The impact of COVID-19 and strategies for mitigation and suppression in low- and middle-income countries

Pandemic response strategies and threshold phenomena

This paper critically evaluates the Suppression Threshold Strategy (STS) for controlling Covid-19 (C-19). STS asserts a "fundamental distinction" between suppression and mitigation strategies, reflected in very different outcomes in eventual mortality depending on whether reproductive number R is caused to fall below 1. We show that there is no real distinction based on any value of R which falls in any case from early on in an epidemic wave. We show that actual mortality outcomes lay on a continuum, correlating with suppression levels, but not exhibiting any step changes or threshold effects. We argue that an excessive focus on achieving suppression at all costs, driven by the erroneous notion that suppression is a threshold, led to a lack of information on how to trade off the effects of different specific interventions. This led many countries to continue with inappropriate intervention-packages even after it became clear that their initial goal was not going to be attained. Future pandemic planning must support the design of "Plan B", which may be quite different from "Plan A".

Scenario Design for Infectious Disease Projections: Integrating Concepts from Decision Analysis and Experimental Design

Across many fields, scenario modeling has become an important tool for exploring long-term projections and how they might depend on potential interventions and critical uncertainties, with relevance to both decision makers and scientists. In the past decade, and especially during the COVID-19 pandemic, the field of epidemiology has seen substantial growth in the use of scenario projections. Multiple scenarios are often projected at the same time, allowing important comparisons that can guide the choice of intervention, the prioritization of research topics, or public communication. The design of the scenarios is central to their ability to inform important questions. In this paper, we draw on the fields of decision analysis and statistical design of experiments to propose a framework for scenario design in epidemiology, with relevance also to other fields. We identify six different fundamental purposes for scenario designs (decision making, sensitivity analysis, value of information, situational awareness, horizon scanning, and forecasting) and discuss how those purposes guide the structure of scenarios. We discuss other aspects of the content and process of scenario design, broadly for all settings and specifically for multi-model ensemble projections. As an illustrative case study, we examine the first 17 rounds of scenarios from the U.S. COVID-19 Scenario Modeling Hub, then reflect on future advancements that could improve the design of scenarios in epidemiological settings.

Why People Stayed Home During the COVID-19 Pandemic: Implications for Health Communication Across Four Countries

Staying at home substantially reduces the spread of COVID-19. Moreover, understanding why people stayed at home by addressing its social cognitive determinants can help create more effective communication to change behaviors. This study analyzed this outcome through an extended model of the theory of planned behavior based on risk perception and personal norms in four countries: the United States, Japan, Brazil, and Taiwan. 1,196 individuals participated in this study through a questionnaire focused on planned behavior, moral norms, and risk perception. The data showed that intention and perceived behavioral control influenced behavior significantly, while attitude, injunctive norms, perceived behavioral control, personal norms, and risk perception influenced intention. With multigroup analysis and ANOVA, we verified significant differences in the estimates and mean scores across cultures, revealing the need for scholars to analyze outcomes based on geography and local political culture. Given that health communications played a key role in managing the pandemic, this study clarifies the social cognitive determinants of staying at home and how the local political culture can impact their influence. Thus, we provide an evidence-based prescription for focused communications.

Are Lockdowns Effective in Managing Pandemics?

The present coronavirus crisis caused a major worldwide disruption which has not been experienced for decades. The lockdown-based crisis management was implemented by nearly all the countries, and studies confirming lockdown effectiveness can be found alongside the studies questioning it. In this work, we performed a narrative review of the works studying the above effectiveness, as well as the historic experience of previous pandemics and risk-benefit analysis based on the connection of health and wealth. Our aim was to learn lessons and analyze ways to improve the management of similar events in the future. The comparative analysis of different countries showed that the assumption of lockdowns’ effectiveness cannot be supported by evidence—neither regarding the present COVID-19 pandemic, nor regarding the 1918–1920 Spanish Flu and other less-severe pandemics in the past. The price tag of lockdowns in terms of public health is high: by using the known connection between health and wealth, we estimate that lockdowns may claim 20 times more life years than they save. It is suggested therefore that a thorough cost-benefit analysis should be performed before imposing any lockdown for either COVID-19 or any future pandemic.

Strategic drivers to overcome the impacts of the COVID-19 pandemic: implications for ensuring resilience in supply chains

The recent coronavirus (COVID-19) pandemic has affected the manufacturing industry’s entire supply chain system. It is important to investigate the strategic drivers to deal with the impacts of COVID-19 in the manufacturing industry. Accordingly, this study aims to identify the strategic drivers to overcome the impacts of the COVID-19 pandemic and improve the resiliency of the Bangladeshi footwear industry, an emerging economy. The strategic drivers are identified after reviewing research papers, reports, blogs, and discussions on social media platforms. The main drivers and their respective sub-drivers are finalized by discussing with domain experts. To offer strategic plans for building resiliency, it is crucial to know the importance of the main drivers and sub-drivers; therefore, the best–worst method is applied to determine the priority importance of the strategic drivers. The findings indicate that the top five drivers to defeat the impacts of COVID-19 are “high capability of reconfigurability,” “enhance the relationship with suppliers,” “develop health protocols to continue manufacturing,” “government support through incentives, subsidy, tax rebate, etc.,” and “set a policy to stable material supply”. Based on the findings, this study also provides practical implications with proposed research themes for policymakers and operations managers towards mitigating the impacts of the COVID-19 pandemic. The study’s contribution is unique and important for the footwear supply chain as the research on COVID-19 in the context of resiliency focusing on the footwear supply chain is non-existent.

Clinical and epidemiological aspects of SARS-CoV-2 infection among pregnant and postpartum women in Mozambique: a prospective cohort study

Background

Although there is a significant increase of evidence regarding the prevalence and impact of COVID-19 on maternal and perinatal outcomes, data on the effects of the pandemic on the obstetric population in sub-Saharan African countries are still scarce. Therefore, the study aims were to assess the prevalence and impact of COVID-19 on maternal and neonatal outcomes in the obstetric population at Central Hospital of Maputo (HCM), Mozambique.

Methods

Prospective cohort study conducted at teaching and referral maternity, HCM, from 20 October 2020 to 22 July 2021. We collected maternal and perinatal outcomes up to 6 weeks postpartum of eligible women (pregnant and postpartum women—up to the 14th day postpartum) screened for COVID-19 (individual test for symptomatic participants and pool testing for asymptomatic). The primary outcome was maternal death, Severe Acute Respiratory Syndrome (SARS) and Intensive Care Unit (ICU) admission. We estimated the COVID-19 prevalence and the unadjusted RR (95% CI) for maternal and perinatal outcomes. We used the chi-square or Fisher's exact test to compare categorical variables (two-sided p-value < 0.05 for statistical significance).

Results

We included 239 participants. The overall prevalence of COVID-19 was 9.2% (22/239) and in the symptomatic group was 32.4% (11/34). About 50% of the participants with COVID-19 were symptomatic. Moreover, the most frequent symptoms were dyspnoea (33.3%), cough (28.6%), anosmia (23.8%), and fever (19%). Not having a partner, being pregnant, and alcohol consumption were vulnerability factors for SARS-CoV-2 infection. The risk of adverse maternal and neonatal outcomes (abortion, foetal death, preterm birth, Apgar, and NICU admission) was not significantly increased with COVID-19. Moreover, we did not observe a significant difference in the primary outcomes (SARS, ICU admission and maternal death) between COVID-19 positive and COVID-19 negative groups.

Conclusion

The prevalence of COVID-19 in the obstetric population is higher than in the general population, and fifty percent of pregnant and postpartum women with COVID-19 infection are asymptomatic. Not having a partner and alcohol consumption were factors of greatest vulnerability to SARS-COV-2 infection. Moreover, being pregnant versus postpartum was associated with increased vulnerability to COVID-19. Data suggest that pregnant women with COVID-19 may have a higher frequency of  COVID-19 infection, reinforcing the need for universal testing, adequate follow-up for this population, and increasing COVID-19 therapy facilities in Mozambique. Moreover, provide counselling during Antenatal care for COVID-19 preventive measures. However, more prospective and robust studies are needed to assess these findings.

The epidemiological pattern of the COVID-19 pandemic in Africa is heterogeneous, and many African countries are still struggling to establish efficient testing policy, guarantee sufficient laboratory supply and achieve or maintain adequate testing capacity. In addition, evidence suggests that sexual and reproductive health services were the most affected by the pandemic; this scenario might have devastating effects on maternal and perinatal health. Moreover, data from non-sub-Saharan countries the SARS-CoV-2 infection among pregnant and postpartum women is associated with an increased risk of adverse maternal and neonatal health (preterm birth, preeclampsia and maternal death).

Although there is a significant increase of evidence regarding the prevalence and impact of COVID-19 on maternal and perinatal health, data on the effects of this condition on the obstetric population in low-income countries are scarce. Therefore, the study objective were to assess the prevalence and impact of COVID-19 on maternal and neonatal health at referral maternity in Maputo, Mozambique.

Our findings suggest that the prevalence of COVID-19 in the obstetric population is higher than the general population, and most pregnant and postpartum women are asymptomatic. Being pregnant, not having a partner and alcohol consumption were factors of greatest vulnerability to SARS-COV-2 infection. Moreover, the risk of COVID-19 among pregnant was seven-fold higher than in postpartum women. Pregnant women with COVID-19 may have a higher frequency of adverse gestational outcomes (foetal death and abortion). Although the risk of adverse maternal outcomes (death, Severe Acute Respiratory Syndrome and Intensive Care Unit admission) did not differ significantly between the COVID-19 and COVID-19 negative groups, universal screening for COVID-19 should be implemented to ensure adequate management of pregnant women and newborns.

Toward the understanding of national culture in the success of non-pharmaceutical technological interventions in mitigating COVID-19 pandemic

This study conceptually explores the relationship between a nation's culture and the success of utilizing various digital technologies to mitigate the spread of a pandemic, such as novel coronavirus (COVID-19). In the absence of a cure or vaccine of COVID-19, the national governments and public health authorities have been aggressively utilizing digital technologies to mitigate the pandemic spread. Given the urgency caused by COVID-19, this study highlights the importance of considering a country's national culture in evaluating the efficacy of a given digital technology, despite how promising or groundbreaking it may sound, in combating the spread of an infectious disease. Relying on the two critical dimensions of national culture, power distance and individualism/collectivism, this study proposes a framework that describes how people from different countries, depending on their prevalent national cultural values, would be receptive (or intolerant) to using government-run technology solutions meant for curbing the pandemic spread.

Crisis management, transnational healthcare challenges and opportunities: The intersection of COVID-19 pandemic and global mental health

The existing literature has paid insufficient attention to crisis management of global health challenges in the advent of epidemics and pandemics. This study articulates resilience importance and opportunities in the COVID-19 from crisis management challenges in essential ways. The second wave of the COVID-19 infectious disease's rapid global spread has developed a severe threat to global peace, which has posed global mental health and crisis management issues worldwide. Public health implementations' aggressive actions recommended a series of precautionary safety measures by the health specialists to suppress, sustain, and manage the local transmission of the COVID-19 pandemic. This study explores adverse consequences of the COVID-19 on communities' behavioral and interventional changes that might specify transmission dynamics. This present study recommends two model strategies that help sustain the rapid transmission and COVID-19′s adverse impacts on mental health in the general population and patients needing treatment. This study proposes mitigation and suppression models in the absence of a vaccine to decrease and manage the healthcare systems' burdens of treating patients. This global health emergency has challenged the global healthcare systems worldwide, and Governments are struggling to upgrade the healthcare systems to provide the best possible healthcare facilities to the patients. The healthcare systems in Pakistan are undeveloped to manage this global health emergency efficiently. Scientists' have already initiated experimental trials worldwide to develop vaccines to treat this infectious disease; however, the proposed two models are useful in managing the health emergency in the present situation. This study discusses global healthcare challenges, crisis management, and two model interventional strategies that help minimize the COVID-19′s rapid spread with practical crisis management preventive measures to reduce burden on healthcare systems.

Brazilian Presidential Pronouncements in the Pandemic: Effectiveness in Crisis Communication and Rule Properties

This work analyzed the six official statements of the president of Brazil that were broadcast on radio and television during the first 4 months of COVID-19 contamination in the country, regarding the efficacy in communicating the crisis and dimensions of rules. We observed a higher frequency of ineffective excerpts in the statements, especially in the categories "effective fear incitement" and "respect." The categories "speed" and "expression of empathy" showed high efficacy. Additionally, there was a higher recurrence of implicit and inaccurate rules and rules opposing the recommendations of experts. These results indicate that the analyzed statements were ineffective in crisis communication and control of behaviors combating the pandemic in Brazil. The analysis of governmental practices by behavioral science can be useful in the planning of public policies.

Psychological Lockdown Experiences: Downtime or an Unexpected Time for Being?

The spread of COVID-19 in Italy resulted in the implementation of a lockdown that obligated the first time the general populace to remain at home for approximately two months. This lockdown interrupted citizens' professional and educational activities, in addition to closing shops, offices and educational institutions. The resulting changes in people's daily routines and activities induced unexpected changes in their thoughts, feelings and attitudes, in addition to altering their life perceptions. Consequently, the present study explores how young adults perceived their lives under lockdown during the final week of March 2020, when the reported number of daily coronavirus infections reached its peak in Italy. The research was carried out among 293 university students (234 women and 59 men) with an average age of 20.85 years old (SD = 3.23). The researchers asked participants to describe the emotions, thoughts and experiences that characterized their time under lockdown. The study analyzed specific narratives related to time and space using grounded theory methodology, which was applied using Atlas 8 software, leading to the creation of 68 codes. The study organized these codes into three specific categories: confined in the present, confined in the past, and striving toward one's goals. Finally, the researchers also created a core-category labeled "continuity of being." The results showed that the closure of open spaces caused a division in participants' perceptions of time continuity, with many viewing themselves as feeling fragmented and as living the present in a static and fixed way. Additionally, participants also saw the present as being discontinuous from the past, while, simultaneously, projecting toward the future and the changes it might bring. Finally, this study examined further implications surrounding individual projecting among young people in greater depth.

Looking for the right balance between human and economic costs during COVID-19 outbreak

Since the beginning of Coronavirus 2019 (COVID-19) disease outbreak, there has been a heated debate about public health measures, as they can presumably reduce human costs in the short term but can negatively impact economies and well-being over a longer period.

MATERIALS AND METHODS

To study the relationship between health and economic impact of COVID-19, we conducted a secondary research on Italian regions, combining official data (mortality due to COVID-19 and contractions in value added of production for a month of lockdown). Then, we added the tertiles of the number of people tested for COVID-19 and those of health aids to evaluate the correspondence with the outcome measures.

RESULTS

Five regions out of 20, the most industrialized northern regions, which were affected both earlier and more severely by the outbreak, registered both mortality and economic value loss above the overall medians. The southern regions, which were affected later and less severely, had low mortality and less economic impact.

CONCLUSIONS

Our analysis shows that considering health and economic outcomes in the assessment of response to pandemics offers a bigger picture perspective of the outbreak and could allow policymakers and health managers to choose systemic, 'personalized' strategies, in case of a feared second epidemic wave.

Flattening the curves: on-off lock-down strategies for COVID-19 with an application to Brazil

The current COVID-19 pandemic is affecting different countries in different ways. The assortment of reporting techniques alongside other issues, such as underreporting and budgetary constraints, makes predicting the spread and lethality of the virus a challenging task. This work attempts to gain a better understanding of how COVID-19 will affect one of the least studied countries, namely Brazil. Currently, several Brazilian states are in a state of lock-down. However, there is political pressure for this type of measures to be lifted. This work considers the impact that such a termination would have on how the virus evolves locally. This was done by extending the SEIR model with an on / off strategy. Given the simplicity of SEIR we also attempted to gain more insight by developing a neural regressor. We chose to employ features that current clinical studies have pinpointed has having a connection to the lethality of COVID-19. We discuss how this data can be processed in order to obtain a robust assessment.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1186/s13362-020-00098-w.

An adaptive governance and health system response for the COVID-19 emergency

In the absence of an efficacious and affordable vaccine, the current crisis of COVID-19 is likely to be a long drawn one for many developing countries. In Bangladesh, where the entire population is susceptible and strict lockdown has been relaxed (as of May 31st 2020) due to concerns over saving livelihoods, the best available resources and capacities in the country have to be mobilized for an integrated and adaptive response strategy. In this paper we argue that a suitable response strategy for a country with highly constrained health system, must consider how response components will be delivered at scale, along with what can be delivered. In order to save maximum number of lives, an optimal strategy will be one that is able to iteratively select the most feasible set of health response and the network of organizations that can deliver most effectively at scale. This might require thinking outside of the conventional vertical network of public health system. Given its history of high-capacity non-government organizations in Bangladesh, it is likely that there are multiple alternative horizontal network options for delivering any set of response interventions. In fact many horizontal networks are already actively engaged in COVID-19 response work. The goal should be to identify and coordinate these networks, create new networks, and embed mechanisms for scaling up what works and scaling down what does not work. For a rapidly escalating and unpredictable crisis such as COVID-19, an adaptive response strategy is needed which allows for old and new networks of organizations to align and work collectively with minimum loss of lives.

Modeling and control of epidemics through testing policies

Testing is a crucial control mechanism in the beginning phase of an epidemic when the vaccines are not yet available. It enables the public health authority to detect and isolate the infected cases from the population, thereby limiting the disease transmission to susceptible people. However, despite the significance of testing in epidemic control, the recent literature on the subject lacks a control-theoretic perspective. In this paper, an epidemic model is proposed that incorporates the testing rate as a control input and differentiates the undetected infected from the detected infected cases, who are assumed to be removed from the disease spreading process in the population. After estimating the model on the data corresponding to the beginning phase of COVID-19 in France, two testing policies are proposed: the so-called best-effort strategy for testing (BEST) and constant optimal strategy for testing (COST). The BEST policy is a suppression strategy that provides a minimum testing rate that stops the growth of the epidemic when implemented. The COST policy, on the other hand, is a mitigation strategy that provides an optimal value of testing rate minimizing the peak value of the infected population when the total stockpile of tests is limited. Both testing policies are evaluated by their impact on the number of active intensive care unit (ICU) cases and the cumulative number of deaths for the COVID-19 case of France.

Application of Optimal Control of Infectious Diseases in a Model-Free Scenario

Optimal control for infectious diseases has received increasing attention over the past few decades. In general, a combination of cost state variables and control effort have been applied as cost indices. Many important results have been reported. Nevertheless, it seems that the interpretation of the optimal control law for an epidemic system has received less attention. In this paper, we have applied Pontryagin's maximum principle to develop an optimal control law to minimize the number of infected individuals and the vaccination rate. We have adopted the compartmental model SIR to test our technique. We have shown that the proposed control law can give some insights to develop a control strategy in a model-free scenario. Numerical examples show a reduction of 50% in the number of infected individuals when compared with constant vaccination. There is not always a prior knowledge of the number of susceptible, infected, and recovered individuals required to formulate and solve the optimal control problem. In a model-free scenario, a strategy based on the analytic function is proposed, where prior knowledge of the scenario is not necessary. This insight can also be useful after the development of a vaccine to COVID-19, since it shows that a fast and general cover of vaccine worldwide can minimize the number of infected, and consequently the number of deaths. The considered approach is capable of eradicating the disease faster than a constant vaccination control method.

The experience of contact tracing in Singapore in the control of COVID-19: highlighting the use of digital technology

Purpose

Containing the coronavirus disease 2019 (COVID-19) pandemic would require aggressive contact tracing and isolation of suspected or confirmed COVID-19 cases. Models in published literature have suggested that digital rather than manual contact tracing might be more effective in containing the pandemic. This article seeks to examine the forms of contact tracing that Singapore, a highly dense city-state, adopts with a focus on new innovations including the use of digital technology.

Methods

An exploratory literature search in PubMed, MEDLINE and EMBASE for studies reviewing technological approaches and responses to COVID-19 was performed. Information published by national agencies was also analysed to ascertain how technology was utilised in contact tracing.

Results

Contact tracing in Singapore is overseen by the Ministry of Health (MOH). COVID-19 cases are interviewed on their whereabouts during a backward and forward activity mapping process to identify close contacts. Extensive contact tracing even involving the police and serological tools have helped to establish links between cases and closed several local clusters. Examination of patient’s digital footprint has helped in contact tracing. Other digital technology introduced includes SafeEntry and TraceTogether. SafeEntry is a cloud-based visitor registration system while TraceTogether is a mobile phone application which operates by exchanging anonymised identifiers between nearby phones via Bluetooth connection.

Conclusion

Digital contact tracing is likely to expand and continue to complement human-based contact tracing for the current and future pandemics. However, at this juncture, it is not ready to replace the manual and meticulous work that only Singapore contact tracers can achieve.

Evaluation of Technology-Supported Distance Measuring to Ensure Safe Aircraft Boarding during COVID-19 Pandemic

With the rise of COVID-19, the sustainability of air transport is a major challenge, as there is limited space in aircraft cabins, resulting in a higher risk of virus transmission. In order to detect possible chains of infection, technology-supported apps are used for social distancing. These COVID-19 applications are based on the display of the received signal strength for distance estimation, which is strongly influenced by the spreading environment due to the signal multipath reception. Therefore, we evaluate the applicability of technology-based social distancing methods in an aircraft cabin environment using a radio propagation simulation based on a three-dimensional aircraft model. We demonstrate the susceptibility to errors of the conventional COVID-19 distance estimation, which can lead to large errors in the determination of distances and to the impracticability of traditional tracing approaches during passenger boarding/deboarding. In the context of the future connected cabin, a robust distance measurement must be implemented to ensure safe travel. Finally, our results can be transferred to similar fields of application, e.g., trains or public transport.

Bioethical Implications in Vaccine Development, a COVID-19 Challenge

Introduction

In the last 18 years, on three occasions, coronavirus has represented a challenge for global health. Between 2002 and 2003 with Severe Acute Respiratory Syndrome, in 2012 with Middle East Respiratory Syndrome, and since the end of 2019 with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causing the coronavirus disease 2019 (COVID-19) pandemic, which has challenged health care models and the way of doing research, placing bioethics at the center of discussion. 

Methods

On August 19, 2020, a webinar organized by the Research Institute of Medical Science (IICIMED, for its acronym in Spanish), entitled 'Bioethical Implications in Vaccine Development, a COVID-19 Challenge' took place. Three experts spoke about the importance of bioethics in the race to develop a COVID-19 vaccine, the risk involved in shortening the terms of the clinical trial phases, and how the associated risks can be minimized, in order to expedite research results. 

Conclusion

With the novel SARS-CoV-2 coronavirus, critical challenges have been posed not only for public health but for research and the scientific community. A safe and effective vaccine is urgently needed to prevent COVID-19 transmission, complications, and deaths; the adherence to ethical principles required by clinical research is mandatory and closer supervision is also essential.

Correlation of COVID-19 Pandemic with Healthcare System Response and Prevention Measures in Saudi Arabia

BACKGROUND

The Saudi government has taken the decision to prevent the entrance of about 2.5 million international pilgrims seeking to perform hajj in order to protect the world from a catastrophic widespread of disease. Moreover, health systems in Saudi Arabia are offering free testing for residents whether Saudi and non-Saudi.

OBJECTIVE

This study aimed to evaluate the spread of COVID-19 associated with preventive measures taken in Saudi Arabia and to develop a detailed COVID-19 prevention strategy as a framework for the Saudi Arabia community.

METHODOLOGY

Population size and age distributions among the country of Saudi Arabia were taken from the 2020 World Population Prospects. Contact patterns were measured using the Saudi Arabia Ministry of Health Statistical Annual Report.

CONCLUSIONS

Our study demonstrates that performing screening tests as early as possible to facilitate the rapid detection of infected cases, fast treatment, and instant isolation for suspected cases is the most definitive rejoinder for public health. Moreover, our study revealed the significance of performing preventive measures in reducing infection and death rates around Saudi Arabia by 27%, while in other countries, it reduced the death rate ranging from 10-73%. This study provides an achievable strategy for prevention and early detection of COVID-19 spread.

Quantifying the effects of quarantine using an IBM SEIR model on scalefree networks

The COVID-19 pandemic led several countries to resort to social distancing, the only known way to slow down the spread of the virus and keep the health system under control. Here we use an individual based model (IBM) to study how the duration, start date and intensity of quarantine affect the height and position of the peak of the infection curve. We show that stochastic effects, inherent to the model dynamics, lead to variable outcomes for the same set of parameters, making it crucial to compute the probability of each result. To simplify the analysis we divide the outcomes in only two categories, that we call best and worst scenarios. Although long and intense quarantine is the best way to end the epidemic, it is very hard to implement in practice. Here we show that relatively short and intense quarantine periods can also be very effective in flattening the infection curve and even killing the virus, but the likelihood of such outcomes are low. Long quarantines of relatively low intensity, on the other hand, can delay the infection peak and reduce its size considerably with more than 50% probability, being a more effective policy than complete lockdown for short periods.

Mapping physical access to healthcare for older adults in sub-Saharan Africa: A cross-sectional analysis with implications for the COVID-19 response

BACKGROUND

SARS-CoV-2, the virus causing coronavirus disease 2019 (COVID-19), is rapidly spreading across sub-Saharan Africa (SSA). Hospital-based care for COVID-19 is particularly often needed among older adults. However, a key barrier to accessing hospital care in SSA is travel time to the healthcare facility. To inform the geographic targeting of additional healthcare resources, this study aimed to determine the estimated travel time at a 1km × 1km resolution to the nearest hospital and to the nearest healthcare facility of any type for adults aged 60 years and older in SSA.

METHODS

We assembled a unique dataset on healthcare facilities' geolocation, separately for hospitals and any type of healthcare facility (including primary care facilities) and including both private- and public-sector facilities, using data from the OpenStreetMap project and the KEMRI Wellcome Trust Programme. Population data at a 1km × 1km resolution was obtained from WorldPop. We estimated travel time to the nearest healthcare facility for each 1km × 1km grid using a cost-distance algorithm.

FINDINGS

9.6% (95% CI: 5.2% - 16.9%) of adults aged ≥60 years had an estimated travel time to the nearest hospital of longer than six hours, varying from 0.0% (95% CI: 0.0% - 3.7%) in Burundi and The Gambia, to 40.9% (95% CI: 31.8% - 50.7%) in Sudan. 11.2% (95% CI: 6.4% - 18.9%) of adults aged ≥60 years had an estimated travel time to the nearest healthcare facility of any type (whether primary or secondary/tertiary care) of longer than three hours, with a range of 0.1% (95% CI: 0.0% - 3.8%) in Burundi to 55.5% (95% CI: 52.8% - 64.9%) in Sudan. Most countries in SSA contained populated areas in which adults aged 60 years and older had a travel time to the nearest hospital of more than 12 hours and to the nearest healthcare facility of any type of more than six hours. The median travel time to the nearest hospital for the fifth of adults aged ≥60 years with the longest travel times was 348 minutes (equal to 5.8 hours; IQR: 240 - 576 minutes) for the entire SSA population, ranging from 41 minutes (IQR: 34 - 54 minutes) in Burundi to 1,655 minutes (equal to 27.6 hours; IQR: 1065 - 2440 minutes) in Gabon.

INTERPRETATION

Our high-resolution maps of estimated travel times to both hospitals and healthcare facilities of any type can be used by policymakers and non-governmental organizations to help target additional healthcare resources, such as new make-shift hospitals or transport programs to existing healthcare facilities, to older adults with the least physical access to care. In addition, this analysis shows precisely where population groups are located that are particularly likely to under-report COVID-19 symptoms because of low physical access to healthcare facilities. Beyond the COVID-19 response, this study can inform countries' efforts to improve care for conditions that are common among older adults, such as chronic non-communicable diseases.

COVID-19 control in low-income settings and displaced populations: what can realistically be done?

COVID-19 prevention strategies in resource limited settings, modelled on the earlier response in high income countries, have thus far focused on draconian containment strategies, which impose movement restrictions on a wide scale. These restrictions are unlikely to prevent cases from surging well beyond existing hospitalisation capacity; not withstanding their likely severe social and economic costs in the long term. We suggest that in low-income countries, time limited movement restrictions should be considered primarily as an opportunity to develop sustainable and resource appropriate mitigation strategies. These mitigation strategies, if focused on reducing COVID-19 transmission through a triad of prevention activities, have the potential to mitigate bed demand and mortality by a considerable extent. This triade is based on a combination of high-uptake of community led shielding of high-risk individuals, self-isolation of mild to moderately symptomatic cases, and moderate physical distancing in the community. We outline a set of principles for communities to consider how to support the protection of the most vulnerable, by shielding them from infection within and outside their homes. We further suggest three potential shielding options, with their likely applicability to different settings, for communities to consider and that would enable them to provide access to transmission-shielded arrangements for the highest risk community members. Importantly, any shielding strategy would need to be predicated on sound, locally informed behavioural science and monitored for effectiveness and evaluating its potential under realistic modelling assumptions. Perhaps, most importantly, it is essential that these strategies not be perceived as oppressive measures and be community led in their design and implementation. This is in order that they can be sustained for an extended period of time, until COVID-19 can be controlled or vaccine and treatment options become available.

The impact of COVID-19 and strategies for mitigation and suppression in low- and middle-income countries

The ongoing coronavirus disease 2019 (COVID-19) pandemic poses a severe threat to public health worldwide. We combine data on demography, contact patterns, disease severity, and health care capacity and quality to understand its impact and inform strategies for its control. Younger populations in lower-income countries may reduce overall risk, but limited health system capacity coupled with closer intergenerational contact largely negates this benefit. Mitigation strategies that slow but do not interrupt transmission will still lead to COVID-19 epidemics rapidly overwhelming health systems, with substantial excess deaths in lower-income countries resulting from the poorer health care available. Of countries that have undertaken suppression to date, lower-income countries have acted earlier. However, this will need to be maintained or triggered more frequently in these settings to keep below available health capacity, with associated detrimental consequences for the wider health, well-being, and economies of these countries.

Understanding COVID-19 transmission, health impacts and mitigation: timely social distancing is the key

COVID-19 is a highly infectious disease caused by SARS-CoV-2, first identified in China and spread globally, resulting into pandemic. Transmission of virus takes place either directly through close contact with infected individual (symptomatic/asymptomatic) or indirectly by touching contaminated surfaces. Virus survives on the surfaces from few hours to days. It enters the human body through nose, eyes or mouth. Other sources of contamination are faeces, blood, food, water, semen etc. Parameters such as temperature/relative humidity also play an important role in transmission. As the disease is evolving, so are the number of cases. Proper planning and restriction are helping in influencing the trajectory of the transmission. Various measures are undertaken to prevent infection such as maintaining hygiene, using facemasks, isolation/quarantine, social/physical distancing, in extreme cases lockdown (restricted movement except essential services) in hot spot areas or throughout the country. Countries that introduced various mitigation measures had experienced control in transmission of COVID-19. Python programming is conducted for change point analysis (CPA) using Bayesian probability approach for understanding the impact of restrictions and mitigation methods in terms of either increase or stagnation in number of COVID-19 cases for eight countries. From analysis it is concluded that countries which acted late in bringing in the social distancing measures are suffering in terms of high number of cases with USA, leading among eight countries analysed. The CPA week in comparison with date of lockdown and first reported case strongly correlates (Pearson's r = - 0.86 to - 0.97) to cases, cases per unit area and cases per unit population, indicating earlier the mitigation strategy, lesser the number of cases. The overall paper will help the decision makers in understanding the possible steps for mitigation, more so in developing countries where the fight against COVID-19 seems to have just begun.

The common personal behavior and preventive measures among 42 uninfected travelers from the Hubei province, China during COVID-19 outbreak: a cross-sectional survey in Macao SAR, China

BACKGROUND

The novel coronavirus diseases 2019 (COVID-19) caused over 1.7 million confirmed cases and cumulative mortality up to over 110,000 deaths worldwide as of 14 April 2020. A total of 57 Macao citizens were obligated to stay in Hubei province, China, where the highest COVID-19 prevalence was noted in the country and a "lockdown" policy was implemented for outbreak control for more than one month. They were escorted from Wuhan City to Macao via a chartered airplane organized by Macao SAR government and received quarantine for 14 days with none of the individual being diagnosed with COVID-19 by serial RNA tests from the nasopharyngeal specimens and sera antibodies. It was crucial to identify common characteristics among these 57 uninfected individuals.

METHODS

A questionnaire survey was conducted to extract information such as behavior, change of habits and preventive measures.

RESULTS

A total of 42 effective questionnaires were analyzed after exclusion of 14 infants and children with age under fifteen as ineligible for the survey and missing of one questionnaire, with a response rate of 97.7% (42 out of 43). The proportion of female composed more than 70% of this group of returners. The main reason for visiting Hubei in 88.1% of respondents was to visit relatives. Over 88% of respondents did not participate in high-risk activities due to mobility restriction. All (100%) denied contact with suspected or confirmed COVID-19 cases. Comparison of personal hygiene habits before and during disease outbreak showed a significant increase in practice including wearing a mask when outdoor (16.7% and 95.2%, P < 0.001) and often wash hands with soap or liquid soap (85.7% and 100%, P = 0.031).

Caring for patients with cancer in the COVID-19 era

The current COVID-19 pandemic challenges oncologists to profoundly re-organize oncological care in order to dramatically reduce hospital visits and admissions and therapy-induced immune-related complications without compromising cancer outcomes. Since COVID-19 is a novel disease, guidance by scientific evidence is often unavailable, and impactful decisions are inevitably made on the basis of expert opinions. Here we report how the seven comprehensive cancer centers of Cancer Core Europe have organized their healthcare systems at an unprecedented scale and pace to make their operations 'pandemic proof'. We identify and discuss many commonalities, but also important local differences, and pinpoint critical research priorities to enable evidence-based remodeling of cancer care during the COVID-19 pandemic. Also, we discuss how the current situation offers a unique window of opportunity for assessing the effects of de-escalating anticancer regimens, which may fast-forward the development of more-refined and less-toxic treatments. By sharing our joint experiences, we offer a roadmap for proceeding and aim to mobilize the global research community to generate the data that are critically needed to offer the best possible care to patients.