The Lancet Regional Health - Europe

ObjectiveTo determine how people in England changed their infection risk-related behaviours during the COVID-19 pandemic and in response to control measures, 19 June 2020 to 31 March 2022. DesignOver 18 (of 19) rounds, randomly selected participants across England completed a questionnaire about risk-related behaviours, socio-demographics, and symptoms. ParticipantsBetween 85,018 and 154,060 randomly selected participants per round, aged 5+ years, totalling 2,177,657 responses with relevant data. Main outcome measuresPrimary outcomes were self-reported shielding and/or taking specific precautions, not leaving home in the prior week, not being in close proximity with anyone outside their household the day before, and wearing face coverings outside the home. Secondary community-level measures of mobility and public health policy stringency were compared to the primary outcomes to provide population-level context to the observed findings. ResultsInfection risk-related behaviours varied considerably over the nearly two years under study. Protective behaviours peaked in January 2021, during Englands winter wave, before widespread vaccination. At that time, the estimated proportion of self-reported shielding and/or taking specific precautions reached 21.6% (95% confidence interval 21.4% to 21.8%), of self-reported not leaving home in the week prior to completing the questionnaire reached 7.99% (7.85% to 8.13%) and of self-reported not having contact with anyone outside their household on the day before answering the questionnaire reached 89.2% (89.1% to 89.4%). As self-reported vaccination rates increased and prevalence of infection decreased, protective behaviours decreased, although patterns varied by demographics. Protective behaviours were strongly correlated with community-level mobility data and the stringency of public health measures. ConclusionsIndividual-based data showed sizeable proportions of people undertook protective behaviours during the pandemic especially during the second lockdown in January 2021 although there was evidence of "pandemic fatigue" in the studys later stages. Self-reported behaviours were closely aligned with community mobility data and the stringency of government policies, indicating policy-driven behaviour changes.

The physiological effects of vaccination against SARS-CoV-2 (COVID-19) are well documented, yet the behavioural effects are largely unknown. Risk compensation suggests that gains in personal safety, as a result of vaccination, are offset by increases in risky behaviour, such as socialising, commuting and working outside the home. This is potentially problematic because transmission of SARS-CoV-2 is driven by contacts, which could be amplified by vaccine-related risk compensation behaviours. Here, we show that behaviours were overall unrelated to personal vaccination, but - adjusting for variation in mitigation policies - were responsive to the level of vaccination in the wider population: individuals in the UK were risk compensating when rates of vaccination were rising. This effect was observed across four nations of the UK, each of which varied policies autonomously.

BackgroundSocio-economic inequalities in COVID-19 case rates have been noted worldwide. Previous studieshave compared case rates over set phases. There has been no analysis of how inequalities in cases changed overtime and were shaped by national mitigation strategies (e.g. lock downs). This paper provides the first analysis of the evolution of area-level inequalities in COVID-19 cases by deprivation levels in the first wave of the pandemic (January to July 2020) in England - with a focus on the effects of the first national lockdown (March - July 2020). MethodsWeekly case rates per Middle Super Output Area (MSOA, n=4412) in England from 2020-03-15 to 2020-07-04 were obtained, and characteristics of local epidemics were calculated, e.g. the highest case rate per area. Simple linear and logistic regression analyses were employed to assess the association of these metrics with index of multiple deprivation (IMD). Local authority-level (n=309) cases were used similarly in a sensitivity analysis, as these data were available daily and extended further back in time. The impact of lockdown was assessed by comparing the cumulative case rate in the most deprived 20% of MSOAs to the least deprived 20%, for the periods before the lockdown, and by the end of lockdown. FindingsLess deprived areas began recording COVID-19 cases earlier than more deprived areas and were more likely to have peaked by March 2020. More deprived areas case rates grew faster and peaked higher than less deprived areas. During the first national lockdown in the UK, the relative excess in case rates in the most deprived areas increased to 130% of that of the least deprived ones. InterpretationThe pattern of disease spread in England confirm the hypothesis that initial cases of a novel infectious disease are likely to occur in more affluent communities, but more deprived areas will overtake them once national mitigation strategies begin, and bear the brunt of the total case load. The strict first national lockdown served to increase case rate inequalities in England. FundingThis work was supported by a grant from The Health Foundation (Ref: 2211473), who took no part in the design, analysis or writing of this study. Research in Context Evidence before this studyThe magnitude and distribution of deprivation-related inequalities in COVID-19 cases have been reported for England and many other countries, however, none have yet investigated the initial evolution of these inequalities, nor the effects of the first national lockdown. Added value of this studyWe leverage the benefits of two separate datasets of COVID-19 case counts to investigate the initiation and evolution in inequalities in disease burden by deprivation. We found that cases were first recorded in less deprived areas before rising faster in more deprived areas. The first national lockdown led to an increase in these geographical inequalities. Implications of all the available evidenceNational lockdowns are an important tool in the armoury of pandemic control, but their timing and duration must be carefully decided and be locally specific. Because case rate inequalities were already present before lockdown in England, movement restrictions served to further increase them. Summary Box Section 1: What is already known on this subjectGeographical inequalities in COVID-19 case rates have been noted worldwide, and in England. However, how these inequalities were affected by policy responses - such as national lockdowns - has yet to be investigated. Section 2: What this study addsWe examined geographical inequalities in COVID-19 case rates by deprivation during the first English lock down (March - July, 2020). We find that cases were first reported in the less deprived areas of England, but this pattern quickly reversed and large excesses of cases occurred in the most deprived areas during the first national lockdown. Case rates in more deprived areas also rose more sharply, peaked higher, and then dropped faster than in less deprived areas. Inequality in cumulative case rates grew over the lockdown, increasing inequalities in disease burden.

BackgroundPrevious studies highlighted the relationships between socioeconomic inequalities and the populations risk to become disease or die during COVID-19 epidemic. In France, socioeconomic inequalities vary across metropolitan areas, but little is known if that could explain the spatial disparities observed in terms of incidence and testing rates. We assessed the impact of socioeconomic inequalities on testing and incidence rates of COVID-19 for each metropolitan area and wave. MethodsFor each of the 22 metropolitan areas, we relied on socioeconomic variables from census data to define socioeconomic profiles using classification on the principal components. We analysed associations between socioeconomic profiles, testing and incidence rates by epidemic wave from July-2020 to March-2023, using spatialised generalised additive mixed models. We performed meta-regressions to study the distribution of testing and incidence rate ratios (socially deprived vs privileged) across metropolitan areas, according to vaccination rates. ResultsSocially deprived metropolitan areas had lower testing rates than privileged, but during wave 4 (July-October-2021, extended health pass), testing rates increased in more deprived areas. Incidence rates were higher in deprived areas (waves 2-4, July-2020 to October-2021) but reversed between waves 6 to 9 (March-2022 to March-2023). Meta-regression analysis indicated that high vaccination coverage narrowed testing and incidence gaps between deprived and privileged. ConclusionsThe impact of social inequalities on the populations testing and incidence COVID-19 epidemic was driven by socioeconomic inequalities across metropolitan areas and varied across epidemic waves. Vaccination rates and the presence of health measures (lockdowns, health pass) seem to help reduce these disparities.

The rollout of COVID-19 vaccines has begun to at-risk populations around the world. It is currently unclear whether rejection of the vaccine will pose challenges for achieving herd/community immunity either through large-scale rejection or localised pockets. Here we predict uptake of the vaccine at unprecedented spatial resolution across the UK using a large-scale survey of over 17,000 individuals. Although the majority of the UK population would likely take the vaccine, there is substantial heterogeneity in uptake intent across the UK. Large urban areas, including London and North West England, females, Black or Black British ethnicities, and Polish-speakers are among the least accepting. This study helps identify areas and socio-demographic groups where vaccination levels may not reach those levels required for herd immunity. Identifying clusters of non-vaccinators is extremely important in the context of achieving herd immunity as vaccination "cold-spots" can amplify epidemic spread and disproportionately increase vaccination levels required for herd protection.

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.

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.

IntroductionEvidence on demographic and socioeconomic differences in adolescent mental health service use is vital for developing equitable health policy and service responses. We quantified inequalities in referrals to National Health Service (NHS)-funded mental health services and NHS-hospital use for mental health concerns by social strata for secondary school pupils in England. MethodsWe used linked records from state-funded schools and national health services (ECHILD) in England to create a secondary school cohort of pupils (age 11 years/Year 7 at entry) from 2012/13 to 2021/22. We measured rates of service use by gender, racial-ethnic group, region of residence, free school meal eligibility, and area-level deprivation defined by the index of multiple deprivation. Service contacts were captured by records in the Mental Health Services Data Set and Hospital Episode Statistics. Pupils were followed up until the first chronological event of: service contact, age 21 years, death or end of study (31st August 2022). ResultsOf 5,629,719 pupils, 980,648 (17.4%) were referred to NHS-funded mental health services; a rate of 45.2 per 1000 person-years (95% confidence interval 45.1-45.2). Within stratum, rates of referrals were higher in females (55.5, 55.4-55.7) than males (35.7, 35.6-35.8), highest in White Irish Traveller (70.8, 66.2-75.8) and lowest in Pakistani racial-ethnic groups (20.8, 20.5-21.1), highest in the North East (58.2, 57.7-58.7) and lowest in London (37.7, 37.5-37.9). Adolescents who were eligible for free school meals had particularly high referral rates (75.3, 75.0-75.6) and there was a gradient in rates by quintiles of area-level deprivation. There was consistency in the sociodemographic patterns across mental health-related referrals, emergency department attendances, and hospital admissions. ConclusionsWe find marked variation in mental health service use across social strata, but with consistency across different service types, indicating significant inequalities in the underlying prevalence of mental ill-health and access to services. Key Messages What is already known on this topicO_ST_ABSsummarise the state of scientific knowledge on this subject before you did your study and why this study needed to be doneC_ST_ABSO_LIImproving access to mental health services for young people is a priority for the English National Health Service, but there is limited population-level information about rates of contacts across multiple health care services and with comprehensive coverage of England. C_LI What this study addsO_ST_ABSsummarise what we now know as a result of this study that we did not know beforeC_ST_ABSO_LIAlmost one fifth of pupils were referred to mental health services, with stark variation by gender, racial-ethnic group, free school meal eligibility, neighbourhood deprivation and region of residence C_LIO_LIRelative patterns of contacts by social strata were similar across emergency department attendances and hospital admissions C_LI How this study might affect research, practice or policyO_ST_ABSSummarise the implications of this studyC_ST_ABSO_LIClear differences in services contacts across social strata indicate significant inequalities, likely reflecting differential barriers to access, the acceptability of NHS services to specific population strata, as well as differences in the underlying prevalence of mental ill-health C_LIO_LIWe find no evidence of disproportionate use of a single service type, suggesting that policies addressing inequalities should span across all services and must seek to address social determinants of health, including differential barriers to service use. C_LI

ObjectiveTo assess the contribution of changing child poverty rates to trends in measles, mumps and rubella (MMR) vaccination. DesignLongitudinal area-level analysis using within-between models to assess the association of increases in child poverty within-areas on MMR vaccination Setting148 upper-tier local authorities in England from 2015 and 2024. ParticipantsChildren aged 5 years or younger eligible for MMR vaccination in England between 2015 and 2024. 6,468,620 children aged 24 months were included in the study and 6,907,640 aged 5 years. ExposuresChild poverty rates for each upper-tier local authority, measured as the percentage of children aged 0 to 15 living in households below 60% of Organisation for Economic Co-operation and Development (OECD) median, before housing costs. Outcome MeasuresMMR 1st and 2nd dose uptake rates by 24 months 5 years of age respectively, at upper-tier local authority. ResultsOver the study period, MMR 1st dose fell by 4.0 percentage-points (%) (range: -20.8 to 7.7) and MMR 2nd dose by 4.9% (range: -23.4 to 10.1) while child poverty rose by 5.6% (range: 0.2 to 13.9) on average. A 1 percentage-point (%) increase in child poverty was associated with a 0.17% [95%CI: -0.29; -0.06] fall in MMR 1st dose rates and a 0.26% [95%CI: -0.42; -0.10] fall in MMR 2nd dose rates. ConclusionRising child poverty rates have contributed to a decrease in MMR vaccination in children in England. Action to reduce child poverty is needed to improve childhood vaccination uptake alongside policies and interventions specific to vaccination and infectious disease prevention. Summary boxO_ST_ABSWhat is already known on this topicC_ST_ABSInequalities in childhood vaccination uptake in England are stark and have widened, especially for MMR vaccination. Child poverty in England has increased and is associated with rising inequalities in multiple domains of childrens health but impacts on inequalities in vaccination uptake are unclear. What this study addsA 1 percentage-point increase in child poverty was associated with a 0.17 percentage point fall in uptake of MMR1 and a 0.26 percentage point fall in MMR2 between 2015 and 2024. Reducing child poverty is likely to increase vaccine uptake and reduce the burden of vaccine preventable diseases in England.

BackgroundHousehold overcrowding is associated with increased risk of infectious diseases across contexts and countries. Limited data exist linking household overcrowding and risk of COVID-19. We used data collected from the Virus Watch cohort to examine the association between overcrowded households and SARS-CoV-2. MethodsThe Virus Watch study is a household community cohort of acute respiratory infections in England & Wales that began recruitment in June 2020. We calculated the persons per room for each household and classified accommodation as overcrowded when the number of rooms{square}was fewer than the number of people. We considered two primary outcomes - PCR-confirmed positive SARS-CoV-2 antigen tests and laboratory confirmed SARS-CoV-2 antibodies (Roche Elecsys anti-N total immunoglobulin assay). We used mixed effects logistic regression models that accounted for household structure to estimate the association between household overcrowding and SARS-CoV-2 infection. ResultsThe proportion of participants with a positive SARS-CoV-2 PCR result was highest in the overcrowded group (6.6%; 73/1,102) and lowest in the under-occupied group (2.9%; 682/23,219). In a mixed effects logistic regression model that included age, sex, ethnicity, household income and geographical region, we found strong evidence of an increased odds of having a positive PCR SARS-CoV-2 antigen result (Odds Ratio 3.72; 95% CI: 1.92, 7.13; p-value < 0.001) and increased odds of having a positive SARS-CoV-2 antibody result in individuals living in overcrowded houses (2.96; 95% CI: 1.13, 7.74; p-value =0.027) compared to people living in under-occupied houses. The proportion of variation at the household level was 9.91% and 9.97% in the PCR and antibody models respectively. DiscussionPublic health interventions to prevent and stop the spread of SARS-CoV-2 should consider the much greater risk of infection for people living in overcrowded households and pay greater attention to reducing household transmission. There is an urgent need to better recognise housing as a leading determinant of health in the context of a pandemic and beyond.

ObjectivesTo estimate the potential impacts of unmitigated and mitigated cost of living increases on real household income, mortality, and mortality inequalities in Scotland. DesignModelling study. SettingScotland, 2022/23. ParticipantsA representative sample of 5,602 Scottish individuals (within 2,704 households) in the 2015/16 Family Resources Survey. We estimated changes in real household income associated with differential price inflation (based on proportion of household spending on different goods and services, by income group), both with and without mitigating UK Government policies, and scaled these to the Scottish population. We estimated mortality effects using a cross-sectional relationship between household income and mortality data, by deprivation group. InterventionsBaseline was Scotland in 2022/23 with the average wage and price inflation of preceding years. The comparison scenarios were unmitigated cost of living increases, and mitigation by the UK Governments Energy Price Guarantee (EPG) and Cost of Living Support payments. Main outcome measuresPremature mortality rate and life expectancy at birth by Scottish Index of Multiple Deprivation (SIMD) group, and inequalities in both. ResultsUnmitigated price inflation was 14.9% for the highest income group and 22.9% for the lowest. UK Government policies partially mitigated impacts of the rising cost of living on real incomes, although households in the most deprived areas of Scotland would still be {pound}1,400 per year worse off than at baseline. With the mitigating measures in place, premature mortality was estimated to increase by up to 6.4%, and life expectancy to decrease by up to 0.9%. Effects would be greater in more deprived areas, and inequalities would increase as a result. ConclusionsLarge and inequitable impacts on mortality in Scotland are predicted if real-terms income reductions are sustained. Progressive Cost of Living Support payments are not sufficient to offset the mortality impacts of the greater real income reductions in deprived areas. What is already known on this topicO_LIOver the last decade, life expectancy in Scotland has stalled and inequalities have increased. C_LIO_LIIncome reductions have been related to increased mortality risk, hence the economy matters for public health. C_LIO_LIThe impacts of the rising cost of living and mitigating policies on mortality and inequalities require estimation to inform policymaking. C_LI What this study addsO_LIThe mortality impacts of inflation and real-terms income reduction are likely to be large and negative, with marked inequalities in how these are experienced. C_LIO_LICurrent public policy responses are not sufficient to protect health and prevent widening inequalities. C_LIO_LIBolder and more progressive policy responses are required if health is to improve and health inequalities are to narrow. C_LI

BackgroundThe COVID-19 pandemic has placed an unprecedented demand on global healthcare resources. Data on whole population healthcare utilisation (HCU) across both primary and secondary care during the COVID-19 pandemic are lacking. AimTo describe primary and secondary HCU stratified by LTCs and deprivation, during the first 19 months of COVID-19 pandemic across a large urban area in the United Kingdom. MethodsObservational HCU data between 30th-December-2019 and 1st-August-2021 were extracted from the Greater Manchester Care Record. Primary care HCU (incident prescribing and recording of healthcare information) and secondary care HCU (planned and unplanned admissions) were assessed. ResultsThe first national lockdown was associated with reductions in all primary HCU measures, ranging from 24.7% (24.0% to 25.5%) for incident prescribing to 84.9% (84.2% to 85.5%) for cholesterol monitoring. Secondary HCU also dropped significantly for planned (47% (42.9% to 51.5%)) and unplanned admissions (35.0% (28.3% to 41.6%)). Only secondary care had significant reductions in HCU during the second national lockdown. Primary HCU measures had not recovered to pre-pandemic levels by the end of the study. The secondary admission rate ratio between multi-morbid patients and those without LTCs increased during the first lockdown by a factor of 2.4 (2.0 to 2.9;p<0.001) for planned admissions and by 1.3 (1.1 to 1.5;p=0.006) for unplanned admissions. No significant changes in this ratio were observed in primary HCU. Different patterns in secondary care HCU were observed by LTC group. ConclusionMajor changes in primary and secondary HCU have been observed during the COVID-19 pandemic. Secondary HCU reduced more in those without LTCs and the ratio of utilisation between the most and least deprived increased for the majority of HCU measures. Overall primary HCU measures and secondary care HCU for some LTC groups had not returned to pre-pandemic levels by the end of the study.

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.

BackgroundStructural barriers to testing may introduce selection bias in COVID-19 research. We explore whether changes to testing and lockdown restrictions introduce time-specific selection bias into analyses of socioeconomic position (SEP) and SARS-CoV-2 infection. MethodsUsing UK Biobank (N = 420 231; 55 % female; mean age = 56{middle dot}3 [SD=8{middle dot}01]) we estimated the association between SEP and i) being tested for SARS-CoV-2 infection versus not being tested ii) testing positive for SARS-CoV-2 infection versus testing negative and iii) testing negative for SARS-CoV-2 infection versus not being tested, at four distinct time-periods between March 2020 and March 2021. We explored potential selection bias by examining the same associations with hypothesised positive (ABO blood type) and negative (hair colour) control exposures. Finally, we conducted a hypothesis-free phenome-wide association study to investigate how individual characteristics associated with testing changed over time. FindingsThe association between low SEP and SARS-CoV-2 testing attenuated across time-periods. Compared to individuals with a degree, individuals who left school with GCSEs or less had an OR of 1{middle dot}05 (95% CI: 0{middle dot}95 to 1{middle dot}16) in March-May 2020 and 0{middle dot}98 (95% CI: 0{middle dot}94 to 1{middle dot}02) in January-March 2021. The magnitude of the association between low SEP and testing positive for SARS-CoV-2 infection increased over the same time-period. For the same comparisons, the OR for testing positive increased from 1{middle dot}27 (95% CI: 1{middle dot}08 to 1{middle dot}50), to 1{middle dot}73 (95% CI: 1{middle dot}59 to 1{middle dot}87). We found little evidence of an association between both control exposures and all outcomes considered. Our phenome-wide analysis highlighted a broad range of individual traits were associated with testing, which were distinct across time-periods. InterpretationThe association between SEP (and indeed many individual traits) and SARS-CoV-2 testing changed over time, indicating time-specific selection pressures in COVID-19. However, positive, and negative control analyses suggest that changes in the magnitude of the association between SEP and SARS-CoV-2 infection over time were unlikely to be explained by selection bias and reflect true increases in socioeconomic inequalities. FundingUniversity of Bristol; UK Medical Research Council; British Heart Foundation; European Union Horizon 2020; Wellcome Trust and The Royal Society; National Institute of Health Research; UK Economic and Social Research Council

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.

ObjectivesTo assess the impact of Tier 3 covid-19 restrictions implemented in December 2020 in England on covid-19 hospital admissions compared to Tier 2 restrictions, and its potential variations by neighbourhood deprivation levels and the prevalence of the Alpha variant (B.1.1.7). DesignObservational study utilising a synthetic control approach. Comparison of changes in weekly hospitalisation rates in Tier 3 areas to a synthetic control group derived from Tier 2 areas. SettingEngland between 4th October 2020 and 21st February 2021. Participants23 million people under Tier 3 restrictions, compared to a synthetic control group derived from 29 million people under Tier 2 restrictions. InterventionsImplementation of Tier 3 covid-19 restrictions in designated areas on 7th December 2020, with additional constraints on indoor and outdoor meetings and the hospitality sector compared to less stringent Tier 2 restrictions. Main Outcome MeasuresWeekly covid-19 related hospital admissions for neighbourhoods in England over a 12-week period following the interventions. ResultsThe introduction of Tier 3 restrictions was associated with a 17% average reduction in hospital admissions compared to Tier 2 areas (95% CI 13% to 21%; 8158 (6286 to 9981) in total)). The effects were similar across different levels of neighbourhood deprivation and prevalence of the Alpha variant (B.1.1.7). ConclusionsRegionally targeted Tier 3 restrictions in England had a moderate but significant effect on reducing hospitalisations. The impact did not exacerbate socioeconomic inequalities during the pandemic. Our findings suggest that regionally targeted restrictions can be effective in managing infectious diseases. SUMMARY BOXESO_ST_ABSWhat is already known on this topicC_ST_ABS-- Previous studies of localised non-pharmaceutical interventions (NPIs) found that they could be effective in reducing covid-19 transmissions. -- covid-19 hospitalisation was a key indicator of healthcare resource dynamics, encompassing supply, demand, burden, and allocation, during the pandemic. -- There is a need for a detailed examination of the impact of specific localised restrictions in the UK, such as Tier 3 measures, on hospital admissions to inform targeted public health strategies. What this study adds-- This study found that additional localised restrictions on outdoor gatherings and in the hospitality sector were effective in mitigating hospital admissions during the pandemic. How this study might affect research, practice or policy-- This study provides evidence for future public health policies and preparedness strategies supporting the use of differential regional restrictions during pandemics.

BackgroundHigh prevalence of SARS-CoV-2 virus in many northern hemisphere populations is causing extreme pressure on healthcare services and leading to high numbers of fatalities. Even though safe and effective vaccines are being deployed in many populations, the majority of those most at-risk of severe COVID-19 will not be protected until late spring, even in countries already at a more advanced stage of vaccine deployment. MethodsThe REal-time Assessment of Community Transmission study-1 (REACT-1) obtains throat and nose swabs from between 120,000 and 180,000 people in the community in England at approximately monthly intervals. Round 8a of REACT-1 mainly covers a period from 6th January 2021 to 15th January 2021. Swabs are tested for SARS-CoV-2 virus and patterns of swab-positivity are described over time, space and with respect to individual characteristics. We compare swab-positivity prevalence from REACT-1 with mobility data based on the GPS locations of individuals using the Facebook mobile phone app. We also compare results from round 8a with those from round 7 in which swabs were collected from 13th November to 24th November (round 7a) and 25th November to 3rd December 2020 (round 7b). ResultsIn round 8a, we found 1,962 positives from 142,909 swabs giving a weighted prevalence of 1.58% (95% CI, 1.49%, 1.68%). Using a constant growth model, we found no strong evidence for either growth or decay averaged across the period; rather, based on data from a limited number of days, prevalence may have started to rise at the end of round 8a. Facebook mobility data showed a marked decrease in activity at the end of December 2020, followed by a rise at the start of the working year in January 2021. Between round 7b and round 8a, prevalence increased in all adult age groups, more than doubling to 0.94% (0.83%, 1.07%) in those aged 65 and over. Large household size, living in a deprived neighbourhood, and Black and Asian ethnicity were all associated with increased prevalence. Both healthcare and care home workers, and other key workers, had increased odds of swab-positivity compared to other workers. ConclusionDuring the initial 10 days of the third COVID-19 lockdown in England in January 2021, prevalence of SARS-CoV-2 was very high with no evidence of decline. Until prevalence in the community is reduced substantially, health services will remain under extreme pressure and the cumulative number of lives lost during this pandemic will continue to increase rapidly.

BackgroundSeroprevalence and the proportion of people with neutralizing activity against SARS-CoV-2 variants was high in early 2022. Since it is unclear how immunity in the general population evolves, the aim of this study was to assess the development of functional and hybrid immunity in the general population during a period of high incidence of infections with Omicron variants. MethodsThis prospective population based multi-region cohort study is part of the Corona Immunitas research programme in Switzerland. In March 2022, we randomly selected individuals from the general population in southern (canton of Ticino) and north-eastern (canton of Zurich) Switzerland, who were assessed again in June/July 2022. We supplemented the June/July 2022 sample with a random sample from western Switzerland (canton of Vaud). We assessed SARS-CoV-2 specific IgG antibodies against spike and nucleocapsid proteins and the presence of SARS-CoV-2 neutralising antibodies against three variants (wildtype, Delta, Omicron). FindingsIn June/July 2022, seroprevalence was >98% in 2553 individuals from the general Swiss population. The proportion of individuals with neutralising antibodies against wildtype, Delta, and Omicron was 94.2%, 90.8%, and 84.9%, and at least 51% of the participants developed hybrid immunity. Individuals with hybrid immunity had, compared to those with only vaccine- or infection-induced immunity, highest levels of both, anti-spike IgG antibodies titres (4518 vs. 4304 vs. 269 WHO U/ml) and neutralisation capacity against wildtype (99.8% vs. 98% vs. 47.5%), Delta (99% vs. 92.2% vs. 38.7%), and Omicron (96.4% vs. 79.5% vs. 47.5%). InterpretationThis first study on functional and hybrid immunity in the general population after Omicron waves showed that SARS-CoV-2 has become endemic. The high levels of antibodies and neutralization in the general populations support the emerging recommendations of some countries where booster vaccinations are still strongly recommended for vulnerable persons but less strongly recommended for individuals in the general population. FundingThe Corona Immunitas research network is coordinated by the Swiss School of Public Health (SSPH+) and funded by fundraising of SSPH+ including funds of the Swiss Federal Office of Public Health and private funders (ethical guidelines for funding stated by SSPH+ were respected), by funds of the cantons of Switzerland (Vaud, Zurich, and Basel), and by institutional funds of the Universities. Study registrationISRCTN18181860 Research in contextO_ST_ABSEvidence before this studyC_ST_ABSWe searched Pubmed, Medline, Scopus and Web of Knowledge, for primary population-based studies prospectively assessing infection-, vaccine-induced, and hybrid immunity and the respective neutralising activity of antibodies against SARS-CoV-2 and its variants of concern. We included articles published between 1 January and 28 September 2022, without language restrictions, and retrieved 540 publications after deduplication. None of the screened studies measured the prevalence of immune response and neutralisation capacity prospectively in population-based, representative samples accounting for type of acquired immunity. Evidence from five studies, all conducted in non-representative, convenience and relatively small samples (N<254), and/or in sub-populations (e.g., healthcare workers and children), shows that hybrid immunity confers higher immune protection and exhibits better neutralising capacity compared to vaccine- and infection-induced immunity. Furthermore, one of the screened studies highlights that antibodies developed by individuals with hybrid immunity show the slowest decline over a period of 10 months. Added value of this studyWe took advantage of an ongoing cohort study on anti-SARS-CoV-2 seroprevalence conducted in a representative sample of the general Swiss population (N=2553) using standard, previously validated methods, to measure changes over time in seroprevalence, neutralisation capacity against wildtype and variants of concerns of the virus (i.e., ACE2r-block), waning of antibodies, and new infections. This is the first study, conducted in the general population and during the pandemic phase characterized by very high incidence of Omicron infections, to assess the extent of hybrid immunity (51%) and neutralising antibodies against the wildtype (94.2%), Delta (90.8%), and Omicron variants (84.9%). Our findings show that individuals with hybrid immunity, compared to those with only vaccine- or infection-induced immunity, had the highest levels of both anti-spike IgG antibodies titres and neutralisation capacity against wildtype, Delta, and Omicron variants. We also found that, from March to June/July 2022, anti-spike IgG antibodies remained stable in the general population (>96%), while anti-nucleocapsid IgG antibodies fluctuated due to their fast waning (7.3% of participants anti-nucleocapsid IgG antibodies became undetectable) and the parallel spread of Omicron infections (18.6% of participants acquired anti-nucleocapsid IgG antibodies). Implications of all the available evidenceBy mid-2022, SARS-CoV-2 has become endemic, and a majority of individuals developed hybrid immunity with high levels of neutralisation against the wildtype, Delta, and Omicron variants of SARS-CoV-2. Combined with existing evidence, our results indicate that hybrid immunity confers higher levels of neutralising activity compared to both vaccine-induced and infection-induced immunity. This study extends findings on the immunological protection conferred by hybrid immunity from sub-populations to the general population. The high levels of antibodies and neutralization in the general populations support the emerging recommendations of some countries where booster vaccinations are still strongly recommended for vulnerable persons but less strongly recommended for individuals in the general population. Monitoring the prevalence, waning, and neutralising activity of antibodies against potential new variants of concern in populations remains crucial.

ObjectiveTo estimate the risk of Long COVID by socioeconomic deprivation and to further examine the socioeconomic inequalities in Long COVID by sex and occupational groups. DesignWe analysed data from the COVID-19 Infection Survey conducted by the Office for National Statistics between 26/04/2020 and 31/01/2022. This is the largest and nationally representative survey of COVID-19 in the UK and provides uniquely rich, contemporaneous, and longitudinal data on occupation, health status, COVID-19 exposure, and Long COVID symptoms. SettingCommunity-based longitudinal survey of COVID-19 in the UK. ParticipantsWe included 201,799 participants in our analysis who were aged between 16 and 64 years and had a confirmed SARS-CoV-2 infection. Main outcome measuresWe used multivariable logistic regression models to estimate the risk of Long COVID at least 4 weeks after acute SARS-CoV-2 infection by deciles of index of multiple deprivation (IMD) and adjusted for a range of demographic and spatiotemporal factors. We further examined the modifying effects of socioeconomic deprivation by sex and occupational groups. ResultsA total of 19,315 (9.6%) participants reported having Long COVID symptoms. Compared to the least deprived IMD decile, participants in the most deprived decile had a higher adjusted risk of Long COVID (11.4% vs 8.2%; adjusted OR: 1.45; 95% confidence interval [CI]: 1.33, 1.57). There were particularly significantly higher inequalities (most vs least deprived decile) of Long COVID in healthcare and patient facing roles (aOR: 1.76; 1.27, 2.44), and in the education sector (aOR: 1.62; 1.26, 2.08). The inequality of Long COVID was higher in females (aOR: 1.54; 1.38, 1.71) than males (OR: 1.32; 1.15, 1.51). ConclusionsParticipants living in the most socioeconomically deprived areas had a higher risk of Long COVID. The inequality gap was wider in females and certain public facing occupations (e.g., healthcare and education). These findings will help inform public health policies and interventions in adopting a social justice and health inequality lens.

BACKGROUNDThere were increased SARS-CoV2 hospitalizations and deaths noted during Omicron (B.1.1.529) variant surge in the UK despite decreased cases, and the reasons are unclear. METHODSIn this retrospective observational study, we analyzed reported SARS-CoV2 cases, hospitalizations, and deaths during the COVID-19 pandemic in the UK. We also analyzed variables that affect the outcomes (including ethnicity, deprivation score, vaccination disparities, and pre-existing conditions). We also analyzed the vaccine effectiveness among those [&ge;]18 years of age (from August 16, 2021 to March 27, 2022). RESULTSOf the total cases (n= 22,072,550), hospitalizations (n=848,911), and deaths (n=175,070) due to COVID-19 in the UK; 51.3% of cases (n=11,315,793), 28.8% of hospitalizations (n=244,708), and 16.4% of deaths (n=28,659) occurred during the Omicron variant surge as of May 1, 2022. During the latter part of the Omicron variant surge (February 28 - May 1, 2022 period), we observed a significant increase in the proportion of cases (23.7% vs 40.3%; RR1.70 [1.70-1.71]; p<0.001) and hospitalizations (39.3% vs 50.3%; RR1.28 [1.27-1.30]; p<0.001) among [&ge;]50 years of age, and deaths (67.89% vs 80.07%; RR1.18 [1.16-1.20]; p<0.001) among [&ge;]75 years of age compared to the earlier period (December 6, 2021-February 27, 2022) during the Omicron variant surge. Using the available data from vaccine surveillance reports, we compared the Omicron variant surge (December 27, 2021-March 20, 2022) with the Delta variant surge (August 16-December 5, 2021). Our comparative analysis shows a significant decline in case fatality rate (all ages [0.21% vs 0.39%; RR 0.54 (0.52-0.55); p<0.001], over 18 years of age [0.25% vs 0.58%; RR 0.44 (0.43-0.45); p<0.001], and over 50 years of age [0.72% vs 1.57%; RR 0.46 (0.45-0.47); P<0.001]) and the risk of hospitalizations (all ages [0.62% vs 0.99%; RR 0.63 (0.62-0.64); p<0.001], over 18 years of age [0.67% vs 1.38%; RR 0.484 (0.476-0.492); p<0.001], and over 50 years of age [1.45% vs 2.81%; RR 0.52 (0.51-0.53); p<0.001]). Both the unvaccinated (0.41% vs 0.77%; RR 0.54 (0.51-0.57); p<0.001) and vaccinated (0.25% vs 0.59%; RR 0.43 (0.42-0.44); p<0.001) populations of over 18 years of age showed a significant decline in the case fatality rate during the Omicron variant surge when compared to the Delta variant surge. In summary, a significant decline in the risk of hospitalizations was observed both among the unvaccinated (1.27% vs 2.92%; RR 0.44 (0.42-0.45); p<0.001) and vaccinated (0.65% vs 1.19%; RR 0.54 (0.53-0.55); p<0.001) populations of over 18 years of age during the same period. We observed negative vaccine effectiveness (VE) for the third dose since December 20, 2021, with a significantly increased proportion of SARS-CoV2 cases hospitalizations, and deaths among the vaccinated; and a decreased proportion of cases, hospitalizations, and deaths among the unvaccinated. The pre-existing conditions were present in 95.6% of all COVID-19 deaths. We also observed various ethnicity, deprivation score, and vaccination rate disparities that can adversely affect hospitalizations and deaths among the compared groups based on vaccination status. CONCLUSIONSThere is no discernable optimal vaccine effectiveness among [&ge;]18 years of age and vaccinated third dose population since the beginning (December 20, 2021) of the Omicron variant surge. Other data including pre-existing conditions, ethnicity, deprivation score, and vaccination rate disparities need to be adjusted by developing validated models for evaluating VE against hospitalizations and deaths. Both the vaccinated and unvaccinated populations showed favorable outcomes with a significant decline in case fatality rate and risk of hospitalizations during the Omicron variant surge. The suboptimal vaccine effectiveness with an increased proportion of cases among the vaccinated population was associated with a significantly increased proportion of hospitalizations and deaths during the Omicron variant surge. This underscores the need to prevent infections, especially in the elderly vaccinated population irrespective of vaccination status by employing uniform screening protocols and protective measures.