Public Health

We evaluated the association between preventative social behaviour and government stringency. Additionally, we sought to evaluate the influence of additional factors including time, need to protect others (using the reported number of COVID-19 deaths as a surrogate measure) and reported confidence in government handling of the COVID-19 pandemic. We used repeated national cross-sectional surveys the UK over the course of 41 weeks from 1st April 2020 to January 28th, 2021, including a total of 38,092 participants. Preventative social behaviour and government stringency index scores were significantly associated on linear regression analyses (R2 =0.6468, p<0.001, and remained significant after controlling for the effect of reported COVID-19 deaths, confidence in government handling of the pandemic, and time (R2=0.898, p<0.001). Longitudinal data suggest that government stringency is an effective tool in promoting preventative social behaviour in the fight against COVID-19.

Data promising effective Covid-19 vaccines have accelerated the UKs mass vaccination programme. The UK publics attitudes to the governments prioritisation list are unknown, and achieving critical population immunity will require the remaining majority to accept both vaccination and the delay in access of up to a year or more. This cross-sectional observational study sent an online questionnaire to registrants of the UK National Health Services largest personal health record. Question items covered willingness for Covid-19 vaccine uptake and attitudes to prioritisation. Among 9,122 responses, 71.5% indicated wanting a vaccine, below what previous modelling indicated as critical levels for progressing towards herd immunity. 22.7% disagreed with the prioritisation list, though 70.3% were against being able to expedite vaccination through payment. Age and female gender were, respectively, strongly positively and negatively associated with wanting a vaccine. Teachers and Black, Asian and Minority Ethnic (BAME) groups were most cited by respondents for prioritisation. This study identifies factors to inform the public health messaging critical to improving uptake.

BackgroundCoronavirus disease 2019 (COVID-19) is an international emergency that has been addressed in many countries by changes in and restrictions on behaviour. These are often collectively labelled social distancing and lockdown. On the 23rd June 2020, Boris Johnson, the Prime Minister of the United Kingdom announced substantial easings of restrictions. This paper examines some of the data he presented. MethodsGeneralised additive models, with negative binomial errors and cyclic term representing day-of-week effects, were fitted to data on the daily numbers of new confirmed cases of COVID-19. Exponential rates for the epidemic were estimated for different periods, and then used to calculate R, the reproduction number, for the disease in different periods. ResultsAfter an initial stabilisation, the lockdown reduced R to around 0.81 (95% CI: 0.79, 0.82). This value increased to around 0.94 (95% CI 0.89, 0.996) for the fortnight from the 9th June 2020. ConclusionsOfficial UK data, presented as the easing of the lockdown was announced, shows that R was already more than half way back to 1 at that point. That suggests there was little scope for the announced changes to be implemented without restarting the spread of the disease.

BackgroundExploring transmission and symptoms of COVID-19 in children is vital, given that schools have recently fully reopened. ObjectivesThis study aimed to characterise the nature and duration of symptoms suggestive of COVID-19 in UK households, and examine whether the symptoms varied between households with and without children and between adults and children from March to May 2020 in the UK. MethodsAn online questionnaire posted on social media (Mumsnet, Twitter, Facebook) was used to gather demographic and symptom information within UK households. ResultsResults from 508 households (1057 adults and 398 children) were available for analysis. 64.1% of respondent households with children and 59.1% of households without children had adults with symptoms suggestive of COVID-19. The proportion of adults that reported being symptomatic was 46.1% in households with children (and 36.7% in households without children. In 37.8% of households with at least one adult and one child with symptoms, the childs onset of symptoms started before the adult. Of all children, 35.7% experienced symptoms, with almost a quarter experiencing fluctuating symptoms for more than 2 weeks compared to almost half of symptomatic adults. In general, children had a shorter (median 5 days) and milder illness course than adults (median 10 days). Fatigue was the most common symptom in adults (79.7%) and cough was the most common symptom in children (53.5%). Chest tightness, shortness of breath, fatigue, muscle ache and diarrhoea were more common in adults than children, while cough and fever were equally common. ConclusionChildren had shorter and milder illness than adults, but in almost a quarter of children symptoms lasted more than 2 weeks. In over a third of both adult-child symptomatic households, the child was the first to become ill. Child to adult transmission and clinical presentation in children need to be further characterised. SynopsisO_LIStudy question. What is the nature and duration of symptoms suggestive of COVID-19 in UK households with and without children during March and May 2020? Do the symptoms vary between adults and children? C_LIO_LIWhats already known. There has been uncertainty about the extent to which children get and transmit SARS-CoV-2 within households. Symptoms associated with SARS-CoV-2 infection are well described in adults but symptoms and their duration are less well-characterised in children. C_LIO_LIWhat this study adds On average, children had shorter and milder illness than adults, but still symptoms lasted more than 2 weeks in a significant proportion of children. In over a third of both adult and child symptomatic households, the child was the first to become ill. C_LI

Polymerase Chain Reaction ("PCR") tests have been used to identify cases of COVID-19 during the course of the pandemic. Notably, PCR alone cannot differentiate between the presence of whole viruses (which can be transmitted and infect individuals) and small fragments of genetic material that are not infectious. A feature of PCR known as the cycle threshold (Ct) can be used to discriminate between these states, but the relationship between Ct and infectiousness is still poorly understood. This well-known limitation of the test compromises the identification of cases and their trends, and consequently those measures to interrupt transmission (such as isolation) that are undertaken on the basis of reliably identifying infectious individuals. Here, we interrogate the public authorities understanding of PCR testing for SARS-CoV-2 in the UK by accessing Freedom of Information requests submitted in 2020-21.We searched WhatDoTheyKnow and found 300 FOI requests, from over 150 individuals. We grouped their questions into four themes addressing the number of tests in use, the reporting of cycle thresholds ( Ct), the Ct values themselves, and the accuracy of tests. The number of validated tests in use in the UK is currently not clear: In FOI responses, Public Health England (PHE) report it may be "80" or "85". However, European regulations suggest there could be over 400 different CE marked tests available on the market and available for use. Laboratories have a statutory duty to report positive cases to PHE, but they do not have to advise which tests they are using nor submit Ct values. Only two FOI responses provided answers on Ct values, indicating that in a set time span, 24-38% of the Ct values were over 30. The most common FOI asked if there was a cycle threshold for positivity. In those that responded, the Ct for a positive result varied from 30 to 45. We found limited information on the technical accuracy of the tests. Several responses stated there is no static, specific or standard cycle threshold. The current system requires significant changes to ensure it offers accurate diagnostic data to enable effective clinical management of SARS-CoV-2. PCR is an important and powerful tool, but its systematic misuse and misreporting risk undermining its usefulness and credibility.

ObjectivesTo inform critical public health messaging by determining how changes in Covid-19 vaccine hesitancy, attitudes to the priorities for administration, the emergence of new variants and availability of vaccines may affect the trajectory and achievement of herd immunity. Methods>9,000 respondents in an ongoing cross-sectional participatory longitudinal epidemiology study (LoC-19, n=18,581) completed a questionnaire within their personal electronic health record in the week reporting first effective Covid-19 vaccines, and then again after widespread publicity of the increased transmissibility of a new variant (November 13th and December 31st 2020 respectively). Questions covered willingness to receive Covid-19 vaccination and attitudes to prioritisation. Descriptive statistics, unadjusted and adjusted odds ratios (ORs) and natural language processing of free-text responses are reported, and how changes over the first 50 days of both vaccination roll-out and new-variant impact modelling of anticipated transmission rates and the likelihood and time to herd immunity. FindingsCompared with the week reporting the first efficacious vaccine there was a 15% increase in acceptance of Covid-19 vaccination, attributable in one third to the impact of the new variant, with 75% of respondents "shielding" - staying at home and not leaving unless essential - regardless of health status or tier rules. 12.5% of respondents plan to change their behaviour two weeks after completing vaccination compared with 45% intending to do so only when cases have reduced to a low level. Despite the increase from 71% to 86% over this critical 50-day period, modelling of planned uptake of vaccination remains below that required for rapid effective herd immunity - now estimated to be 90 percent in the presence of a new variant escalating R0 to levels requiring further lockdowns. To inform the public messaging essential therefore to improve uptake, age and female gender were, respectively, strongly positively and negatively associated with wanting a vaccine. 22.7% disagreed with the prioritisation list, though 70.3% were against being able to expedite vaccination through payment. Teachers (988, 12.6%) and Black, Asian and Minority Ethnic (BAME) (837, 10.7%) groups were most cited by respondents for prioritisation. InterpretationIn this sample, the growing impact of personal choice among the increasingly informed public highlights a decrease in Covid-19 vaccine hesitancy over time, with news of a new variant motivating increased willingness for vaccination but at levels below what may be required for effective herd immunity. We identify public preferences for next-in-line priorities, headed by teachers and BAME groups, consideration of which will help build trust and community engagement critical for maximising compliance with not only the vaccination programme but also all other public health measures.

The COVID-19 monitoring behavioural insights study was conducted from April-May 2020 in Finland. Respondents reported feeling confident protecting themselves against COVID-19 infection. Worries shifted from overloading the health system (mean value 5.5 [95% CI: 5.4-5.6]) to mental health concerns (mean value 5.3 [95% CI 5.2-5.4]). Maintaining physical distancing from families and friends decreased by 7% and 6%. Respondents mostly agreed that if a vaccine would become available, they would get it. The decrease in acceptance of recommended measures needs further analysis, but current results provide evidence to support the response. Key pointsO_LICurrently limited information available on the complex interaction between epidemiology, media attention, pandemic control measures, risk perception and compliance with public health measures. C_LIO_LIDespite the relatively high risk perception of a possible infection with COVID-19, we observed a steady decrease in adherence to public health measures. C_LIO_LIThroughout the study, information-seeking behaviour shifted. C_LIO_LIWe observed a decrease in acceptance among the participants in regards to avoiding physical contact. C_LI

Reports of COVID-19 prevalence through national statistics, community surveys and targeted testing at places of work or study have guided national and institutional responses to the pandemic. The University of Edinburgh established a mass testing programme, TestEd, for detection of COVID-19 in asymptomatic staff and students who are studying or working on campus. The study has tested more than 100,000 samples with more than 170 confirmed positive results. Since the introduction of a change in policy in England and the UK devolved nations in early January 2022, to limit eligibility for PCR testing in the community to those with symptoms, we have noticed a divergence between the reports in Scottish and UK-wide prevalence, and the magnitude and frequency of positive results in the University datasets. While the national UK-wide and Scottish case figures show declining or stable prevalence, University case reports have risen more than five-fold since early December 2021 and continue to rise. These observations could be important in the face of future variants of concern and emphasise the need for continued access to high sensitivity PCR testing and other forms of surveillance.

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.

As COVID-19 testing is rolled out increasingly widely, the use of a range of alternative testing methods will be beneficial in ensuring testing systems are resilient and adaptable to different clinical and public health scenarios. Here, we compare and discuss the diagnostic performance of a range of different molecular assays designed to detect the presence of SARS-CoV-2 infection in people with suspected COVID-19. Using findings from a systematic review of 103 studies, we categorised COVID-19 molecular assays into 12 different test classes, covering point-of-care tests, various alternative RT-PCR protocols, and alternative methods such as isothermal amplification. We carried out meta-analyses to estimate the diagnostic accuracy and clinical utility of each test class. We also estimated the positive and negative predictive values of all diagnostic test classes across a range of prevalence rates. Using previously validated RT-PCR assays as a reference standard, 11 out of 12 classes showed a summary sensitivity estimate of at least 92% and a specificity estimate of at least 99%. Several diagnostic test classes were estimated to have positive predictive values of 100% throughout the investigated prevalence spectrum, whilst estimated negative predictive values were more variable and sensitive to disease prevalence. We also report the results of clinical utility models that can be used to determine the information gained from a positive and negative test result in each class, and whether each test is more suitable for confirmation or exclusion of disease. Our analysis suggests that several tests exist that are suitable alternatives to standard RT-PCR and we discuss scenarios in which these could be most beneficial, such as where time to test result is critical or, where resources are constrained. However, we also highlight methodological concerns with the design and conduct of many included studies, and also the existence of likely publication bias for some test classes. Our results should be interpreted with these shortcomings in mind. Furthermore, our conclusions on test performance are limited to their use in symptomatic populations: we did not identify sufficient suitable data to allow analysis of testing in asymptomatic populations.

ObjectiveTo gain a better understanding of decisions around adherence to self-isolation advice during the first phase of the COVID-19 response in England. DesignA mixed-methods cross sectional study. Setting: EnglandParticipants COVID-19 cases and contacts who were contacted by Public Health England (PHE) during the first phase of the response in England (January-March 2020). ResultsOf 250 respondents who were advised to self-isolate, 63% reported not leaving home at all during their isolation period, 20% reported leaving only for lower risk activities (dog walking or exercise) and 16% reported leaving for potentially higher risk, reasons (shopping, medical appointments, childcare, meeting family or friends). Factors associated with adherence to never going out included: the belief that following isolation advice would save lives, experiencing COVID-19 symptoms, being advised to stay in their room (rather than just "inside"), having help from outside and having regular contact by text message from PHE. Factors associated with non-adherence included being angry about the advice to isolate, being unable to get groceries delivered and concerns about losing touch with friends and family. Interviews highlighted that a sense of duty motivated people to adhere to isolation guidance and where people did leave their homes, these decisions were based on rational calculations of the risk of transmission - people would only leave their homes when they thought they were unlikely to come into contact with others. ConclusionsMeasures of adherence should be nuanced to allow for the adaptations people make to their behaviour during isolation. Understanding adherence to isolation and associated reasoning during the early stages of the pandemic is an essential part of pandemic preparedness for future emerging infectious diseases. Strengths and limitations of this studyO_LIOur participants were contacted directly by Public Health England during the first three months of the pandemic - the only cohort of cases and contacts who experienced self-isolation during this early phase of the pandemic. C_LIO_LIResults may not be directly generalisable to wider populations or later phases of pandemic response. C_LIO_LIWe classified reasons for leaving the home as higher or lower contact, as a proxy for potential risk of transmission, however further research published since we conducted our research as refined our understanding of transmission risk, highlighting the need for more in-depth research on adherence behaviour and transmission risk. C_LIO_LIThe mixed methods approach combined quantitative measures of adherence with an exploration of how and why these decisions were being made in the same people. C_LIO_LIOur study provides unique insights into self-isolation during the earliest stages of the pandemic, against a background of uncertainty and lack of information that will recur, inevitably, in the face of future pandemic and similar threats. C_LI

As of June 2021, the European Union (EU) and Switzerland have published information about the introduction of COVID certificates in order to facilitate the safe free movement of their citizens. With implementation underway, little is known about the public perception of such certificates with potential differences in acceptability among individuals. In March 2021, a self-administered online questionnaire was proposed to all individuals 18 years and older participating in the longitudinal follow-up of population-based seroprevalence studies in Geneva, Switzerland. The questionnaire covered aspects of individual and collective benefits, while allowing participants to select contexts in which vaccination certificates should be presented. Results were presented as the proportion of individuals agreeing or disagreeing with the implementation of vaccination certificates, selecting specific contexts where certificates should be presented, and agreeing or disagreeing with the potential risks related to certificates. Logistic regression was used to calculate odds ratios for factors associated with certificate non-acceptance. Overall, 4,056 individuals completed the questionnaire (response rate 77.6%; mean age 53.3 {+/-} standard deviation 14.4 years; 56.1% were women). About 61.0% of participants agreed or strongly agreed that a vaccination certificate was necessary in certain contexts; and 21.6% believed there was no context where vaccination certificates should be presented. Contexts where a majority of participants perceived a vaccination certificate should be presented included jobs where others would be at risk of COVID-related complications (60.7%), jobs where employees would be at risk of getting infected (58.7%), or to be exempt from quarantine when traveling abroad (56.1%). Contexts where fewer individuals perceived the need for vaccination certificates to be presented were participation in large gatherings (36.9%), access to social venues (35.5%), or sharing the same workspace (21.5%). Younger age, an absence of willingness to get vaccinated, and an absence of belief in vaccination as an important step in surmounting the pandemic were factors associated with certificate non-acceptance. This large population-based study showed that the general adult population in Geneva, Switzerland, agreed with the implementation of vaccination certificates in work-related and travel-related contexts. However, this solution was perceived as unnecessary for access to large gatherings or social venues, or to share the same workspace. Differences were seen with gender, age, education, socio-economic status, and vaccination willingness and perception, highlighting the importance of taking personal and sociodemographic variations into consideration when predicting acceptance of such certificates.

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 re-commence, 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 mass gatherings, particularly mass participation sports events such as running, but also events in other sectors such as concerts, carnivals and festivals. This paper sets out a protocol for a rapid scoping review of evidence of incidents of outdoor transmission of COVID-19, including the settings, environments and circumstances of such transmission, and their comparative prevalence to incidents of indoor transmission. Its purpose is to inform discussions about the recommencement of activities that generate mass gatherings.

BackgroundCOVID-19 testing and contact tracing has been crucial in Australias prevention strategy. However, testing for COVID-19 is far from optimal, and behavioural barriers are unknown. Study 1 aimed to identify the range of barriers to testing. Study 2 aimed to estimate prevalence in a nationally relevant sample to target interventions. MethodsStudy 1: National longitudinal COVID-19 survey from April-November 2020. Testing barriers were included in the June survey (n=1369). Open responses were coded using the COM-B framework (capability-opportunity-motivation). Study 2: Barriers from Study 1 were presented to a new nationally representative sample in November to estimate prevalence (n=2869). Barrier prevalence was analysed by health literacy level using Chi square tests. ResultsStudy 1: 49% strongly agreed to get tested for symptoms, and 69% would self-isolate. Concern about pain was the top barrier from a provided list (11%), but 32 additional barriers were identified from open responses and coded to the COM-B framework. Study 2: The most prevalent barriers were motivation issues (e.g. dont believe symptoms are COVID-19: 28%, few local cases: 18%). Capability issues were also common (e.g. not sure symptoms are bad enough: 19%, not sure whether symptoms need testing: 15%). Many barriers were more prevalent amongst people with low compared to high health literacy, including motivation (preference to self isolate: 21% vs 12%, pain: 15% vs 9%) and capability (not sure symptom needs testing: 12% vs 8%, not sure how to test:11% vs 4%). ConclusionEven in a health system with free and widespread access to COVID-19 testing, motivation and capability barriers were prevalent issues, particularly for people with lower health literacy. This study highlights the important of diagnosing behaviour barriers to target public health interventions for COVID-19 and future pandemics.

AimsWith a social media analysis of the discourse surrounding the prevalence of Long COVID in children and young people (CYP), this study aims to explore healthcare workers perceptions concerning Long COVID in CYP in the UK between January 2021 and January 2022. This will allow to contribute to the emerging knowledge on Long COVID and identify critical areas and future directions for researchers and policymakers. DesignA mixed methods approach with a discourse, keywords, sentiment, and image analysis, using Pulsar and Infranodus. SettingA discussion of the experience of Long COVID in CYP in the UK shared on Twitter between 1 January 2021 and 31 January 2022. ParticipantsA sample of health workers with Twitter accounts whose bio has them identifying themselves as HCWs. ResultsWe obtained 2588 tweets. HCW were responsive to announcements issued by authorities regarding the management of COVID-19 in the UK. The most frequent feelings were negative. The main themes were uncertainty about the future, policies and regulations, managing and addressing COVID-19 and Long COVID in CYP, vaccination, using Twitter to share scientific literature and management strategies, and clinical and personal experiences. ConclusionsThe perceptions described on Twitter by HCW concerning the presence of Long COVID in CYP appear to be a relevant and timely issue and responsive to the declarations and guidelines issued by health authorities over time. We recommend further support and training strategies for health workers and school staff regarding the manifestations and treatment of Long COVID in CYP. Strengths and limitations of this study- Our online analysis of Long COVID contributes towards an emerging understanding of reported experiential, emotional and practical dimensions of Long COVID in CYP specifically, as well as questions of vaccine hesitancy in CYP with Long COVID. - We identify key policy areas that need considered attention and focus, such as: a) the provision of psychosocial support with access to quality mental health resources to alleviate the impact that Long COVID can have on the mental health of CYP; and b) the development of clear Long COVID pandemic recovery policies that are informed from a health equity perspective and how this affects CYP living with Long COVID. - This is one of few studies to collect healthcare workers perceptions regarding Long COVID in CYP in the UK, using information from Twitter. - This study is limited to the perception of those who identified as healthcare workers via their online biographies, and so is not representative of the general UK or the global population.

Background Early recognition of presentations consistent with the deliberate release of a Category A bioterrorism agent is essential for rapid isolation, public health notification, and containment. The ability of UK clinicians-in-training to recognise these syndromes is unstudied. This pilot assessed final-year UK medical students' ability to recognise these syndromes. Methods A pilot cross-sectional online survey of final-year UK medical students used single-best-answer clinical vignettes depicting syndromes associated with Category A bioterrorism agents (BT vignettes) and clinically overlapping non-bioterrorism syndromes (NBT vignettes). Performance was summarised as the proportion of vignettes correctly identified, with primary analysis comparing within-participant BT and NBT performance. Results Twenty-five participants completed the survey. Participants performed worse on BT vignettes (M = 0.55) than on NBT vignettes (M = 0.81), with a within-participant difference of -0.26 (95% CI [-0.35, -0.18]; t(24) = -6.33, p < 0.001; Cohen's dz = -1.27). Botulism (96.0%) and Ebola virus disease (88.0%) were recognised by most participants, while anthrax (40.0%), pneumonic plague (28.0%), and smallpox (24.0%) were recognised by fewer than half. Conclusion This pilot provides the first UK evidence of a substantial diagnostic deficit in final-year medical students' recognition of Category A bioterrorism agent syndromes.

BackgroundCOVID-19 vaccines have been the central pillar of the public health response to the pandemic, intended to enable us to live with Covid. It is important to understand COVID-19 vaccines attitudes and decisions in order to maximise uptake through an empathetic lens. ObjectiveTo explore the factors that influenced peoples COVID-19 vaccines decisions and how attitudes towards the vaccines had changed in an eventful year. Design and participantsThis is a follow up study that took place in Bradford, UK one year after the original study, between October 2021 and January 2022. In-depth phone interviews were conducted with 12 (of the 20 originally interviewed) people from different ethnic groups and areas of Bradford. Reflexive thematic analysis was conducted. Results11 of the 12 participants interviewed had received both doses of the COVID-19 vaccine and most intended to have a booster dose. Participants described a variety of reasons why they had decided to have the vaccines, including: feeling at increased risk at work; protecting family and others in their communities, unrestricted travel and being influenced by the vaccine decisions of family, friends and colleagues. All participants discussed ongoing interaction with COVID-19 misinformation and for some this meant they were uneasy about their decision to have the vaccine. They described feeling overloaded by and disengaged from COVID-19 information, which they often found contradictory and some felt mistrustful of the UK governments motives and decisions during the pandemic. ConclusionsThe majority of participants had managed to navigate an overwhelming amount of circulating COVID-19 misinformation and chosen to have two or more COVID-19 vaccines, even if they had been previously said they were unsure. However, these decisions were complicated, and demonstrate the continuum of vaccine hesitancy and acceptance. This follow up study underlines that vaccine attitudes are changeable and contextual. Patient or Public ContributionThe original study was developed through a rapid community and stakeholder engagement process in 2020. Discussion with the Bradford Council Public Health team and the public through the Bradford COVID-19 Community Insights Group was undertaken in 2021 to identify important priorities for this follow up study.

ObjectivesTo develop a toolkit to provide a structured framework for assessing whether large events are COVID-secure. Study designCross-sectional reporting on the development of the COVID-19 Suffolk Events Toolkit (C-SET). MethodsThe toolkit was developed through an iterative process of writing, discussion, and modification, drawing upon national UK guidance. Pilot cases and a contemporaneous consultation with experts were also undertaken, and C-SET was revised in line with the findings. ResultsC-SET offers a robust, structured approach to identifying areas of concern and potential mitigations, and collates and synthesises current national UK guidance. A flexible, modular design allows it to provide high-level input across all types of event, and allow modification to suit the needs of individual organisations. It is applicable to a variety of users, including event organisers in need of a structure, or bodies whose role is to appraise such events. It provides a semi-quantitative summary output, and in conjunction with the detailed links to guidance in the framework, allows development of clear, actionable recommendations to tangibly improve the quality of events. ConclusionsA necessary trade-off exists between COVID-related health risks and wider risks due to economic downturn, and facilitating large events in a way that minimises COVID transmission risk may offer a way to balance these competing priorities. C-SET was developed to provide a structured approach to identifying areas of improvement across key risk domains, and suggests potential mitigations that are underpinned by national UK guidance. Use of this toolkit may aid event organisers in developing COVID-secure events, and aid regulatory bodies in suggesting actionable recommendations through generation of a summary report of areas of concern.

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

BackgroundAccurate and reliable diagnosis of COVID-19 is essential for effective disease management and public health interventions. SARS-CoV-2 antibody/antigen tests play a crucial role in identifying covid-19 infections and assessing immunity in populations. This systematic review aimed to evaluate the sensitivity, specificity, and accuracy of SARS-CoV-2 antibody tests in diagnosing COVID-19. MethodA comprehensive systematic review of the literature was conducted using prominent scientific databases, including PubMed, Google Scholar, Cochrane, and Scopus to search studies published from January 2020 to May 2023. The review followed the PRISMA-DTA framework to ensure transparency and rigor in the selection and evaluation of studies. The QUADAS-2 tool was utilized to assess study quality and risk of bias. This review was registered on PROSPERO (registration number CRD 42023445695). ResultsThe pooled sensitivity of SARS-CoV-2 antibody/antigen tests was found to be 73% (95% CI: 60-86), with individual studies reporting a wide range from 30% to 100%. The pooled specificity was 98% (95% CI: 97-100), with values ranging from 85.9% to 100%. The pooled accuracy was 88%, showing variation from 50% to 100% across different studies. ConclusionThis review highlights the moderate to high sensitivity and specificity of SARS-CoV-2 antibody/antigen tests for COVID-19 diagnosis. The substantial variability in test performance necessitates the standardization of testing protocols and further research to improve accuracy and reliability. These findings offer valuable insights for clinical decision-making and the formulation of effective public health strategies related to COVID-19 diagnosis.