decreased significantly by 0.272 (95% confidence interval [CI]:0.192-0.352), 0.244 (95%CI:0.174-0.314), and 0.324 (95%CI:0.06-0.589), respectively. Bacteria transmitted by contact infection, such as Staphylococcus aureus, did not decrease. Differences in slope change were not significant in all species.

CONCLUSIONS

The ratios of isolated bacteria transmitted by droplet infection decreased immediately after the early phase of COVID-19 and maintained the same level. The awareness and behavioral changes toward increased COVID-19 prevention might have a substantial impact on the prevention of bacterial infections, especially droplet infections.

Communicating with Patients about COVID-19 Vaccination: A Qualitative Study on Vaccinators in Tuscany Region, Italy

The rapid development of the vaccine and the infodemia have challenged communication about COVID-19 vaccines. This study aims to characterize-through the experience of vaccinators-the challenges faced during COVID-19 vaccination consultations and the communication strategies adopted. A qualitative study was conducted on COVID-19 vaccinators in Tuscany, Italy. Face-to-face interviews were conducted and examined by thematic analysis. In total, 30 vaccinators were interviewed. Four main themes emerged. The first highlighted distinct profiles of users' attitudes toward COVID-19 vaccination. Barriers and promoters of vaccine uptake emerged in the second theme: concerns over the vaccine, excessive exposure to information, and a lack of clear guidance from institutions were the main factors behind hesitancy. The third theme highlighted users' information-seeking behaviors; vaccinators observed that users ideologically opposed to the vaccine (IOV) unconsciously seek information that confirms their theories. The last theme comprised communication strategies for dealing with hesitancy. Empathy, first-hand examples, transparency, and tailored communication style appear to be effective in building vaccine trust. Lastly, the impossibility of developing a decision-making partnership with IOVs was noticed. These findings may help to better characterize public attitudes toward COVID-19 vaccination and highlight key communication principles and strategies to foster vaccine confidence.

Clinical, economic, and humanistic burden of community acquired pneumonia in Europe: a systematic literature review

BACKGROUND

Community-acquired pneumonia (CAP) is an infectious lung inflammation contracted outside the hospital. CAP is a leading cause of death among young children, elderly, and immunocompromised persons. Incidence can reach 14 cases/1,000 adults. Up to 50% of cases require inpatient hospitalization. Mortality is 0.7/1,000 cases or 4 million deaths per year. We sought to summarize multi-dimensional burden of CAP for selected European countries.

METHODS

We conducted a systematic literature review of literature published from 2011 to 2021 whereby we sought information pertaining to the epidemiologic, clinical, economic, and humanistic burden of CAP. Findings were summarized descriptively.

RESULTS

CAP incidence in Europe is variable, with the highest burden among those of advanced age and with chronic comorbidities. Etiology is primarily bacterial infection with Streptococcus pneumoniae being the most frequently implicated. Direct medical costs are primarily attributable to inpatient stay, which is exacerbated among high-risk populations. Higher mortality rates are associated with increasing age, the need for inpatient hospitalization, and antibiotic resistance.

CONCLUSIONS

A better understanding of CAP is needed, specifically the economic and quality of life burden on patients and caregivers. We recommend further assessments using population-level and real-world data employing consistent disease definitions.

Indirect impact of the COVID-19 pandemic on the incidence of non-COVID-19 infectious diseases: a region-wide, patient-based database study in Japan

OBJECTIVES

The COVID-19 pandemic has forced people to change many behaviours, including physical distancing, hygiene measures and lifestyles. This study aimed to evaluate the indirect impact of the COVID-19 pandemic on the incidence of non-COVID-19 infections and medical care costs/visits using health insurance claims.

STUDY DESIGN

This was an observational study using patient-based administrative claims covering approximately 800,000 insured persons and their dependents in the Mie Prefecture in Japan.

METHODS

This study identified non-COVID-19 infectious disease incidences, number of outpatient visits and healthcare costs between 2017 and 2021. Each year was divided into quarters. The adjusted incidence rate ratios (IRRs) during the pandemic (January 2020 to September 2021) and during the prepandemic period (January 2017 to December 2019) were determined using Poisson regression.

RESULTS

The adjusted influenza IRRs from April 2020 were close to zero. The incidence of upper respiratory tract infections and bacterial pneumonia was significantly reduced (IRRs range: 0.39-0.73 and 0.43-0.84, respectively). Gastrointestinal and urinary tract infection incidences decreased by approximately 30% and 10%, respectively. In contrast, sexually transmitted infections (STIs), including syphilis, gonococcal infection and Chlamydia trachomatis infection, did not decrease during the pandemic but increased significantly between April and June 2021 (adjusted IRR, 1.37; 95% confidence interval, 1.18-1.60). The adjusted IRRs for outpatient visits and healthcare costs were 0.86-0.93 and 0.91-0.97, respectively.

CONCLUSIONS

In contrast to other infections, STIs did not decrease during the COVID-19 pandemic. The IRR of STIs during the pandemic period is an area of public health concern. Appropriate screening and medical consultations are strongly recommended.

The indirect impact of COVID-19 pandemic on the utilization of the emergency medical services during the first pandemic wave: A system-wide study of Tuscany Region, Italy

Background

Utilization of Emergency Medical Services (EMS) declined during COVID-19 pandemic, but most of the studies analyzed components of the EMS system individually. The study aimed to evaluate the indirect impact of COVID-19 pandemic on the utilization of all the components of the EMS system of Tuscany Region (Italy) during the first pandemic wave.

Methods

Administrative data from the health care system of Tuscany were used. Changes in utilization for out-of-hospital emergency calls and emergency vehicle dispatched, emergency department (ED) visits, and patients being admitted from the ED to an inpatient hospital bed (hospitalizations from ED) during the first pandemic wave were analyzed in relation with corresponding periods of the previous two years. Percentage changes and 95%CI were calculated with Poisson models. Standardized Ratios were calculated to evaluate changes in in-hospital mortality and hospitalizations requiring ICU.

Results

Significant declines were observed in the utilization of all the EMS considered starting from the week in which the first case of COVID-19 was diagnosed in Italy till the end of the first pandemic wave. During the epidemic peak, the maximum decreases were observed: -33% for the emergency calls, -45% for the dispatch of emergency vehicles, -71% for ED admissions. Furthermore, a decline of 37% for hospitalizations from ED was recorded. Significant decreases in ED admissions for life threatening medical conditions were observed: acute cerebrovascular disease (-36%, 95% CI: -43, -29), acute myocardial infarction (-42%, 95% CI: -52, -31) and renal failure (-42%, 95% CI: -52, -31). No significant differences were found between the observed and the expected in-hospital mortality and hospitalizations requiring ICU during the epidemic peak.

Conclusion

All the components of the EMS showed large declines in their utilization during COVID-19 pandemic; furthermore, major reductions were observed for admissions for time-dependent and life-threatening conditions. Efforts should be made to ensure access to safe and high-quality emergency care during pandemic.

The secondary outcome of public health measures amidst the COVID-19 pandemic in the spread of other respiratory infectious diseases in Thailand

The coronavirus disease 2019 (COVID-19) has promoted stringent public health measures such as hand hygiene, face mask wearing, and physical distancing to contain the spread of the viral infection. In this retrospective study, the secondary outcomes of those public health measures on containing other respiratory infections among the Thai population were investigated. Hospitalization data spanning from 2016 to 2021 of six respiratory infectious diseases, namely influenza, measles, pertussis, pneumonia, scarlet fever, and tuberculosis (TB), were examined. First, the expected respiratory infectious cases where no public health measures are in place are estimated using the seasonal autoregressive integrated moving average (SARIMA) model. Then the expected number of cases and the observed cases were compared. The results showed a significant drop in the incidence of respiratory infectious diseases by an average of 61%. The reduction in hospitalization is significant for influenza, measles, pertussis, pneumonia, and scarlet fever (p < 0.05), while insignificant for TB (p = 0.54). The notable decrease in the incidence of cases is ascribed to the implementation of public health measures that minimized the opportunity for spread of disease. This decline in cases following relaxation of pandemic countermeasure is contingent on its scope and nature, and it is proof that selective physical distancing, hand hygiene, and use of face masks in public places is a viable route for mitigating respiratory morbidities.

Changing Epidemiology of Respiratory Tract Infection during COVID-19 Pandemic

The outbreak of COVID-19 has significantly changed the epidemiology of respiratory tract infection in several ways. The implementation of non-pharmaceutical interventions (NPIs) including universal masking, hand hygiene, and social distancing not only resulted in a decline in reported SARS-CoV-2 cases but also contributed to the decline in the non-COVID-19 respiratory tract infection-related hospital utilization. Moreover, it also led to the decreased incidence of previous commonly encountered respiratory pathogens, such as influenza and Streptococcus pneumoniae. Although antimicrobial agents are essential for treating patients with COVID-19 co-infection, the prescribing of antibiotics was significantly higher than the estimated prevalence of bacterial co-infection, which indicated the overuse of antibiotics or unnecessary antibiotic use during the COVID-19 pandemic. Furthermore, inappropriate antimicrobial exposure may drive the selection of drug-resistant microorganisms, and the disruption of infection control in COVID-19 setting measures may result in the spread of multidrug-resistant organisms (MDROs). In conclusion, NPIs could be effective in preventing respiratory tract infection and changing the microbiologic distribution of respiratory pathogens; however, we should continue with epidemiological surveillance to establish updated information, antimicrobial stewardship programs for appropriate use of antibiotic, and infection control prevention interventions to prevent the spread of MDROs during the COVID-19 pandemic.

The Role of Health Literacy in COVID-19 Preventive Behaviors and Infection Risk Perception: Evidence from a Population-Based Sample of Essential Frontline Workers during the Lockdown in the Province of Prato (Tuscany, Italy)

Background: The effectiveness of pandemic control measures requires a broad understanding from the population. This study aimed to evaluate the role played by health literacy (HL) in influencing the adherence to COVID-19 preventive measures and risk perception of essential frontline workers during the lockdown period. Methods: A cross-sectional survey was conducted on a population-based sample of frontline workers from Prato Province (Italy). Data on knowledge, attitudes and practices towards COVID-19 preventive measures and risk perception were collected. HL was measured with the HLS-EU-Q6 tool. Multivariate linear regression analyses were performed. Results: A total of 751 people participated in this study, and 56% of the sample showed a sufficient level of HL. In the multivariate models, HL resulted in being positively correlated with both knowledge (beta 0.32 for sufficient HL, 0.11 for problematic HL) and attitudes (beta 0.33 for sufficient HL, 0.17 for problematic HL) towards the importance of COVID-19 preventive measures. The HL level was not associated with the adoption of preventive behaviors and COVID-19 risk perception. Conclusions: HL may play a key role in maintaining a high adherence to infection prevention behaviors and may be a factor to take into account in the implementation of public health interventions in pandemic times.

COVID-19 and schools: what is the risk of contagion? Results of a rapid-antigen-test-based screening campaign in Florence, Italy

Introduction

In the coronavirus disease 2019 era, debate around the risk of contagion in school is intense in Italy. The Department of Welfare and Health of Florence promoted a screening campaign with rapid antigen tests for all students and school personnel. The aim of this study was to assess the circulation of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) in the school setting by means of mass screening in every primary and middle school in Florence.

Methods

All students and school personnel at primary and middle schools in Florence were asked to take part. The campaign started on 16 November 2020 and was completed on 12 February 2021. If a subject had a positive result on rapid antigen testing, a molecular test was performed to confirm the result.

Results

In total, 18,414 subjects were tested: 15,233 students (82.7%) and 3181 school personnel (17.3%). The rapid antigen test gave a positive result in 27 cases (0.15%). Of these, only 14 tests were confirmed to be positive on molecular testing. These results show a very low number of cases of SARS-CoV-2 among the study subjects (0.08%).

Conclusions

These results show that the spread of SARS-CoV-2 in the school setting was low in Florence during the screening period.