The Lancet Regional Health - Europe

Pre-vaccine SARS-CoV-2 seroprevalence data from Germany are scarce outside hotspots, and socioeconomic disparities remained largely unexplored. The nationwide RKI-SOEP study with 15,122 adult participants investigated seroprevalence and testing in a supplementary wave of the Socio-Economic-Panel conducted predominantly in October-November 2020. Self-collected oral-nasal swabs were PCR-positive in 0.4% and Euroimmun anti-SARS-CoV-2-S1-IgG ELISA from dry capillary blood in 1.3% (95% CI 0.9-1.7%, population-weighted, corrected for sensitivity=0.811, specificity=0.997). Seroprevalence was 1.7% (95% CI 1.2-2.3%) when additionally adjusting for antibody decay. Overall infection prevalence including self-reports was 2.1%. We estimate 45% (95% CI 21-60%) undetected cases and analyses suggest lower detection in socioeconomically deprived districts. Prior SARS-CoV-2 testing was reported by 18% from the lower educational group compared to 25% and 26% from the medium and high educational group (p<0.0001). Symptom-triggered test frequency was similar across educational groups. However, routine testing was more common in low-educated adults, whereas travel-related testing and testing after contact with an infected person was more common in highly educated groups. In conclusion, pre-vaccine SARS-CoV-2-seroprevalence in Germany was very low. Notified cases appear to capture more than half of infections but may underestimate infections in lower socioeconomic groups. These data confirm the successful containment strategy of Germany until winter 2020.

BackgroundPost-pandemic years are characterized by widespread previous population immunisation against COVID-19. Whether and for whom SARS-CoV-2 vaccinations are still justified is unclear. We use nationwide estimates of IFR and literature derived estimates of vaccine effectiveness (VE) to calculate numbers needed to vaccinate to prevent one COVID-19 death (NNV) and for one life-year saved (LYS) in Austria in 2024. MethodsIn this retrospective analysis we calculate SARS-CoV-2 IFR during 2024 in Austria according to previously published wastewater-based infection estimates and available mortality data. Using literature derived VE estimates we calculate NNV to prevent one COVID-19 death and for one LYS in strata according to age groups, nursing home residency and vaccination in 2024. We repeat analyses with sensitivity range values of parameters. ResultsIn 2024, total IFR was 0.048%. NNV (LYS) in the age groups 0-19, 20-39, 40-59, 60-74 and 75-84 years were very high: e.g. 5,497,526 (151,570), 2,432,498 (92,614), 415,714 (24,777), 35,925 (3,748), and 4,882 (1,009), respectively, in community dwellers. In the 85+ years age group, IFRs of unvaccinated/vaccinated were 0.91%/0.77% for community dwellers, and 1.22%/1.04% for nursing home residents. The 85+ year age group had NNV estimates of 1,215 and 907 (LYS: 525 and 1,896) in community dweller and nursing home residents, respectively. Sensitivity analyses yielded LYS<1,000 only under some favourable assumptions in the 75-84 and 85+ years old age strata. ConclusionsIn 2024 SARS-CoV-2 IFR was low and NNV and LYS of COVID-19 vaccinations correspondingly non-favourably high, even for very old individuals.

BackgroundDuring the Covid19 pandemic, school closure has been mandated in analogy to its known effect against influenza, but it is unclear whether schools are early amplifiers of Covid19 cases. MethodsWe performed a cross-sectional and prospective cohort study in Italy. We used databases from the Italian Ministry of Education containing the number of new positive SARS-CoV-2 cases per school from September 20 to November 8, 2020 to calculate incidence among students and staff. We calculated incidence across each age group using databases from the Veneto Region system of SARS-CoV-2 cases notification in the period August 26- November 24, 2020. We used a database from the Veneto Region system of SARS-CoV-2 secondary cases tracing in Verona province schools to estimate number of tests, the frequency of secondary infections at school by type of index case and the ratio positive cases/ number of tests per school institute using an adjusted multivariable generalized linear regression model. We estimated the reproduction number Rt at the regional level from the Italian Civil Protection of regional SARS-CoV-2 cases notification database in the period 6 August-2 December 2020. FindingsFrom September 12 to November 7 2020, SARS-CoV-2 incidence among students was lower than that in the general population of all but two Italian regions. Secondary infections were <1%, and clusters of >2 secondary cases per school were 5-7% in a representative November week. Incidence among teachers was greater than in the general population. However, when compared with incidence among similar age groups, the difference was not significant (P=0.23). Secondary infections among teachers were more frequent when the index case was a teacher than a student (38% vs. 11%, P=0.007). From August 28 to October 25 in Veneto where school reopened on September 14, the growth of SARS-CoV- 2 incidence was lower in school age individuals, maximal in 20-29 and 45-49 years old individuals. The delay between the different school opening dates in the different Italian regions and the increase in the regional Covid19 reproduction number Rt was not uniform. Reciprocally, school closures in two regions where they were implemented before other measures did not affect the rate of Rt decline. InterpretationOur analysis does not support a role for school opening as a driver of the second wave of SARS-CoV-2 epidemics in Italy, a large European country with high SARS-CoV-2 incidence. Research in contextO_ST_ABSEvidence before this studyC_ST_ABSThe role of schools and at large of children as amplifiers of the Covid19 pandemics is debated. Despite biological and epidemiological evidence that children play a marginal role in Sars-CoV-2 spread, policies of school closures have been predicated, mostly based on the temporal coincidence between school reopening in certain countries and Covid19 outbreaks. Whether schools contributed to the so called "second wave" of Covid19 is uncertain. Italys regionalized calendar of school reopening and databases of positivity at school allows to estimate the impact of schools on the increase of Sars-CoV-2 that occurred in autumn 2020. Added value of this studyWe found that incidence among students is lower than in the general population and that whereas incidence among teachers appears higher than that in the general population, it is comparable to that among individuals of the same age bracket. Moreover, secondary infections at school are rare and clusters even less common. The index case of a secondary teacher case is more frequently a teacher than a student. In Veneto, during the first phase of the second wave incidence among school age individuals was low as opposed to the sustained incidence among individuals of 45-49 years. Finally, the time lag between school opening and Rt increase was not uniform across different Italian regions with different school opening dates, with lag times shorter in regions where schools opened later. Implications of the available evidenceThese findings contribute to indicate that Covid19 infections rarely occur at school and that transmission from students to teachers is very rare. Moreover, they fail to support a role for school age individuals and school openings as a driver of the Covid19 second wave. Overall, our findings could help inform policy initiatives of school openings during the current Covid19 pandemic.

BackgroundDecisions to impose temporary travel measures are less common as the global epidemiology of COVID-19 evolves. Risk-based travel measures may avoid the need for a complete travel ban, however evaluations of their effects are lacking. Here we investigated the public health effects of a temporary traffic light system introduced in the United Kingdom (UK) in 2021, imposing red-amber-green (RAG) status based on risk assessment. MethodsWe analysed data on international flight passengers arriving into Scotland, COVID-19 testing surveillance, and SARS-CoV-2 whole genome sequences to quantify effects of the traffic light system on (i) international travel frequency, (ii) travel-related SARS-CoV-2 case importations, (iii) national SARS-CoV-2 case incidence, and (iv) importation of novel SARS-CoV-2 variants. ResultsInternational flight passengers arriving into Scotland had increased by 754% during the traffic light period. Amber list countries were the most frequently visited and ranked highly for SARS-CoV-2 importations and contribution to national case incidence. Rates of international travel and associated SARS-CoV-2 cases varied significantly across age, health board, and deprivation groups. Multivariable logistic regression revealed SARS-CoV-2 cases detections were less likely among travellers than non-travellers, although increasing from green-to-amber and amber-to-red lists. When examined according to travel destination, SARS-CoV-2 importation risks did not strictly follow RAG designations, and red lists did not prevent establishment of novel SARS-CoV-2 variants. ConclusionsOur findings suggest that country-specific post-arrival screening undertaken in Scotland did not prohibit the public health impact of COVID-19 in Scotland. Travel rates likely contributed to patterns of high SARS-CoV-2 case importation and population impact.

AO_SCPLOWBSTRACTC_SCPLOWO_ST_ABSBackgroundC_ST_ABSIt is now established that a significant proportion of adults experience persistent symptoms after SARS-CoV-2 infection. However, evidence for children and adolescents is still inconclusive. In this population-based study, we examine the proportion of children and adolescents reporting persistent symptoms after SARS-CoV-2 infection, as assessed by serological status, and compare this to a seronegative control group. MethodsWe conducted a serosurvey in June-July 2021, recruiting 660 children and adolescents from 391 households selected randomly from the Geneva population. We tested participants for anti-SARS-CoV-2 antibodies targeting the nucleocapsid (N) protein to determine previous infection. A parent filled a questionnaire including questions on COVID-19-related symptoms lasting at least 2 weeks. FindingsAmong children seropositive for anti-SARS-CoV-2 antibodies, the sex- and age-adjusted prevalence of symptoms lasting longer than two weeks was 18.3%, compared to 11.1% among seronegative children (prevalence difference ({Delta}aPrev)=7.2%, 95%CI:1.5-13.0). Main symptoms declared among seropositive children were fatigue (11.5%) and headache (11.1%). For 8.6% (aPrev, 95%CI: 4.7-12.5) of seropositives, these symptoms were declared to be highly limiting of daily activities. Adolescents aged 12-17 years had a higher adjusted prevalence of persistent symptoms (aPrev=29.1%, 95%CI:19.4-38.7) than younger children. Comparing seropositive and seronegative adolescents, the estimated prevalence of symptoms lasting over four weeks is 4.4% ({Delta}aPrev, 95%CI:-3.8-13.6). InterpretationA significant proportion of children aged 12 to 17 years had symptoms lasting over two weeks after SARS-CoV-2 infection, with an estimated prevalence of symptoms lasting over 4 weeks of 4.4% in this age group. This represents a large number of adolescents in absolute terms, and should raise concern in the context of unknown long-term evolution of symptoms. Younger children appear to experience long-lasting symptoms less frequently, as no difference was observed between the seropositive and seronegative sample. Further studies with larger samples sizes are needed. FundingSwiss Federal Office of Public Health, Geneva General Directorate of Health, HUG Private Foundation, SSPH+, Fondation des Grangettes.

BackgroundDespite high levels of vaccination in the adult population, cases of COVID-19 have risen exponentially in England since the start of May 2021 driven by the Delta variant. However, with far fewer hospitalisations and deaths per case during the recent growth in cases compared with 2020, it is intended that all remaining social distancing legislation in England will be removed from 19 July 2021. MethodsWe report interim results from round 13 of the REal-time Assessment of Community Transmission-1 (REACT-1) study in which a cross-sectional sample of the population of England was asked to provide a throat and nose swab for RT-PCR and to answer a questionnaire. Data collection for this report (round 13 interim) was from 24 June to 5 July 2021. ResultsIn round 13 interim, we found 237 positives from 47,729 swabs giving a weighted prevalence of 0.59% (0.51%, 0.68%) which was approximately four-fold higher compared with round 12 at 0.15% (0.12%, 0.18%). This resulted from continued exponential growth in prevalence with an average doubling time of 15 (13, 17) days between round 12 and round 13. However, during the recent period of round 13 interim only, we observed a shorter doubling time of 6.1 (4.0, 12) days with a corresponding R number of 1.87 (1.40, 2.45). There were substantial increases in all age groups under the age of 75 years, and especially at younger ages, with the highest prevalence in 13 to 17 year olds at 1.33% (0.97%, 1.82%) and in 18 to 24 years olds at 1.40% (0.89%, 2.18%). Infections have increased in all regions with the largest increase in London where prevalence increased more than eight-fold from 0.13% (0.08%, 0.20%) in round 12 to 1.08% (0.79%, 1.47%) in round 13 interim. Overall, prevalence was over 3 times higher in the unvaccinated compared with those reporting two doses of vaccine in both round 12 and round 13 interim, although there was a similar proportional increase in prevalence in vaccinated and unvaccinated individuals between the two rounds. DiscussionWe are entering a critical period with a number of important competing processes: continued vaccination rollout to the whole adult population in England, increased natural immunity through infection, reduced social mixing of children during school holidays, increased proportion of mixing occurring outdoors during summer, the intended full opening of hospitality and entertainment and cessation of mandated social distancing and mask wearing. Surveillance programmes are essential during this next phase of the epidemic to provide clear evidence to the government and the public on the levels and trends in prevalence of infections and their relationship to vaccine coverage, hospitalisations, deaths and Long COVID.

Long covid follows 10-20% of first-time SARS-CoV-2 infections, but the societal burden of long covid and risk factors for the condition are not well-understood. Here, we report findings about self-reported sick leave and risk factors thereof from a hybrid survey and register study, which included 37,482 RT- PCR confirmed SARS-CoV-2 cases and 51,336 test-negative controls who were tested during the index and alpha waves. An additional 33 individuals per 1000 took substantial sick leave following acute infection compared to persons with no known history of infection, where substantial sick leave was defined as >1 month of sick leave within the period 1-9 months after the RT-PCR test date. Being female, [&ge;]50 years, and having certain pre-existing conditions such as fibromyalgia increased risks for taking substantial sick leave. Further research exploring this heterogeneity is urgently needed and may provide important evidence for more targeted preventative strategies.

BackgroundWomen are overrepresented amongst individuals suffering from post-acute sequelae of SARS-CoV-2 infection (PASC). Biological (sex) as well as sociocultural (gender) differences between women and men might account for this imbalance, yet their impact on PASC is unknown. Methods and FindingsBy using Bayesian models comprising >200 co-variates, we assessed the impact of social context in addition to biological data on PASC in a multi-centre prospective cohort study of 2927 (46% women) individuals in Switzerland. Women more often reported at least one persistent symptom than men (43.5% vs 32.0% of men, p<0.001) six (IQR 5-9) months after SARS-CoV-2 infection. Adjusted models showed that women with personality traits stereotypically attributed to women were most often affected by PASC (OR 2.50[1.25-4.98], p<0.001), in particular when they were living alone (OR 1.84[1.25-2.74]), had an increased stress level (OR 1.06[1.03-1.09]), had undergone higher education (OR 1.30[1.08-1.54]), preferred pre-pandemic physical greeting over verbal greeting (OR 1.71[1.44-2.03]), and had experienced an increased number of symptoms during index infection (OR 1.27[1.22-1.33]). ConclusionBesides gender- and sex-sensitive biological parameters, sociocultural variables play an important role in producing sex differences in PASC. Our results indicate that predictor variables of PASC can be easily identified without extensive diagnostic testing and are targets of interventions aiming at stress coping and social support.

In early January 2021, England entered its third national lockdown of the COVID-19 pandemic to reduce numbers of deaths and pressure on healthcare services, while rapidly rolling out vaccination to healthcare workers and those most at risk of severe disease and death. REACT-1 is a survey of SARS-CoV-2 prevalence in the community in England, based on repeated cross-sectional samples of the population. Between 6th and 22nd January 2021, out of 167,642 results, 2,282 were positive giving a weighted national prevalence of infection of 1.57% (95% CI, 1.49%, 1.66%). The R number nationally over this period was estimated at 0.98 (0.92, 1.04). Prevalence remained high throughout, but with suggestion of a decline at the end of the study period. The average national trend masked regional heterogeneity, with robustly decreasing prevalence in one region (South West) and increasing prevalence in another (East Midlands). Overall prevalence at regional level was highest in London at 2.83% (2.53%, 3.16%). Although prevalence nationally was highest in the low-risk 18 to 24 year old group at 2.44% (1.96%, 3.03%), it was also high in those over 65 years who are most at risk, at 0.93% (0.82%, 1.05%). Large household size, living in a deprived neighbourhood, and Black and Asian ethnicity were all associated with higher levels of infections compared to smaller households, less deprived neighbourhoods and other ethnicities. Healthcare and care home workers, and other key workers, were more likely to test positive compared to other workers. If sustained lower prevalence is not achieved rapidly in England, pressure on healthcare services and numbers of COVID-19 deaths will remain unacceptably high.

BackgroundPost-pandemic mortality rates can explore the residual COVID-19 burden and changes in other causes of death. Considering weighted multiple causes of death from death certificates (underlying and others) may help compare post-versus pre-pandemic mortality patterns, while potentially reducing the impact of cause misattribution. Estimates of post-pandemic impact are critical also for proper continuing public health policies (e.g. vaccinations). MethodsWe retrospectively analyse national all-cause mortality rate ratios between 2024 and pre-pandemic years (2017-2019) for sex-stratified 10-year age groups in Austria. In weighted analyses, the underlying death cause was weighted 50% and other causes shared the remaining 50%. Sensitivity analyses explored different weightings. Cause-specific weightings were also compared between 2024 and 2019. ResultsDespite 1,212 reported COVID-19 deaths in 2024, all-cause mortality rates were equal or lower in 2024 compared to 2019 in all strata at risk from COVID-19 (i.e., aged 60 years and over). All-cause mortality rates in 2024 were higher than in 2019 in adolescent and young adult strata. The ratio of weighted over unweighted COVID-19 death rates was 0.51-0.58 for age strata 60 years and older and even lower in sensitivity analyses, indicating that COVID-19 deaths were possibly overestimated. ConclusionsPost-pandemic COVID-19 deaths had no visible impact on mortality patterns in Austria and were possibly overcounted. Increased post-pandemic mortality patterns in the young are particularly worrisome.

BackgroundEngland will start to exit its third national lockdown in response to the COVID-19 pandemic on 8th March 2021, with safe effective vaccines being rolled out rapidly against a background of emerging transmissible and immunologically novel variants of SARS-CoV-2. A subsequent increase in community prevalence of infection could delay further relaxation of lockdown if vaccine uptake and efficacy are not sufficiently high to prevent increased pressure on healthcare services. MethodsThe PCR self-swab arm of the REal-time Assessment of Community Transmission Study (REACT-1) estimates community prevalence of SARS-CoV-2 infection in England based on random cross-sections of the population ages five and over. Here, we present results from the complete round 9 of REACT-1 comprising round 9a in which swabs were collected from 4th to 12th February 2021 and round 9b from 13th to 23rd February 2021. We also compare the results of REACT-1 round 9 to round 8, in which swabs were collected mainly from 6th January to 22nd January 2021. ResultsOut of 165,456 results for round 9 overall, 689 were positive. Overall weighted prevalence of infection in the community in England was 0.49% (0.44%, 0.55%), representing a fall of over two thirds from round 8. However the rate of decline of the epidemic has slowed from 15 (13, 17) days, estimated for the period from the end of round 8 to the start of round 9, to 31 days estimated using data from round 9 alone (lower confidence limit 17 days). When comparing round 9a to 9b there were apparent falls in four regions, no apparent change in one region and apparent rises in four regions, including London where there was a suggestion of sub-regional heterogeneity in growth and decline. Smoothed prevalence maps suggest large contiguous areas of growth and decline that do not align with administrative regions. Prevalence fell by 50% or more across all age groups in round 9 compared to round 8, with prevalence (round 9) ranging from 0.21% in those aged 65 and over to 0.71% in those aged 13 to 17 years. Round 9 prevalence was highest among Pakistani participants at 2.1% compared to white participants at 0.45% and Black participants at 0.83%. There were higher adjusted odds of infection for healthcare and care home workers, for those working in public transport and those working in education, school, nursery or childcare and lower adjusted odds for those not required to work outside the home. ConclusionsCommunity prevalence of swab-positivity has declined markedly between January and February 2021 during lockdown in England, but remains high; the rate of decline has slowed in the most recent period, with a suggestion of pockets of growth. Continued adherence to social distancing and public health measures is required so that infection rates fall to much lower levels. This will help to ensure that the benefits of the vaccination roll-out programme in England are fully realised.

BackgroundWith the potential for and emergence of new COVID-19 variants, such as the reportedly more infectious Omicron, and their potential to escape the existing vaccines, understanding the relative importance of which non-household activities increase risk of acquisition of COVID-19 infection is vital to inform mitigation strategies. MethodsWithin an adult subset of the Virus Watch community cohort study, we sought to identify which non-household activities increased risk of acquisition of COVID-19 infection and which accounted for the greatest proportion of non-household acquired COVID-19 infections during the second wave of the pandemic. Among participants who were undertaking antibody tests and self-reporting PCR and lateral flow tests taken through the national testing programme, we identified those who were thought to be infected outside the household during the second wave of the pandemic. We used exposure data on attending work, using public or shared transport, using shops and other non-household activities taken from monthly surveys during the second wave of the pandemic. We used multivariable logistic regression models to assess the relative independent contribution of these exposures on risk of acquiring infection outside the household. We calculated Adjusted Population Attributable Fractions (APAF - the proportion of non-household transmission in the cohort thought to be attributable to each exposure) based on odds ratios and frequency of exposure in cases. ResultsBased on analysis of 10475 adult participants including 874 infections acquired outside the household, infection was independently associated with: leaving home for work (AOR 1.20 (1.02 - 1.42) p=0.0307, APAF 6.9%); public transport use (AOR for use more than once per week 1.82 (1.49 - 2.23) p<0.0001, APAF for public transport 12.42%); and shopping (AOR for shopping more than once per week 1.69 (1.29 - 2.21) P=0.0003, APAF for shopping 34.56%). Other non-household activities such as use of hospitality and leisure venues were rare due to restrictions and there were no significant associations with infection risk. ConclusionsA high proportion of the second wave of the pandemic was spent under conditions where people were being advised to work from home where possible, and to minimize exposure to shops, and a wide range of other businesses were subject to severe restrictions. Vaccines were being rolled out to high-risk groups. During this time, going to work was an important risk factor for infection but public transport use likely accounted for a lot of this risk. Only a minority of the cohort left home for work or used public or shared transport. By contrast, the majority of participants visited shops and this activity accounted for about one-third of non-household transmission.

BackgroundDespite the high number of post-COVID-19 condition (PCC) cases worldwide, little is known about recovery and its associated factors yet. This study aimed to estimate the proportion of PCC patients that recover, and identity environment and individual factors. MethodsLongitudinal data of the PRIME cohort were analysed in patients with past infection who felt unrecovered at baseline (November 2021), grouped based on capacity of daily functioning (i.e., moderate to severe problems (PCC-impairedDA) or no or slight problems (PCC-affectedDA)). Proportions of recovery or deterioration at follow-up (after 9 months) were calculated. A range of individual, interpersonal, social network, and social and physical environment factors were assessed for lower likelihood for recovery, using multivariable logistic regression. Findings879 patients were analysed. Of patients with PCC-affectedDA (n=602), 222 (36.9%) recovered and 59 (9.8%) deteriorated to PCC-impairedDA. Of patients with PCC-impairedDA (n=277), 30 (10.8%) recovered and 88 (31.8%) improved in daily functioning; recovery was 2.1% when acute illness was >12 months before baseline, and was 12.5% and 13.6% when acute illness was 6-12 and 3-6 months before baseline, respectively. In both PCC groups, individual and environment factors that lowered recovery likelihood included worse physical health (mild/severe fatigue, severe dyspnea, severe symptoms of amnesia, concentration difficulties, muscle pain or -weakness, loss/change of smell/taste), worse mobility (hours spend lying down, problems with walking), worse mental health (depression), worse acute illness (more symptoms, hospitalization/oxygen use), former smoking, living in a rural area, having a relationship, and having more practical social network supporters (in patients with chronic co-morbidities). InterpretationOnly 11%-37% of PCC patients recovered after 9 months, leaving significant room for improvement. Future research should identify modifiable factors and treatments to help assist the recovery of PCC patients. FundingThis study was funded by the Dutch National Institute for Health and Environment, Ministry of Health, Welfare and Sport (Grant numbers: 3910090442/3910105642/3910121041).

BackgroundSocioeconomic differences in body mass index (BMI) have widened alongside the obesity epidemic. However, the utility of socioeconomic position (SEP) indicators at the individual level remains uncertain, as does the potential temporal variation in their predictive value. Examining this is important in light of the increasing incorporation of SEP indicators into predictive algorithms and the possibility that SEP has become a more important predictor of BMI over time. We thus investigated SEP differences in BMI over three decades of the obesity epidemic in England and compared population-wide (SEP group differences in mean BMI) and individual-level (out-of-sample prediction of individuals BMI) approaches. MethodsWe used repeated cross-sectional data from the Health Survey for England, 1991-2019. BMI (kg/m2) was measured objectively, and SEP was measured via educational attainment and neighborhood index of deprivation (IMD). We ran random forest models for each survey year and measure of SEP adjusting for age and sex. ResultsThe mean and variance of BMI increased within each SEP group over the study period. Mean differences in BMI by SEP group also increased across time: differences between lowest and highest education groups were 1.0 kg/m2 (0.4, 1.6) in 1991 and 1.5 kg/m2 (0.9, 1.8) in 2019. At the individual level, the predictive capacity of SEP was low, though increased in later years: including education in models improved predictive accuracy (mean absolute error) by 0.14% (-0.9, 1.08) in 1991 and 1.06% (0.17, 1.84) in 2019. Similar patterns were obtained when analyzing obesity, specifically. ConclusionSEP has become increasingly important at the population (group difference) and individual (prediction) levels. However, predictive ability remains low, suggesting limited utility of including SEP in prediction algorithms. Assuming links are causal, abolishing SEP differences in BMI could have a large effect on population health but would neither reverse the obesity epidemic nor explain the vast majority of individual differences in BMI.

BackgroundFood insecurity is associated with mental ill-health, but there is limited evidence on ethnicity despite indication that minority ethnic groups are at risk of food insecurity and worse mental health. We assess the relationship between UK food insecurity, ethnicity and mental health using a representative household survey. MethodsData from the 2019/20 Family Resource Survey provided information on ethnicity, subjective rating of anxiety (10-point scale), presence of long-standing illnesses affecting mental health, and food security assessed using 10-item Adult Food Security module. Linear and logistic regression was used to assess the relationship between food security status and degree of anxiety and presence of long-standing illness affecting mental health. Analyses were adjusted for covariates and stratified by ethnicity. Results19,210 participants were included. The majority were food secure (87%), identified as White (90.7%), reported a median and interquartile range of anxiety of 2 (0-5), and 22% reported a long-standing illness affecting mental health. Food insecurity was associated with increased levels of anxiety (adjusted {beta}=1.51, 95% CI:(1.34, 1.68)) among all ethnic groups, with greatest increase among people identifying as Black/African/Caribbean/Black British ({beta}=1.75 (1.05, 2.44)). Food insecurity was associated with longstanding illness affecting mental health (adjusted OR 2.01 (1.70, 2.39)) among all ethnic groups; Asian/Asian British respondents reported the highest odds of having a longstanding illness affecting their mental health (OR=2.63 (1.05, 6.56)). ConclusionThe impact of UK food insecurity on mental health affects all ethnic groups but is worse for ethnic minorities, necessitating a population-wide response to food insecurity alongside targeted interventions addressing ethnic inequalities.

BackgroundEngland has experienced one of the highest rates of confirmed COVID-19 mortality in the world. SARS-CoV-2 virus has circulated in hospitals, care homes and the community since January 2020. Our current epidemiological knowledge is largely informed by clinical cases with far less understanding of community transmission. MethodsThe REal-time Assessment of Community Transmission (REACT) study is a nationally representative prevalence survey of SARS-CoV-2 virus swab-positivity in the community in England. We recruited participants regardless of symptom status. ResultsWe found 159 positives from 120,610 swabs giving an average prevalence of 0.13% (95% CI: 0.11%,0.15%) from 1st May to 1st June 2020. We showed decreasing prevalence with a halving time of 8.6 (6.2, 13.6) days, implying an overall reproduction number R of 0.57 (0.45, 0.72). Adults aged 18 to 24 yrs had the highest swab-positivity rates, while those >64 yrs had the lowest. Of the 126 participants who tested positive with known symptom status in the week prior to their swab, 39 reported symptoms while 87 did not, giving an estimate that 69% (61%,76%) of people were symptom-free for the 7 days prior testing positive in our community sample. Symptoms strongly associated with swab-positivity were: nausea and/or vomiting, diarrhoea, blocked nose, loss of smell, loss of taste, headache, chills and severe fatigue. Recent contact with a known COVID-19 case was associated with odds of 24 (16, 38) for swab-positivity. Compared with non-key workers, odds of swab-positivity were 7.7 (2.4, 25) among care home (long-term care facilities) workers and 5.2 (2.9, 9.3) among health care workers. However, some of the excess risk associated with key worker status was explained by recent contact with COVID-19 cases. We found no strong evidence for geographical variability in positive swab results. ConclusionOur results provide a reliable baseline against which the impact of subsequent relaxation of lockdown can be assessed to inform future public health efforts to control transmission.

ImportanceAll U.S. states provided Covid-19 vaccine access to frontline healthcare workers first, but after that, states varied in whether they gave earlier access to the elderly, versus the vulnerable with comorbidities, or school employees or essential workers, reflecting the underlying scientific and policy uncertainty. ObjectiveTo evaluate if risk-based or age-based prioritization is more effective at reducing reported Covid-19 cases and deaths. DesignA serial cross-sectional study Setting50 U.S. states and Washington D.C. Participants60+ years of age, high-risk individuals, K-12 school employees, and essential workers Main Outcomes and MeasuresHospitalizations and deaths ResultsSeven to nine weeks after 60-year-olds became eligible for a vaccine, there was a statistically significant 40-50% decline in Covid-19 hospitalizations in that state. In contrast, there was no statistically detectable change in hospitalizations in the 7-9 weeks after K-12 employees become eligible for vaccines. Vaccine eligibility of "high-risk adults" and "essential workers" produces effects somewhere in the middle, with reductions in hospitalization of about 25%. There was a large statistically significant decline in death rates (25-38%) 10 to 11 weeks after people aged over 60 became vaccine-eligible. These effects were generally statistically larger than high risk individuals, K-12 school employees, and essential workers. Conclusions and RelevancePanel data analysis of weekly variation in Covid-19 health outcomes reveals that prioritizing adults 60+ years of age is associated with the largest reduction in hospitalizations and Covid-19 cases, followed by vaccines for adults with high-risk comorbidities. Vaccinations extended to K-12 school employees and essential workers is associated with the smallest reductions in hospitalizations and deaths. Key PointsO_ST_ABSQuestionC_ST_ABSDid Risk-based or Age-based Vaccine Prioritization for Covid-19 Save More Lives? FindingsPanel data analysis of weekly variation in Covid-19 health outcomes reveals that prioritizing adults 60+ years of age is associated with the largest reduction in hospitalizations and Covid-19 cases, followed by vaccines for adults with high-risk comorbidities. Vaccinations extended to K-12 school employees and essential workers is associated with the smallest reductions in hospitalizations and deaths. MeaningPrioritizing adults 60+ years of age can lead to a higher estimated reduction in hospitalizations and deaths, followed by a strategy of prioritizing adults with high-risk comorbidities. Our findings add to the limited evidence for the roadmap for prioritizing use of Covid-19 vaccines, and help address uncertainties about the relative effectiveness of different vaccine strategies.

BackgroundThe UK was the first country to start national COVID-19 vaccination programmes, initially administering doses 3-weeks apart. However, early evidence of high vaccine effectiveness after the first dose and the emergence of the Alpha variant prompted the UK to extend the interval between doses to 12-weeks. In this study, we quantify the impact of delaying the second vaccine dose on the epidemic in England. MethodsWe used a previously described model of SARS-CoV-2 transmission and calibrated the model to English surveillance data including hospital admissions, hospital occupancy, seroprevalence data, and population-level PCR testing data using a Bayesian evidence synthesis framework. We modelled and compared the epidemic trajectory assuming that vaccine doses were administered 3-weeks apart against the real vaccine roll-out schedule. We estimated and compared the resulting number of daily infections, hospital admissions, and deaths. A range of scenarios spanning a range of vaccine effectiveness and waning assumptions were investigated. FindingsWe estimate that delaying the interval between the first and second COVID-19 vaccine doses from 3- to 12-weeks prevented an average 64,000 COVID-19 hospital admissions and 9,400 deaths between 8th December 2020 and 13th September 2021. Similarly, we estimate that the 3-week strategy would have resulted in more infections and deaths compared to the 12-week strategy. Across all sensitivity analyses the 3-week strategy resulted in a greater number of hospital admissions. InterpretationEnglands delayed second dose vaccination strategy was informed by early real-world vaccine effectiveness data and a careful assessment of the trade-offs in the context of limited vaccine supplies in a growing epidemic. Our study shows that rapidly providing partial vaccine-induced protection to a larger proportion of the population was successful in reducing the burden of COVID-19 hospitalisations and deaths. There is benefit in carefully considering and adapting guidelines in light of new emerging evidence and the population in question. FundingNational Institute for Health Research, UK Medical Research Council, Jameel Institute, Wellcome Trust, and UK Foreign, Commonwealth and Development Office, National Health and Medical Research Council. Research in ContextO_ST_ABSEvidence before this studyC_ST_ABSWe searched PubMed up to 10th June 2022, with no language restrictions using the following search terms: (COVID-19) AND (vaccin*) AND (dose OR dosing) AND (delay OR interval) AND (quant* OR assess* OR impact). We found 14 studies that explored the impact of different vaccine dosing intervals. However, the majority were prospective assessments of optimal vaccination strategies, exploring different trade-offs between vaccine mode of action, vaccine effectiveness, coverage, and availability. Only two studies retrospectively assessed the impact of different vaccination intervals. One assessed the optimal timing during the epidemic to switch to an extended dosing interval, and the other assessed the risk of all-cause mortality and hospitalisations between the two dosing groups. Added value of this studyOur data synthesis approach combines real-world evidence from multiple data sources to retrospectively quantify the impact of extending the COVID-19 vaccine dosing interval from the manufacturer recommended 3-weeks to 12-weeks in England. Implications of all the available evidenceOur study demonstrates that rapidly providing partial vaccine-induced protection to a larger proportion of the population was successful in reducing the COVID-19 hospitalisations and mortality. This was enabled by rapid and careful monitoring of vaccine effectiveness as nationwide vaccine programmes were initiated, and adaptation of guidelines in light of emerging evidence.

BackgroundIn Germany, primary vaccination against invasive meningococcal disease (IMD) serogroup C aims to reduce the highest burden of IMD in infants aged 12-23 month. Due to another IMD-peak in adolescents, we modelled the potential impact of introducing adolescent boosters with conjugate meningococcal C or ACWY (MenC/MenACWY) vaccines. MethodsWe built an age- and serogroup-structured dynamic-transmission model for Germany, which we calibrated to national surveillance data in 2005-2019. We simulated five vaccination scenarios of either continuing with the current MenC primary vaccination (scenario 1), or additionally introducing MenC or MenACWY boosters at age 13 years (scenarios 2-3) or 16 years (scenarios 4-5). We performed comprehensive sensitivity analyses, including on the protection against carriage and serotype replacement. ResultsThe calibrated model projected for scenario 1 an annual mean of 243 (95%-uncertainty interval: 220-258) expected IMD cases over a 10-year period. Introducing the MenC booster prevented an estimated 5 (3.9-6.7) and the MenACWY booster 8 (6.7-9.1) IMD cases per year on average (scenario 2 and 3). The number-needed-to-vaccinate (NNVs) to prevent one IMD case were 140,000 (100,000-180,000) and 91,000 (76,000-100,000), respectively. To prevent one sequela or death, NNVs were higher (i.e., less efficient). Results were broadly similar for scenarios 4-5. Simulations suggested relevant serotype replacement starting eight-to-ten years after introducing the MenACWY booster. ConclusionsIntroducing adolescent MenC or MenACWY boosters marginally reduces the expected IMD burden in Germany. Effectiveness and efficiency of evaluated strategies depend on future incidence. The magnitude of future serotype replacement for the MenACWY vaccine is highly uncertain.

BackgroundThe announcement of efficacious vaccine candidates against SARS-CoV-2 has been met with worldwide acclaim and relief. Many countries already have detailed plans for vaccine targeting based on minimising severe illness, death and healthcare burdens. Normally, relatively simple relationships between epidemiological parameters, vaccine efficacy and vaccine uptake predict the success of any immunisation programme. However, the dynamics of vaccination against SARS-CoV-2 is made more complex by age-dependent factors, changing levels of infection and the potential relaxation of non-pharmaceutical interventions (NPIs) as the perceived risk declines. MethodsIn this study we use an age-structured mathematical model, matched to a range of epidemiological data in the UK, that also captures the roll-out of a two-dose vaccination programme targeted at specific age groups. FindingsWe consider the interaction between the UK vaccination programme and future relaxation (or removal) of NPIs. Our predictions highlight the population-level risks of early relaxation leading to a pronounced wave of infection, hospital admissions and deaths. Only vaccines that offer high infection-blocking efficacy with high uptake in the general population allow relaxation of NPIs without a huge surge in deaths. InterpretationWhile the novel vaccines against SARS-CoV-2 offer a potential exit strategy for this outbreak, this is highly contingent on the infection-blocking (or transmission-blocking) action of the vaccine and the population uptake, both of which need to be carefully monitored as vaccine programmes are rolled out in the UK and other countries. Research in contextO_ST_ABSEvidence before this studyC_ST_ABSVaccination has been seen as a key tool in the fight against SARS-CoV-2. The vaccines already developed represent a major technological achievement and have been shown to generate significant immune responses, as well as offering considerable protection against disease. However, to date there is limited information on the degree of infection-blocking these vaccines are likely to induce. Mathematical models have already successfully been used to consider age- and risk-structured targeting of vaccination, highlighting the importance of prioritising older and high-risk individuals. Added value of this studyTranslating current knowledge and uncertainty of vaccine behaviour into meaningful public health messages requires models that fully capture the within-country epidemiology as well as the complex roll-out of a two-dose vaccination programme. We show that under reasonable assumptions for vaccine efficacy and uptake the UK is unlikely to reach herd immunity, which means that non-pharmaceutical interventions cannot be released without generating substantial waves of infection. Implications of all the available evidenceVaccination is likely to provide substantial individual protection to those receiving two doses, but the degree of protection to the wider population is still uncertain. While substantial immunisation of the most vulnerable groups will allow for some relaxation of controls, this must be done gradually to prevent large scale public health consequences.