BMC Public Health

BackgroundDuring Fall 2020 in the United States (U.S.), despite high COVID-19 case numbers and recommendations from public health officials not to travel and gather with individuals outside ones household, millions of people gathered for Thanksgiving. The objective of this study was to understand if individuals behaviors and risk perceptions influenced their decision to gather, and if they did gather, their subsequent test seeking and diagnoses. MethodsParticipants were part of the CHASING COVID Cohort study - a U.S. national prospective cohort. The study sample consisted of participants who completed routine questionnaires before and after Thanksgiving. Non-pharmaceutical interventions (NPIs) use informed behavioral risk scores and a score of perceived risk of COVID-19 were assigned to each participant. Multinomial logistic regression models were used to assess the association between higher risk behaviors and gathering with other households, and the association of gathering with subsequent testing and test positivity. ResultsA total of 1,932 (40.5%) cohort participants spent Thanksgiving with individuals from at least one other household. Participants with higher behavioral risk scores had greater odds of gathering with one other household (aOR: 2.35, 95% CI: 2.0, 2.7), two other households (aOR: 4.54, 95% CI: 3.7, 5.6), and three or more other households (aOR: 5.44, 95% CI: 4.1, 7.2). Participants perceiving COVID-19 as a low-risk to themselves and others had greater odds of gathering with one other household (aOR: 1.12, 95% CI: 0.97, 1.3), two other households (aOR: 1.39, 95% CI: 1.1, 1.7), and three or more other households (aOR: 1.86, 95% CI: 1.4, 2.4). Those who spent Thanksgiving with one or more other households had 1.23 times greater odds (95% CI: 1.1, 1.4) of having a COVID-19 test afterward. There was no association between gathering for Thanksgiving and subsequent COVID-19 test positivity or developing COVID-19 symptoms. ConclusionsThose who gathered with other households for Thanksgiving tended to engage in higher-risk activities. Thanksgiving gathering with other households was not associated with subsequently testing positive for COVID-19, but only a small proportion obtained post-travel testing. Public health messaging should emphasize behavior change strategies that promote safer gathering.

In the fall 2021, immunity mandates/passports for COVID-19 started to be discussed and implemented globally. In addition to increasing vaccination levels, these interventions isolate non-immune individuals from various settings to reduce non-household transmission and severe/critical illness. This is based on the hypothesis that the non-immune are at high absolute risk of these outcomes. However, these absolute risks were not quantified in the literature such that the absolute risk reductions of isolation on these outcomes remain unknown. This study estimated these absolute risks from September to November 2021 prior to the emergence of Omicron (B.1.1.529) using known data on the risk of infection, transmission in non-household settings, and age-stratified severe/critical illness in non-immune individuals for the Delta (B.1.617.2) variant, focusing on the European Union, United Kingdom, United States, Canada, Australia, and Israel. This allowed us to quantify the absolute risk reductions of isolation on (1) non-household transmission from the non-immune and (2) severe/critical illness amongst the non-immune in these regions during this period. We observed that on any given day the absolute risk reductions of isolation were typically small for transmission in most types of non-household settings and severe/critical illness in most age-groups, especially those aged <40. During a wave or sustained higher infection risks, the risk reductions were modest only for transmission in intimate social gatherings and severe/critical illness in adults aged [&ge;]50-60. The limitations of this study and the implications for the expected benefits of isolating non-immune individuals on reducing these outcomes are discussed.

BackgroundThe COVID-19 pandemic disrupted social life and forced people to reconsider how, where, and with whom to spend time. These decisions are deeply personal and their intricacies are still poorly understood. MethodsTo understand how people make such decisions, we conducted an online survey in summer 2023, collecting self-reported absolute contact numbers for four time points: 2019, 03/2020, summer 2021, and 01/2023. We analyzed the resulting contact data, focusing on the quantification of heterogeneities in reductions. ResultsAnalysis of the survey data revealed that the COVID-19 pandemic triggered substantial reductions in both the work and the leisure context. Mean reductions gradually decreased as time progressed, but by 01/2023 contact numbers remained below pre-pandemic levels. We found contact behavior to demonstrate heterogeneity in three different aspects. First, the distribution of contact reductions followed a bimodal pattern, with a distinct peak at either extreme: A large fraction of the survey participants initially strongly reduced their contacts, a smaller group maintained nearly normal contact levels, and the remainder of participants reduced their contacts intermediately. Consistent with the decrease of mean contact reductions, the relative sizes of these behavioral groups shifted over time, with participants relaxing their reductions incrementally. Second, we found risk perception to be an indicator for the strength of contact reductions: Risk-averse participants reduced their leisure contacts significantly more than risk-tolerant participants, resulting in a trend of both fewer and later COVID-19 infections. Neither age, gender, nor having a COVID-19-relevant comorbidity significantly influenced self-reported contact reductions. Third, the survey results provide evidence that social homophily persisted during the COVID-19 pandemic, revealing a correlation between participants and their closest contacts number of contacts during the COVID-19 pandemic. Risk-averse participants hereby especially preferred to maintain contact with equally careful individuals. ConclusionsOur study emphasizes the time-dependency and heterogeneity of contact reductions. On the one hand, our findings can easily be integrated into epidemiological models, improving their accuracy and predictive power. On the other hand, the results may guide the design of effective public health interventions, and help to predict and understand their effectiveness.

ObjectivesTo know and explore from convalescent plasma donators voices the experience in the blood donation process at a Peruvian social security hospital. MethodsQualitative study with a phenomenological design. The investigation was carried out in 01 hospitals of the social security of Peru. Semi-structured interviews were carried out. ResultsEleven donors of convalescent plasma were interviewed. The main motivations for donating were being able to contribute to national research and supporting patients affected by COVID-19. Fears focus on the possible risk of contagion within the hospital. Donors emphasised the attention and support of health personnel alongside the donation procedure. The main expectations and suggestions point towards greater dissemination of donation campaigns with special emphasis on safety. Likewise, an improvement in the time of the donation procedure (from enrolment to the extraction of convalescent plasma), and the implementation of friendly spaces to encourage future blood donation campaigns were highlighted. ConclusionsThe experience of the convalescent plasma donors was positive. However, improvements must be made in terms of processes and infrastructure to ensure future successful blood donation campaigns.

BackgroundWhile democracy typically correlates with superior population health outcomes, and inequality adversely affects population wellbeing, their roles in pandemic performance remain contested, particularly across geographic context and when using methodologically robust metrics. MethodsWe examined associations between liberal democracy (V-Dem Liberal Democracy Index) and income inequality (Gini coefficient) with Covid-19 health and economic outcomes across 193 jurisdictions, stratified by island (n = 48) versus non-island (n = 145) status. Outcomes were age-standardised cumulative excess mortality (2020-2021) and GDP per capita growth (2019-2020, 2020-2021). Ordinary least squares regression models controlled for GDP per capita, population size, Global Health Security Index, and government corruption. ResultsDemocracy predicted reduced excess mortality in islands ({beta} = -5.92 {+/-}2.20 SE, p = 0.013, adjusted R{superscript 2} = 0.37) but not non-islands ({beta} = -0.47 {+/-}0.65 SE, p = 0.47), confirmed by island interaction ({beta} = -4.51 {+/-}1.72, p = 0.0095). Higher inequality predicted increased mortality in non-islands ({beta} = +0.052 {+/-}0.019 SE, p = 0.009, adjusted R{superscript 2} = 0.50) and larger GDP contractions in 2019-2020 ({beta} = -0.242 {+/-}0.053 SE, p = 0.000013, adjusted R{superscript 2} = 0.22), but not in islands. Democracy showed no systematic association with economic trajectories. ConclusionsDemocracys pandemic benefits are geographically contingent, concentrated in island jurisdictions, while inequalitys adverse effects on health and economic outcomes are pervasive in non-island states. Preparedness strategies should account for these contextual dependencies to mitigate the impact of infectious disease and potential future global catastrophic biological risks. Key messagesO_LIThis research aimed to establish the relationship between jurisdiction regime type (level of democracy) as well as level of income inequality and Covid-19 pandemic health and economic outcomes. C_LIO_LIWe found that a higher Gini inequality coefficient predicted greater cumulative excess mortality (2020-2021) and a larger initial economic contraction, while greater democracy predicted lower cumulative excess mortality in islands only. C_LIO_LIThese findings suggest that non-specific factors such as inequality and democracy may drive pandemic outcomes and important policy relevant differences exist across jurisdiction types (island vs non-island). C_LI

IntroductionThe COVID-19 pandemic has disproportionately affected people with intellectual disabilities worldwide. The objective of this study was to identify global rates of COVID-19 vaccination and reasons not to vaccinate among adults with intellectual disabilities (ID) associated with country economic income levels. MethodsThe Special Olympics COVID-19 online survey was administered in January-February 2022 to adults with ID from 138 countries. Descriptive analyses of survey responses include 95% margins of error. Logistic regression and Pearson Chi-squared tests were calculated to assess associations with predictive variables for vaccination using R 4.1.2 software. ResultsParticipants (n=3560) represented 18 low (n=410), 35 lower-middle (n=1182), 41 upper-middle (n=837), and 44 high (n=1131) income countries. Globally, 76% (74.8-77.6%) received a COVID-19 vaccination while 49.5% (47.9-51.2%) received a COVID-19 booster. Upper-middle (93% (91.2-94.7%)) and high-income country (94% (92.1-95.0%)) participants had the highest rates of vaccination while low-income countries had the lowest rates (38% (33.3-42.7%)). In multivariate regression models, country economic income level (OR = 3.12, 95% CI [2.81, 3.48]), age (OR = 1.04, 95% CI [1.03, 1.05]), and living with family (OR = 0.70, 95% CI [0.53, 0.92]) were associated with vaccination. Among LLMICs, the major reason for not vaccinating was lack of access (41.2% (29.5-52.9%)). Globally, concerns about side effects (42%, (36.5-48.1%)) and parent/guardian not wanting the adult with ID to vaccinate (32% (26.1-37.0%)) were the most common reasons for not vaccinating. ConclusionAdults with ID from low and low-middle income countries reported fewer COVID-19 vaccinations, suggesting reduced access and availability of resources in these countries. Globally, COVID-19 vaccination levels among adults with ID were higher than the general population. Interventions should address the increased risk of infection for those in congregate living situations and family caregiver apprehension to vaccinate this high-risk population.

As COVID-19 has caused significant morbidity and mortality throughout the world, the development and distribution of an effective vaccine have been swift but not without challenges. Earlier demand and access barriers have seemingly been addressed with more free and accessible vaccines now available for a wide variety of ages. While rates of COVID-19 have decreased overall, some geographic areas continue to experience rapid outbreaks. The purpose of this study was to examine the relationship between vaccination uptake and weekly COVID-19 cases throughout locations in the state of Missouri. MethodsAmong all Missouri counties and two cities (n=117), weekly COVID-19 incidence and cumulative proportion of residents fully vaccinated were abstracted from the Missouri Department of Health and Senior Services during a 25-week period from January 4 to Jun 26, 2021. Additional ecological variables known to be associated with COVID-19 incidence and prevalence were collected from the U.S. Census Bureau and integrated into data: total population, proportion of nonwhite residents, annual median household income, proportion of residents working in public facing occupations. Descriptive and inferential statistics were completed which included the calculation of both linear and nonlinear models using repeated measure data to determine the quantitative association between vaccination uptake and reported COVID-19 cases in the presence of location characteristics. ResultsThroughout the 25 weeks of observations, the average weekly number of COVID-19 cases reported was 66.1 (SD=260.8) while the average cumulative proportion vaccinated individuals at the end of the 25 weeks was 25.8% (SD=6.8%) among study locations. While graphing seemed to suggest a more nonlinear relationship between COVID-19 incidence and proportion vaccinated, comparison of crude linear and nonlinear models pointed to the relationship likely being linear during study period. The final adjusted linear model exhibited a significant relationship between COVID-19 cases and proportion vaccinated, specifically every percent increase in population vaccinated resulted in 3 less weekly COVID-19 cases being reported ({beta} -3.74, p<0.001. Additionally, when controlling for other factors, the adjusted model revealed locations with higher proportions of nonwhite residents were likely to experience less weekly COVID-19 cases ({beta} -1.48, p=0.037). DiscussionOverall, this study determined that increasing the proportion of residents vaccinated decreases COIVD-19 cases by a substantial amount over time. These findings provide insights into possible messaging strategies that can be leveraged to develop more effective implementation and uptake. As the COVID-19 pandemic persists and vaccination numbers begin to plateau, diverse communication strategies become a critical necessity to reach a wider population.

BackgroundSex workers struggled to adhere to isolation guidelines following COVID-19 diagnosis because of financial pressure to keep working. We co-developed and evaluated for feasibility, acceptability, and cost an intervention for promoting isolation and community-based self-monitoring for COVID-19. MethodsSex workers testing positive for COVID-19 received the following co-developed intervention: i) risk-differentiated support, including immediate hospitalization and/or treatment for serious illness, and community-based self-monitoring for those at risk of progressing to severe illness, ii) food packs lasting two weeks. Using Proctors Framework, we interviewed purposively selected health-workers and sex workers before intervention implementation (26 sex workers and 24 health workers) and during implementation (8 sex workers of whom 5 tested positive, and 5 health workers) to evaluate the intervention. We determined intervention development and implementation costs using program data. ResultsThe intervention was implemented between March-June 2023. Sex workers and health workers reported that the intervention was highly acceptable and was implemented with fidelity. Food packs were highly appreciated; participants said they promoted isolation although vulnerability to non-food financial pressures persisted. Unanticipated impacts were increased testing uptake following introduction of food packs. Self-monitoring at home was acceptable although fear of stigma prevented some participants from seeking the needed support. The cost per sex worker testing positive was $49 and $54 respectively excluding/including intervention co-development costs. ConclusionA co-developed intervention for promoting isolation and community-based self-monitoring for COVID-19 was feasible and acceptable, with costs comparing favorably with similar interventions. Addressing stigma could optimise implementation and potential for future pandemics.

ObjectivesTo prevent hepatitis B (HBV) and hepatitis C (HCV) infections and associated deaths from hepatocellular carcinoma and cirrhosis, better identification of transmission routes is needed. Here, we reassessed the impact of different tattooing practices on viral transmission. DesignPopulation based cohort-study. SettingCancer Risk Associated to the Body Art of Tattooing (CRABAT) cohort as part of the ongoing French national cohort study Constances (baseline examination from 2012-2018). Participants110,402 participants (60,387 women and 50,015 men), of which 11.6% (12,789) were tattooed as per Constances follow-up questionnaire 2020. Complete exposure data on different exposure settings and countries of tattooing collected via complementary exposure assessment in 2023 (response rate 60%) was available for 7740 tattooed (4930 women and 2810 men) participants. Main outcome measuresSelf-reported HBV and HCV infections that were confirmed by surface antigen testing (HBsAG) and antibody (Anti-HCV) testing, respectively. Associations of different tattoo exposure characteristics (any tattoo; tattooed in/outside tattoo parlours; tattooed in/outside regulating countries; no tattoos (reference)) on subsequent HBV and/or HCV infections were assessed via multivariate logistic regression models, minimally adjusted and adjusted for known hepatitis risk factors, in the population >=45 years. Post-hoc, number of preventable HCV infections due to unsafe tattooing outside tattoo parlours was estimated. ResultsIn fully adjusted models, tattooing was associated with increased risk of any hepatitis infection (Odds ratio (OR): 1.46 (95% confidence interval: 1.15; 1.86), with a particularly strong increased risk for HCV (2.26 (1.64; 3.11)) compared to HBV (1.08 (0.77; 1.52)) infection. The increased risk for HCV and to a lesser extend for HBV was due to tattooing outside tattoo parlours (HCV: 4.75 (2.81; 8.03); HBV: 1.88 (0.99; 3.57)) whereas tattooing outside regulating countries was associated with an increased risk for HCV (2.74 (1.00; 7.45) and HBV (1.96 (0.80; 4.84)). Risk of HBV and/or HCV were around 10-fold for tattooing outside tattoo parlours outside regulating countries. The estimated number of preventable HCV infections through safe tattoo practices was around 12,000 in France and over 150,000 in Europe. ConclusionThe impact of unsafe tattooing practices as a preventable risk factor for HCV transmissions is highly underestimated. What is already known on the topic?O_LITattooing was identified as a potential transmission route for hepatitis infections in the early 1990s. C_LIO_LIHygiene measures were implemented in tattoo parlours throughout (many) European countries to prevent bloodborne infection transmission through tattooing needles. C_LIO_LICurrent hepatitis prevention strategies rarely/never consider tattooing as a common transmission route. C_LI What this study addsO_LIUnsafe tattooing practices are very common. One in four tattooed people got at least one tattoo outside parlours and one in five got tattooed in a country without strict hygiene regulations. C_LIO_LIUnsafe tattooing practices strongly increase the risk of HCV and to a lesser extend for HBV, making it the most important HCV transmission route after injecting drugs. C_LIO_LIThe study provides evidence that raising awareness on unsafe tattooing and upscaling screening of persons that underwent unsafe tattooing might help to substantially reduce hepatitis infections and related morbidity and mortality. C_LI

BackgroundDespite being known independently as important aetiological agents of liver disease, little is known about the prevalence, patterns, and risk factors associated with co-occurring alcohol use and Schistosoma mansoni infection in rural endemic settings. MethodsA cross-sectional analysis was completed of 3198 individuals aged 10-90 years from 52 rural villages in Uganda. Alcohol use was assessed using the World Health Organisation STEPwise Approach to Surveillance survey, and S. mansoni infection was diagnosed using Kato-Katz microscopy. Logistic regressions with biomedical, demographic, socioeconomic, and spatial variables were run. ResultsThe overall prevalence of S. mansoni infection was approximately 44% (1405/3198) and current alcohol use was reported by over 12% (392/3198) of participants. Among males aged [&ge;]20 years, the prevalence of co-occurring current alcohol use and S. mansoni infection was 18.7% (148/791). Females were less likely to have S. mansoni infection (odds ratio [OR] 0.83, 95% CI 0.69 - 0.99) or report current alcohol use (OR 0.44, 95% CI 0.32 - 0.62). Smoking (OR 9.43, 95% CI 6.66 - 13.37) and participating in fishing activity (OR 3.50, 95% CI 2.57 - 4.76) were associated with current alcohol use. Age (OR 0.95, 95% CI 0.94 - 0.97), fishing activity (OR 1.82, 95% CI 1.16 - 2.84), and smoking (OR 5.25, 95% CI 3.49 - 7.90) were associated with co-occurring current alcohol use and S. mansoni infection. ConclusionCo-occurrence of alcohol use and schistosome infection is common. Future research should investigate multi-sectoral public health interventions that simultaneously address the risk factors associated with both alcohol use and S. mansoni infection. Key messagesO_LIThis study aims to characterise the co-occurrence of alcohol use and S. mansoni infection, and to identify shared risk factors for these hepatotoxic exposures in a rural Ugandan population. C_LIO_LIAlcohol use was most prevalent among males aged [&ge;]20 years, and key risk factors for both alcohol use and S. mansoni infection were male sex, current smoking status, and participation in fishing activity. C_LIO_LIThe findings of this study highlight the need for integrated public health interventions that simultaneously target alcohol use and S. mansoni infection, focusing on high-risk occupational groups such as those involved with fishing and high-risk behaviours such as smoking. C_LI

BackgroundThe COVID-19 pandemic poses an unprecedented and cascading threat to the health and economic prosperity of the worlds population. ObjectivesTo understand whether the institutional and cultural context influences the COVID-19 outbreak. MethodsAt the ecological level, regression coefficients are examined to figure out contextual variables influencing the pandemics exponential growth rate across 96 countries. ResultsWhile a strong institutional context is negatively associated with the outbreak (B = -0.55 ... -0.64, p < 0.001), the pandemics growth rate is steeper in countries with a quality education system (B = 0.33, p < 0.001). Countries with an older population are more affected (B = 0.46, p < 0.001). Societies with individualistic (rather than collectivistic) values experience a flatter rate of pathogen proliferation (B = -0.31, p < 0.001), similarly for higher levels of power distance (B = -0.32, p < 0.001). Hedonistic values, that is seeking indulgence and not enduring restraints, are positively related to the outbreak (B = 0.23, p = 0.001). ConclusionsThe results emphasize the need for public policy makers to pay close attention to the institutional and cultural context in their respective countries when instigating measures aimed at constricting the pandemics growth.

IntroductionNon-Hodgkins Lymphoma (NHL) remains a significant public health concern with notable disparities in survival outcomes. Sex and marital status are two critical social determinants that influence both cancer-specific survival (CSS) and overall survival (OS). Prior studies suggest that women with NHL face poorer survival outcomes compared to men, and marital status modulates survival, with married individuals demonstrating better outcomes. However, the interplay between sex and marital status on NHL survival has not been thoroughly examined. ObjectiveTo investigate the combined effects of sex and marital status on CSS and OS in NHL patients. MethodologyA retrospective cohort study was conducted using SEER registry data spanning 2000 to 2020. Individuals aged 18-85 diagnosed with NHL were included. Cox regression models assessed the interaction between sex and marital status on CSS and OS, adjusting for covariates such as age, race, household income, cancer stage, and treatment modalities. Predicted probabilities of mortality and the differences in sex effects across marital status categories were estimated using interaction terms and linear combinations. ResultsA total of 291,608 patients were included, with females accounting for 54.6% of the cohort. Sex disparities were observed across marital status groups. Married women exhibited a significantly higher probability of overall mortality than married men (9.26, 95% CI: 7.61-10.92, p < 0.001). The disparity was most pronounced among single individuals, where women had a 22.93-unit higher probability of overall mortality compared to men (95% CI: 18.49-27.37, p < 0.001). Similarly, widowed women had higher probabilities of mortality than widowed men (13.10, 95% CI: 10.08-16.11, p < 0.001). Cancer-specific mortality followed a similar pattern, with single women experiencing the greatest disparity compared to single men (8.44, 95% CI: 6.21-10.68, p < 0.001). Comparisons of effects between marital status groups revealed that single individuals exhibited a 13.67-unit greater disparity in overall mortality than married individuals (95% CI: 10.26-17.07, p < 0.001). ConclusionThis study underscores the significant influence of sex and marital status on survival outcomes in NHL patients. Women face higher cancer-specific and overall mortality risks across all marital status categories. Marital status modifies these disparities, with marriage conferring a survival advantage, particularly for men. These findings highlight the need for targeted interventions to address sex and social disparities in NHL outcomes, emphasizing the importance of social support and tailored survivorship care. Key PointsO_LIWomen with NHL have higher overall and cancer-specific mortality than men, with the greatest disparity seen in single individuals. C_LIO_LIMarriage reduces survival disparities, benefiting men most, while single and widowed women face the highest mortality risks. C_LI

Recent studies assessing COVID-19 vaccine efficacy at the population level found counterintuitive results, such as positive associations between vaccination and infections or deaths. These ecological studies have limitations, including too short observation periods, focusing on infections, and not controlling for age groups and dominant variants. The current study addresses these limitations by investigating the relations between vaccination and COVID-19 cases, hospitalizations, and deaths over a longer period (9[1/2] months) while also considering age groups (from 10 to 80+ years old) and variants (Alpha and Delta), utilizing data from Switzerland. Results suggest that vaccination is negatively related to cases overall and in all cantons of Switzerland, and that vaccination is negatively related to hospitalizations and deaths from 50 years old. Furthermore, vaccination is a significant predictor of cases, hospitalizations, and deaths while holding the effects of age and dominant variant constant.

ObjectiveWe aimed to determine which aspects of the COVID-19 national response are independent predictors of COVID-19 mortality and case numbers. DesignComparative observational study between nations using publicly available data. SettingWorldwide Participants Covid-19 patients InterventionsStringency of 11 lockdown policies recorded by the Blavatnik School of Government database and earliness of each policy relative to first recorded national cases Main outcome measuresAssociation with log10 National deaths (LogD) and log10 National cases (LogC) on the 29th April 2020 corrected for predictive demographic variables ResultsEarly introduction was associated with reduced mortality (n=137) and case numbers (n=150) for every policy aside from testing policy, contact tracing and workplace closure. Maximum policy stringency was only found to be associated with reduced mortality (p=0{middle dot}003) or case numbers (p=0{middle dot}010) for international travel restrictions. A multivariate model, generated using demographic parameters (r2=0{middle dot}72 for LogD and r2=0{middle dot}74 for LogC), was used to assess the timing of each policy. Early introduction of first measure (significance p=0{middle dot}048, regression coefficient {beta}=-0{middle dot}004, 95% confidence interval 0 to -0{middle dot}008), early international travel restrictions (p=0{middle dot}042, {beta}=-0{middle dot}005, -0{middle dot}001 to - 0{middle dot}009) and early public information (p=0{middle dot}021, {beta}=-0{middle dot}005, -0{middle dot}001 to -0{middle dot}009) were associated with reduced LogC. Early introduction of first measure (p=0{middle dot}003, {beta}=-0{middle dot}007, -0{middle dot}003 to -0{middle dot}011), early international travel restrictions (p=0{middle dot}003, {beta}=-0{middle dot}008, -0{middle dot}004 to-0{middle dot}012), early public information (p=0{middle dot}003, {beta}=-0{middle dot}007, 0{middle dot}003 to -0{middle dot}011), early generalised workplace closure (p=0{middle dot}031, {beta}=-0{middle dot}012, -0{middle dot}002 to -0{middle dot}022) and early generalised school closure (p=0{middle dot}050, {beta}=-0{middle dot}012, 0 to -0{middle dot}024) were associated with reduced LogC. ConclusionsAt this stage in the pandemic, early institution of public information, international travel restrictions, and workplace closure are associated with reduced COVID-19 mortality and maintaining these policies may help control the pandemic. What is already known on this topicThe COVID-19 pandemic has spread rapidly throughout the world and presented vast healthcare, economic and political challenges. Many nations have recently passed the peak of their infection rate, and are weighing up relaxation of lockdown strategies. Though the effect of individual lockdown policies can be estimated by modelling, little is known about the impact of individual policies on population case numbers or mortality through comparison of differing strategies between nations. A PubMed search was carried out on the 14/5/20 using keywords including "novel coronavirus-infected pneumonia", "2019-nCoV", "Sars-Cov-2", "Covid-19", "lockdown"," policy", "social distancing", "isolation", "quarantine" and "contact tracing" returned 258 studies in total. Following scanning of the above results, we found 19 studies that have examined the effect of lockdown within a region, which have demonstrated a reduction in case numbers after the introduction of a lockdown. There are no previous studies that have compared the effectiveness of government lockdowns between nations to determine the effectiveness of specific policies. What this study addsThis study examines the corollary between government policy and COVID-19 case numbers and mortality, correct as of the 29th of April 2020, for every nation that there is available date within the Blavatnik School of Government database on COVID-19 policy. The study demonstrates that early generalised school closure, early generalised workplace closure, early restriction of international travel and early public information campaigns are independently associated with reduced national COVID-19 mortality. The maximum stringency of individual lockdown policies were not associated with reduced case numbers or mortality. Early reintroduction of these policies may be most effective in a relapse of the pandemic, though, school closure, workplace closure and restriction of international travel carry heavy politico-economic implications. There was no measurable effect of maximum stringency of lockdown policy on outcome at this point in time, indicating that early timing of lockdown introduction is of greater importance than its stringency, provided that the resultant viral reproductive rate is less than 1.

ImportanceHomelessness is a complex challenge with an estimated yearly economic burden of $6 billion in the United States. Mitigating homelessness requires an understanding of determinants of homelessness, their interaction with health factors, and quantification of impact. ObjectiveTo investigate the health, social and policy factors influencing homelessness in a longitudinal integrative machine learning analysis. Data Sources and Study designThis retrospective longitudinal study integrated Global Burden of Disease (GBD), Health Inequality, and Housing and Urban Development (HUD) datasets for 3131 counties in the United States. We used the disease burden data of 2014, health inequalities data of 2001-2014, and homelessness count of 2015. Primary Outcome and Measurement ResultsHomelessness, the burden of disease, health inequalities, economic policies, ethnic, social, and racial factors. MethodsSpearman rank correlation test was performed to check pairwise associations. A unified probabilistic model with temporal causality was fitted using a data-driven structure learning algorithm. The resulting associations adjusted for other variables in the network were quantified using network inference algorithms. Finally, counterfactual analysis was performed to quantify the potential impact of the learned interventions. ResultsThe total burden of homelessness was significantly (p<0.001) and positively associated with rates of HIV and hepatitis mortality. Inference from the unified probabilistic model indicated that a state with a high hepatitis mortality rate had a 9% higher homelessness. Further, the rate of rheumatic heart disease mortality had a 29% decrease with the provision of shelter in young adults experiencing homelessness (p<0.001). Finally, states with moderate tax progressivity had a mitigating effect on homelessness as compared to both high and low tax progressivity (2% and 5% respectively). We evaluated the counterfactual impact of policy interventions to provide more support to cancer patients to prevent homeless and provision of shelter to prevent rheumatic heart disease mortality in young adults experiencing homelessness. Conclusion and RelevanceControl of infectious diseases and the implementation of tax policies are critical interventions for the reduction of homelessness in the United States. Key PointsHomelessness, Bayesian Network, Counterfactual Analysis QuestionWhat are the health associations and determinants of homelessness in the United States? FindingIn this study on 3131 US Counties, we found infectious diseases mortality and tax progressivity to be strong determinants of homelessness using a Bayesian network model. MeaningThese findings suggest that decreasing the burden of infectious diseases and moderate tax progressivity are vital factors for mitigating homelessness in the United States.

The COVID-19 pandemic is both a global health crisis, and a civic emergency for national governments, including the UK. As countries across the world loosen their lockdown restrictions, the assumption is generally made that the risk of COVID-19 transmission is lower outdoors, and this assumption has shaped decisions about what activities can recommence, the circumstances in which they should re-commence, and the conditions under which they should re-commence. This is important for events and activities that generate outdoor gatherings of people, including both participatory and spectator sport events, protests, concerts, carnivals, festivals, and other celebrations. The review, which was designed to be undertaken rapidly in 15 days, returned 14 sources of evidence of outdoor transmission of COVID-19, and a further 21 sources that were used to set the context and understand the caveats that should be considered in interpreting the review findings. The review found very few examples of outdoor transmission of COVID-19 in everyday life among c. 25,000 cases considered, suggesting a very low risk. However risk of outdoor transmission increases when the natural social distancing of everyday life is breached, and gathering density, circulation and size increases, particularly for an extended duration. There was also evidence that weather had a behavioural effect on transmission, with temperatures that encourage outdoor activity associated with lower COVID-19 transmission. Due to lack of surveillance and tracing systems, and confounding factors and variables, there was no evidence that robustly tested transmission at outdoor mass gatherings (circa 10,000+ people), which are as likely to generate transmission from the activities they prompt (e.g. communal travel and congregation in bars) as from outdoor transmission at the gathering itself. The goal of hosts and organisers of events and activities that generate outdoor gatherings of people is to prevent the escalation of risk from sporadic transmission to the risk of transmission through a cluster outbreak. Considerations for such hosts and organisers include: (1) does the gathering prompt other behaviours that might increase transmission risk?; (2) for each part of the event or activity, how dense is the gathering, how much do people circulate, how large is the gathering, and how long are people there?; (3) is rapid contact tracing possible in the event of an outbreak? These considerations should take place relevant to the size of the underlying risk, which includes the rate of infection in the community and the likely attendance of vulnerable groups. Risk must be balanced and mitigated across the risk factors of density, circulation, size and duration. No one risk factor presents an inherently larger risk than any other, but neither is any one risk factor a magic bullet to eliminate risk. Finally, it is clear that the largest risks from gatherings come from spontaneous or informal unregulated and unmitigated events or activities which do not consider any of the issues, risks and risk factors outlined in this paper

IntroductionOver 1 billion smokers worldwide, one-third of whom have mental and behavioral disorders, exist. However, factors influencing mental and behavioral disorders due to use of tobacco remain unexplored. We aim to investigate the relationship between dietary iron intake and mental and behavioral disorders due to use of tobacco. MethodsUsing large population cohort data from the UK Biobank, we employed logistic and Cox regression to explore the cross-sectional and longitudinal associations between dietary iron intake and mental and behavioral disorders due to use of tobacco. Additionally, we assessed the nonlinear relationship between dietary iron intake and mental and behavioral disorders due to use of tobacco using restricted cubic spline plots. ResultsThe cross-sectional analysis included 50,991 participants. The logistic regression results indicated that dietary iron intake was negatively associated with mental and behavioral disorders due to use of tobacco. A total of 50,921 participants were included in the cohort study. The Cox regression results supported the protective effect of increased dietary iron intake against mental and behavioral disorders due to use of tobacco. The stratified and sensitivity analysis results were consistent with the main results. The restricted cubic spline plots showed a nonlinear relationship between dietary iron intake and mental and behavioral disorders due to use of tobacco. The risk reduction rate initially accelerated and then slowed in the total sample, the two age, and the male groups. In contrast, it declined rapidly at first and then leveled off in the female group. ConclusionThis study found that dietary iron intake has a protective effect against mental and behavioral disorders due to use of tobacco, revealing a nonlinear association between the two. These findings offer valuable insights for the prevention and treatment of mental and behavioral disorders due to use of tobacco in the future. What is already known on this topicExisting research primarily focuses on tobacco as a risk factor for physical diseases. In contrast, the factors influencing mental and behavioral disorders due to use of tobacco have not been adequately explored. Furthermore, findings regarding the relationship between dietary iron intake and mental health in the general population are inconsistent, highlighting the need for this study to clarify the potential association between dietary iron intake and mental and behavioral disorders due to use of tobacco among smokers. What this study addsIn this combined cross-sectional and longitudinal study, we assessed the association between dietary iron intake and mental and behavioral disorders due to use of tobacco using data from UK Biobank. We found that high dietary iron intake was protective against mental and behavioral disorders due to use of tobacco. In the fully adjusted model, the OR (95% CI) and HR (95% CI) for the highest intake group compared to the lowest intake group were 0.41 (0.18 - 0.98) and 0.50 (0.43 - 0.58), respectively. In addition, we found a similar L-shaped nonlinear association between dietary iron intake and mental and behavioral disorders due to use of tobacco utilizing restricted cubic spline plots. How this study might affect research, practice or policyOur study provides evidence of a negative association between dietary iron intake and mental and behavioral disorders due to use of tobacco. For groups that find it difficult to quit smoking, increasing iron intake to an appropriate level may alleviate the discomfort associated with mental and behavioral disorders due to use of tobacco. National mental health is crucial for every country, and this becomes especially important in a modern context where mental stress is increasingly recognized.

BackgroundMosquito-borne pathogens are transmitted through bites of female mosquito vectors that are actively seeking hosts for a blood meal and hosts, when either of them is infectious. Different mosquito species have different preferences for the time of the day/night when they actively seek blood meals. In the United States, the encounters between mosquito vectors and human hosts primarily take place outdoors. Socioeconomic factors such as occupation and income are major determinants of the hour of the day and total amount of time spent outdoors by different population groups. The aim of this study is to quantify: i) diel variations in the level of human exposure to mosquito vectors, and ii) exposure heterogeneities by human population group. MethodsWe collected both diel activity data for two mosquito vector species (Aedes aegypti and Culex quinquefasciatus) and time-use data for the United States. Then, we analyzed the diel overlap between the two at the population level and by human population group. ResultsFor both mosquito species, we found a substantial heterogeneity in their diel overlap with human outdoors activities. We estimated that the time periods with the highest risk of exposure to bites of Ae. aegypti are 7am-11am and 5pm-8pm, while the highest risk for Cx. Quinquefasciatus is 6am-7am and 6pm-9pm. Moreover, we found disparities in the exposure to mosquito vector species across different demographic groups. Workers with primarily outdoor occupations, males, and Hispanics/Latinos were shown to have higher levels of exposure as compared to the general population. In particular, we estimated that workers with primarily outdoor occupations were 7.50-fold (95%CI: 7.18-7.84) and 6.63-fold (95%CI: 6.09-7.35) more exposed to Ae. aegypti and Cx. quinquefasciatus than the general population, respectively. ConclusionThis study serves as a steppingstone to quantify the risk of exposure to mosquito vector species in the United States. The obtained results can be instrumental for the design of public health interventions such as education campaigns, which could contribute to improve health and health equity.

BackgroundIn Bogota by August 1st, more than 27,000 COVID-19 deaths have been reported, while complete and partial vaccination coverage reached 30% and 37%, respectively. Although reported cases are decreasing, the potential impact of new variants is uncertain. MethodsWe used an agent-based model of COVID-19 calibrated to local data. Variants and vaccination strategies were included. We estimated the impact of vaccination and modelled scenarios of early and delayed introduction of the delta variant, along with changes in mobility, social contact, and vaccine uptake over the next months. FindingsBy mid-July, vaccination may have prevented 17,800 (95% CrI: 16,000 - 19,000) deaths in Bogota. We found that delta could lead to a fourth wave of magnitude and timing dependent on social mixing, vaccination strategy, and delta dominance. In scenarios of early dominance of delta by mid-July, age prioritization and maintaining the interval between doses were important factors to avert deaths. However, if delta dominance occurred after mid-September, age prioritization would be less relevant, and the magnitude of a four wave would be smaller. In all scenarios, higher social mixing increased the magnitude of the fourth wave. Increasing vaccination rates from 50,000/day to 100,000/day reduced the impact of a fourth wave due to delta. InterpretationThe magnitude and timing of a potential fourth wave in Bogota caused by delta would depend on social mixing and the timing of dominance. Rapidly increasing vaccination coverage with non-delayed second doses could reduce the burden of a new wave. FundingNSF RAPID DEB 2027718. HERMES 50419. Medical Research Council. MR/R024855/1 Research in ContextO_ST_ABSEvidence before this studyC_ST_ABSThe impact of vaccination strategies in the context of emerging SARS-CoV-2 variants and increasing social mixing in Colombia had not been previously evaluated through mathematical modelling. We searched PubMed for modelling studies using the terms "COVID-19 vaccine AND model AND variant AND Colombia" or "SARS-CoV-2 AND vaccine AND model AND variant AND Colombia" (From 2021/1/1 to 2021/07/31). We did not find studies addressing this question. However, we found a model describing the evolution of the epidemic in the country during the first year, and research on the emergence of alpha, gamma, and B.1.621 variants in Colombia. We extended a previous version of our SARS-CoV-2 agent-based model for Bogota to include the potential effect of vaccination and variants. This model simulates transmission of SARS-CoV-2 based on daily activity patterns of a synthetic population, representing demographic and geographic characteristics of the total population of the city. Added value of this studyFirst, our study provides a preliminary estimate of the impact of the vaccination program in Bogota in terms of the number of deaths prevented. The second major finding is the indication that due to the introduction of the delta variant in the city, and based on the current knowledge of its biology, there is a risk of a fourth epidemic wave, whose time of occurrence and magnitude would depend mainly on three factors: when delta becomes dominant, the intensity of social contact, and vaccination roll-out strategy and coverage. Implications of all the available evidenceWe estimate that by mid-July, vaccination may have already prevented 17,800 (95% CrI: 16,000 - 19,000) deaths in Bogota. The delta variant could become dominant and lead to a fourth wave later in the year, but its timing will depend on the date of introduction, social mixing patterns, and vaccination strategy. In all scenarios, higher social mixing is associated with a fourth wave of considerable magnitude. If an early delta introduction occurred (dominance by mid-July), a new wave may occur in August/September and in such case, age prioritization of vaccination and maintaining the 21-day interval between doses of the Pfizer-BioNTech BNT162b2 are more important. However, if introduction occurred one or two months later (with dominance by mid-August/September) a fourth wave would be of smaller magnitude, the age-prioritization is less relevant, but maintaining the dose scheme without postponement is more important. In all scenarios we found that increasing the vaccination rate from the current average of 50,000/day to 100,000/day reduces the impact of a potential fourth wave due to the delta variant. Our study indicates that given the possibility of a fourth wave in the city, it is necessary to continue maintaining adherence to non-pharmacological interventions, such as the use of face masks and physical distancing, to be cautious with the intensification of social activities, and that it is essential to increase the current pace of vaccinations to rapidly reach high vaccination coverage in the population of the city.

From December 2020 to July 2021, $700,000 was distributed in direct cash transfers to residents of Immokalee, FL who tested positive for COVID-19. The goal of this study is to evaluate the impact of this cash transfer program. We conducted 157 structured interviews with program beneficiaries via phone call or home visit and asked about sociodemographic variables, how the money was used, whether the money was sufficient for two weeks financial needs, and participant ability to self-isolate. A logit regression model was then used to explore the relationships between sociodemographic variables and whether the respondent thought the money was enough for two weeks of financial needs. A majority of respondents (83.7%) reported spending the check exclusively on living expenses, and 99.3% reported that the money helped them stay home and quarantine while having COVID-19. Offering direct cash transfers of $800-$1200 to residents of Immokalee, FL who tested positive for COVID-19 was effective in reducing COVID-associated financial burden, and this money was most likely to be spent on living necessities rather than temptation goods. People with housing insecurity and without a high school degree were significantly less likely to report that the money was enough for two weeks financial needs, indicating that these characteristics mark those in the population who may have needed more support. Given that the COVID-19 pandemic has exacerbated pre-existing health disparities, it is important to understand the role of cash transfers as a public health tool and their potential impact on community mitigation efforts.