Leveraging epidemiological principles to evaluate Sweden's COVID-19 response

In the response to COVID-19, countries have implemented response strategies along a continuum of population- and venue-level specificity ranging from suppression to mitigation strategies. Suppression strategies generally include population-wide shelter-in-place mandates or lockdowns, closure of nonessential physical venues, travel bans, testing and contact tracing, and quarantines. Sweden followed a mitigation strategy focused on risk-tailored approaches to mitigate specific acquisition risks among the elderly, minimizing the disruption to education and the delivery of other health care services, and recommendations for social distancing to minimize the disease burden. To date, Sweden has reported higher case counts and attributable mortality than other Scandinavian countries and lower than other Northern European countries. However, there are several limitations with comparison given heterogeneity in testing strategies, suspected and confirmed case definitions, and assessment of attributable mortality. The decisions in Sweden also reflect social priorities such as equity being a foundational principle of Swedish social systems. Consistently, in-person education for those aged less than 16 years continued throughout. Notably, the mitigation strategy did not eliminate the inequitable impacts of COVID-19 cases and mortality in Sweden with higher-exposure and generally lower-income occupations being associated with higher risks intersecting with these communities often residing in more dense multigenerational households. From January 1 to November 15, there has been a 1.8% increase in all-cause mortality in 2020 compared with the average of 2015-2019, representing an excess of 14.3 deaths per 100,000 population. However, the final assessment of excess deaths in Sweden in 2020 including stratification by age and integration of secular trends can only be calculated in the coming years. In response to increasing cases in the fall of 2020, Sweden has continued to leverage business-oriented regulations and public-oriented guidelines for social distancing rather than police-enforced mandates. Ultimately, pandemics present no winners. Countries have implemented a range of different COVID-19 prevention and mitigation strategies responsive to their own priorities and legal systems including equity and the balancing of competing health priorities. Given these varied approaches, countries that pursued elimination, suppression, or mitigation strategies can collaboratively learn from both successes and challenges of the different strategies to inform COVID-19 and future pandemic responses.

Differences between diabetic and non-diabetic patients with community-acquired pneumonia in primary care in Spain

BACKGROUND

Diabetes is one of the underlying risk factors for developing community-acquired pneumonia (CAP). The high prevalence of diabetes among population and the rising incidence of this illness, converts it as an important disease to better control and manage, to prevent its secondary consequences as CAP. The objective of this research is to describe the characteristics of the patients with diabetes and the differences with the no diabetes who have had an episode of CAP in the context of the primary care field.

METHODS

A retrospective, observational study in adult patients (> 18 years-old) who suffer from CAP and attended at primary care in Spain between 2009 and 2013 was developed using the Computerized Database for Pharmacoepidemiological Studies in Primary Care (BIFAP). We carried out a descriptive analysis of the first episodes of CAP, in patients with or without diabetes as comorbidity. Other morbidity (CVA, Anaemia, Arthritis, Asthma, Heart disease, Dementia, Depression, Dysphagia, Multiple sclerosis, Epilepsy, COPD, Liver disease, Arthrosis, Parkinson's disease, Kidney disease, HIV) and life-style factors were also included in the study.

RESULTS

A total of 51,185 patients were included in the study as they suffer from the first episode of CAP. Of these, 8012 had diabetes as comorbidity. There were differences between sex and age in patients with diabetes. Patients without diabetes were younger, and had less comorbidities including those related to lifestyles such as smoking, alcoholism, social and dental problems than patients with diabetes.

CONCLUSIONS

Patients who developed an episode of CAP with diabetes have more risk factors which could be reduced with an appropriate intervention, including vaccination to prevent successive CAP episodes and hospitalization. The burden of associated factors in these patients can produce an accumulation of risk. Health care professional should know this for treating and control these patients in order to avoid complications. Diabetes and those other risk factors associated could be reduced with an appropriate intervention, including vaccination to prevent the first and successive CAP episodes and the subsequent hospitalization in severe cases.

Herpes zoster-associated mortality in Europe: a systematic review

Background

Reactivation of latent varicella zoster virus, partly due to age-related immunosenescence and immunosuppressive conditions, results in herpes zoster (HZ) and its associated complications. The management of the most important complication, post-herpetic neuralgia (PHN), is challenging, particularly in the elderly, and is generally unsatisfactory. No previous reviews have reported the incidence of HZ-associated mortality.

Methods

We carried out a systematic literature review to identify studies and databases providing data for HZ-associated mortality in adults aged ≥50 years in Europe.

Results

We identified 12 studies: Belgium (1); France (1); Germany (1); the Netherlands (2); Portugal (1); Spain (4) and England/Wales (2) and 4 databases from Europe: France; Germany and England/Wales. The incidence was available from eight studies; it was highest in those aged ≥95 in France (19.48/100,000). In the European (WHO) database, the overall mortality ranged from 0 to >0.07/100,000. The age- and gender-specific HZ mortality rates from the other databases showed that while in younger age groups the HZ mortality rate was higher in males, in older patients the rate was much higher in women. The case fatality rate was 2 and 61/100 000 in those 45–65 and ≥65 years, respectively. A similar increase with age was seen for the hospital fatality rate; 0.6% in those 45–65 years in the UK and 7.1% in those ≥80 in Spain.

Conclusions

Although the data were sparse and heterogeneous, HZ-associated mortality clearly increases with age. In addition, the elderly who develop HZ often have underlying diseases and are at increased risk of functional decline and loss of independence. Mortality should be taken into account in health-economics models.