Key lessons from the COVID-19 public health response in Australia

Metagenomic analysis of human, animal, and environmental samples identifies potential emerging pathogens, profiles antibiotic resistance genes, and reveals horizontal gene transfer dynamics

Antimicrobial resistance (AMR) poses a significant threat to global health. The indiscriminate use of antibiotics has accelerated the emergence and spread of drug-resistant bacteria, compromising our ability to treat infectious diseases. A One Health approach is essential to address this urgent issue, recognizing the interconnectedness of human, animal, and environmental health. This study investigated the prevalence and transmission of AMR in a temporary settlement in Kathmandu, Nepal. By employing shotgun metagenomics, we analyzed a diverse range of samples, including human fecal samples, avian fecal samples, and environmental samples. Our analysis revealed a complex interplay of pathogenic bacteria, virulence factors (VF), and antimicrobial resistance genes (ARGs) across these different domains. We identified a diverse range of bacterial species, including potential pathogens, in both human and animal samples. Notably, Prevotella spp. was the dominant gut bacterium in human samples. Additionally, we detected a wide range of phages and viruses, including Stx-2 converting phages, which can contribute to the virulence of Shiga toxin-producing E. coli (STEC) strains. Our analysis revealed the presence of 72 virulence factor genes and 53 ARG subtypes across the studied samples. Poultry samples exhibited the highest number of ARG subtypes, suggesting that the intensive use of antibiotics in poultry production may contribute to the dissemination of AMR. Furthermore, we observed frequent horizontal gene transfer (HGT) events, with gut microbiomes serving as key reservoirs for ARGs. This study underscores the critical role of a One Health approach in addressing AMR. By integrating human, animal, and environmental health perspectives, we can better understand the complex dynamics of AMR and develop effective strategies for prevention and control. Our findings highlight the urgent need for robust surveillance systems, judicious antibiotic use, and improved hygiene practices to mitigate the impact of AMR on public health.

The Global Influenza Hospital Surveillance Network: A Multicountry Public Health Collaboration

Respiratory viruses represent a significant public health threat. There is the need for robust and coordinated surveillance to guide global health responses. Established in 2012, the Global Influenza Hospital Surveillance Network (GIHSN) addresses this need by collecting clinical and virological data on persons with acute respiratory illnesses across a network of hospitals worldwide. GIHSN utilizes a standardized patient enrolment and data collection protocol across its study sites. It leverages pre-existing national infrastructures and expert collaborations to facilitate comprehensive data collection. This includes demographic, clinical, epidemiological, and virologic data, and whole genome sequencing (WGS) for a subset of viruses. Sequencing data are shared in the Global Initiative on Sharing All Influenza Data (GISAID). GIHSN uses financing and governance approaches centered around public-private partnerships. Over time, GIHSN has included more than 100 hospitals across 27 countries and enrolled more than 168,000 hospitalized patients, identifying 27,562 cases of influenza and 44,629 of other respiratory viruses. GIHSN has expanded beyond influenza to include other respiratory viruses, particularly since the COVID-19 pandemic. In November 2023, GIHSN strengthened its global impact through a memorandum of understanding with the World Health Organization, aimed at enhancing collaborative efforts and data sharing for improved health responses. GIHSN exemplifies the value of integrating scientific research with public health initiatives through global collaboration and public-private partnerships governance. Future efforts should enhance the scalability of such models and ensure their sustainability through continued public and private support.

Infection Prevention and Control Response and Escalation Framework: Evaluation and application beyond a pandemic

BACKGROUND

The COVID-19 pandemic resulted in constant changes to Infection Prevention and Control (IPAC) recommendations, impacting clinician capacity to stay up to date. The COVID-19 IPAC Response and Escalation Framework (IPAC Framework), rarely reported or evaluated was developed to provide scalable IPAC guidance during the pandemic to health care in New South Wales (NSW), Australia.

METHODS

Using a thematic analysis approach, a qualitative study using an online, cross-sectional survey comprising 27 questions was sent to 248 key stakeholders. Participants were health workers with broad clinical and system representation with responsibilities for risk assessment, communicating, implementing, or monitoring the IPAC Framework.

RESULTS

The IPAC Framework provided a useful IPAC tool for the management of COVID-19 as perceived by 93% of respondents. The overwhelming majority (91%) reported the Framework provided enough information on IPAC strategies needed for COVID-19 that were aligned with transmission risk. Resources supporting the IPAC Framework were reported by most respondents (84%) as being widely accepted as the authoritative guidance.

CONCLUSIONS

An IPAC Framework is perceived as invaluable by clinicians and administrators to manage IPAC requirements in health care during a pandemic. The IPAC Framework can be applied more generally to support ongoing IPAC requirements.

Lessons Learned From the Deployment of Registered Nurses to Surged Intensive Care Units During the COVID-19 Pandemic: A Qualitative Study

AIM

To explore the perspectives of nurse educators, clinical nurse educators and nurse specialists with regard to supporting the deployed registered nurses in Australian intensive care units during the COVID-19 pandemic surge.

DESIGN

A qualitative-descriptive study design was used.

METHODS

Intensive care nurse educators, clinical nurse educators and nurse specialists who had been involved with the preparation and support of nurses for deployment to intensive care units for COVID-19 surge were purposively recruited from around Australia. Data were collected through 18 semi-structured interviews and examined using thematic framework analysis of NVivo software.

RESULTS

Participants described a number of challenges related to surge deployment including the varied skill sets and inadequate preparation for deployed staff, lack of a clear scope of practice and their general reluctance to deploy to intensive care units. Mixed communication from hospital managers about the mandatory or voluntary nature of deployments and the plans for return of nurses to their usual place of work were also considered problematic. Conversely, factors that supported effective deployment included consistently deploying the same staff, scope of practice guides, task cards and colour coding to identify the experience of nurses. The burden of the pandemic, including variable waves of surge, infection control complexities and fear of caring for patients with COVID-19, influenced the participants' experiences and perspectives. Additionally, there was a significant personal toll for participants because of the increased load of supervising deployed staff and concerns related to accountability for nursing care, and personal and patient safety.

CONCLUSION

The deployment of nursing staff to intensive care units to support increased patient numbers is necessary during surge events. Having clarity about what role those nurses perform within intensive care units is essential in order to design training and support strategies that prepare them adequately so as not to place undue burden on an already strained intensive care nursing workforce.

IMPLICATIONS FOR THE PROFESSION

The toll of the COVID pandemic on ICU nurses was immense. This was further compounded by inadequate preparation and the strain of supporting deployed nurses in surged intensive care units.

IMPACT

This research outlines the lessons learned from deploying nurses into surged intensive care units in the Australian setting. Supporting deployed nurses places a significant burden on the intensive care team; this is heavier when there is uncertainty about the scope of deployed staff and accountability for patient safety. These findings contribute to the body of evidence that will assist in for planning more effective deployment strategies for future intensive care surge events.

REPORTING METHOD

Reporting complied with the COREQ criteria for qualitative research.

PATIENT OR PUBLIC CONTRIBUTION

There was no patient or public contribution.

What impact did the COVID-19 pandemic have on psychosis and the delivery of early intervention psychosis services?

BACKGROUND

In Australia, the first nationwide COVID-19 lockdown occurred in March 2020 bringing challenges for early intervention psychosis (EIP) services. Limited evidence exists on the impacts of the pandemic on treatment outcomes among EIP clients.

METHODS

This prospective cohort study analysed routine data from 15 headspace Early Psychosis centres in Australia. Participants were 12 to 25 years, meeting criteria for First Episode Psychosis (FEP) or Ultra High Risk of psychosis (UHR) comparing those who commenced treatment 'pre-COVID-19' (between 16th August 2018 and 15th August 2019), and 'during-COVID-19' (between 1st March 2020 and 15th September 2020). Clinical symptoms at treatment commencement were assessed using the Brief Psychiatric Rating Scale (BPRS) and the Kessler Psychological Distress Scale (K10). with outcomes after 6 months compared between cohorts using linear mixed-effects regression, controlling for confounders.

RESULTS

Of 1246 young people analysed (653 FEP, 596 UHR), significant improvements were observed with treatment in both groups (5 to 13-point reduction in BPRS score per 6-months treatment). Treatment effectiveness reduced during-COVID-19 for psychosis symptoms, with the FEP BPRS treatment effect lower by 4.3 points (95%CI: 0.5, 8.1). UHR clients had lower BPRS negative symptoms during-COVID-19 (p = 0.020). Service contacts increased during-COVID-19, with increased telehealth services (p < 0.001).

CONCLUSIONS

Early intervention remained effective for FEP and UHR, despite the pandemic and transition of EIP services to virtual service delivery. Reduced treatment efficacy in FEP psychosis symptoms may indicate potential limitations of telehealth. Further research to examine longer term clinical and functional outcomes due to the pandemic is required.

"COVID-19 - A Perfect Storm": A Qualitative Exploration of Residential Care Facility Managers Perspectives on the Psychosocial Impacts of COVID-19

Growing evidence highlights the negative impact of managing the COVID-19 pandemic on the wellbeing of the healthcare workforce, including in the aged care sector. We undertook a qualitative study during the pandemic's third year to explore the psychosocial impacts on nine managers of residential care facilities (RCFs) across metropolitan and rural New South Wales, the largest state in Australia. Four themes were identified: (1) Increased pressure on maintaining aged care services, (2) Increased responsibility on RCF managers, (3) Psychosocial impacts due to accumulating pressures, and (4) Experience of beneficial supports. COVID-19 compounded pre-pandemic sector challenges and added new stressors. While resilient and resourceful, RCF managers experienced workplace stress and burnout, which may affect quality of resident care and impact on staff retention. There is a need for more investment to effectively support staff, and research to identify optimal psychosocial and management supports.

The seroprevalence of SARS-CoV-2-specific antibodies in Australian children: A cross-sectional study

BACKGROUND

Following reduction of public health and social measures concurrent with SARS-CoV-2 Omicron emergence in late 2021 in Australia, COVID-19 case notification rates rose rapidly. As rates of direct viral testing and reporting dropped, true infection rates were most likely to be underestimated.

OBJECTIVE

To better understand infection rates and immunity in this population, we aimed to estimate SARS-CoV-2 seroprevalence in Australians aged 0-19 years.

METHODS

We conducted a national cross sectional serosurvey from June 1, 2022, to August 31, 2022, in children aged 0-19 years undergoing an anesthetic procedure at eight tertiary pediatric hospitals. Participant questionnaires were administered, and blood samples tested using the Roche Elecsys Anti-SARS-CoV-2 total spike and nucleocapsid antibody assays. Spike and nucleocapsid seroprevalence adjusted for geographic and socioeconomic imbalances in the participant sample compared to the Australian population was estimated using multilevel regression and poststratification within a Bayesian framework.

RESULTS

Blood was collected from 2,046 participants (median age: 6.6 years). The overall adjusted seroprevalence of spike-antibody was 92.1% (95% credible interval (CrI) 91.0-93.3%) and nucleocapsid-antibody was 67.0% (95% CrI 64.6-69.3). In unvaccinated children spike and nucleocapsid antibody seroprevalences were 84.2% (95% CrI 81.9-86.5) and 67.1% (95%CrI 64.0-69.8), respectively. Seroprevalence was similar across geographic remoteness index and socioeconomic quintiles. Nucleocapsid antibody seroprevalence increased with age while the point seroprevalence of the spike antibody seroprevalence decreased in the first year of life and then increased to 97.8 (95% Crl 96.1-99.2) by 12-15 years of age.

CONCLUSION

Most Australian children and adolescents aged 0-19 years, across all jurisdictions were infected with SARS-CoV-2 by August 2022, suggesting rapid and uniform spread across the population in a very short time period. High seropositivity in unvaccinated children informed COVID-19 vaccine recommendations in Australia.

Implementing recommended COVID-19 public health measures in the era of living with COVID-19: Experiences of residential aged care facility managers in New South Wales, Australia

OBJECTIVES

To understand residential aged care facility (the facility) managers' perspectives on implementing public health measures (the measures) in their facilities in terms of barriers, facilitators and suggestions for improvement, after three years of the COVID-19 pandemic.

METHODS

Nine managers of the facilities without an active COVID-19 outbreak across New South Wales, Australia, representing metropolitan and rural locations, diverse facility size and star quality rating were interviewed (April-June 2023) and data qualitatively analysed.

RESULTS

Broader policy context, the need to balance the measures with resident well-being, facility-built infrastructure and mask fatigue were reported as barriers to implementation. Workplace policies, cultural embedding and local innovations were reported as facilitators. Suggested strategies included recommending the measures consistent with temporal COVID-19 risk; government agencies improving communication about the measures; mandatory staff vaccination; and simplified reporting requirements.

CONCLUSIONS

We recommend that relevant government agencies develop a single source of formalised, endorsed, up-to-date advice for the sector-specific COVID-19 information and communications; streamline outbreak notification and reporting requirements; and improve consultation with the sector.

The mental health of Australians bereaved during the first two years of the COVID-19 pandemic: a latent class analysis

BACKGROUND

The COVID-19 pandemic disrupted many areas of life, including culturally accepted practices at end-of-life care, funeral rites, and access to social, community, and professional support. This survey investigated the mental health outcomes of Australians bereaved during this time to determine how these factors might have impacted bereavement outcomes.

METHODS

An online survey indexing pandemic and bereavement experiences, levels of grief, depression, anxiety, and health, work, and social impairment. Latent class analysis (LCA) was used to identify groups of individuals who shared similar symptom patterns. Multinomial regressions identified pandemic-related, loss-related, and sociodemographic correlates of class membership.

RESULTS

1911 Australian adults completed the survey. The LCA identified four classes: low symptoms (46.8%), grief (17.3%), depression/anxiety (17.7%), and grief/depression/anxiety (18.2%). The latter group reported the highest levels of health, work, and social impairment. The death of a child or partner and an inability to care for the deceased due to COVID-19 public health measures were correlated with grief symptoms (with or without depression and anxiety). Preparedness for the person's death and levels of pandemic-related loneliness and social isolation differentiated all four classes. Unemployment was associated with depression/anxiety (with or without grief).

CONCLUSIONS

COVID-19 had profound impacts for the way we lived and died, with effects that are likely to ricochet through society into the foreseeable future. These lessons learned must inform policymakers and healthcare professionals to improve bereavement care and ensure preparedness during and following future predicted pandemics to prevent negative impacts.

Ecological comparison of six countries in two waves of COVID-19

Objective

The purpose of this study is to provide experience and evidence support for countries to deal with similar public health emergencies such as COVID-19 by comparing and analyzing the measures taken by six countries in epidemic prevention and control.

Methods

This study extracted public data on COVID-19 from the official website of various countries and used ecological comparative research methods to compare the specific situation of indicators such as daily tests per thousand people, stringency index, and total vaccinations per hundred people in countries.

Results

The cumulative death toll in China, Germany and Australia was significantly lower than that in the United States, South Africa and Italy. Expanding the scale of testing has helped control the spread of the epidemic to some extent. When the epidemic situation is severe, the stringency index increases, and when the epidemic situation tends to ease, the stringency index decreases. Increased vaccination rates, while helping to build an immune barrier, still need to be used in conjunction with non-drug interventions.

Conclusion

The implementation of non-drug interventions and vaccine measures greatly affected the epidemic prevention and control effect. In responding to public health emergencies such as the COVID-19 epidemic, countries should draw on international experience, closely align with their national conditions, follow the laws of epidemiology, actively take non-drug intervention measures, and vigorously promote vaccine research and development and vaccination.

Adequacy of health message tailoring for ethnic minorities: Pasifika communities in Sydney, Australia, during COVID-19

Ethnic minorities, such as Pasifika, residing in high-income countries were at higher risk of COVID-19 infection during the pandemic. To understand the experiences of Pasifika, including message dissemination and barriers to tailored public health messaging during the pandemic, a qualitative study was undertaken, underpinned by Laswell's Model of Communication and Bandura's social cognitive theory with data collected using Pasifika methods. Pasifika adults (n = 65) were recruited across Sydney from July 2020 to March 2022. Health care professionals (HCP) (n = 17) employed by four local health districts (LHDs) and Pasifika community-based organizations delivering multicultural COVID-19-related work within the study catchment, were also recruited. Five themes were constructed from the data of: (i) prevailing fear and uncertainty over COVID-19 infection and losing employment; (ii) limited knowledge of government perpetuating distrust in Government as a benevolent source of information; (iii) faith and trust as priorities for health decision-making; (iv) 'Coconut wireless'-the role of family, friends and community in disseminating public health messages through word of mouth; and (v) limited health literacy affecting compliance with public health orders. Community members identified important messages and resources had not been sufficiently distributed. Most HCPs understood the necessity of grassroots-level engagement but reported existing approaches were inadequate to navigate challenges. These findings highlight the need for public health promotion and communication strategies that consider both the social and cultural determinants of health. We propose a 7-point checklist as a cultural appropriateness lens to assist the development and rating of existing or new health promotion messaging and resources.

COVID-19 and End of Life in a Quaternary Australian Hospital: Referral for Palliative Care Consultation

Background

The coronavirus disease 2019 (COVID-19) pandemic resulted in complex physical and psychosocial symptom burden at end of life. The benefit of specialist palliative care input in other disease states has been established, however, there is little evidence on referral patterns to these services in patients dying from COVID-19.

Objectives

This retrospective audit investigated the referral patterns for patients who died from COVID-19 at a quaternary hospital in South Australia (the Royal Adelaide Hospital) over a six-month period in 2022, and whether demographic features or COVID-19 specific factors had an impact on whether these patients received specialist palliative care services (PCS). The second aim was to identify prescription patterns for patients in the last 24 hours of life, and whether this was impacted by referral.

Method

Data were obtained from electronic medical records and analyzed using binary logistic regressions for referral to PCS versus no referral based on various predictors.

Results

There was no significant difference comparing patient demographics or COVID-19 specific factors with referral to PCS. There was statistical significance between patients who received referral to PCS and those who had a higher oral morphine equivalent daily dose (OMEDD) in the 24 hours before death, as well as the presence of a continuous subcutaneous infusion. Although the cause of this relationship is undetermined, it may represent the prescription patterns of the palliative care physicians during consultation or potentially higher symptom burden prompting referral. There was also a higher proportion of patients who received hydromorphone compared with other opioids, though the OMEDD was consistent with other published literature.

Global Perspective on the Impact of the COVID-19 Pandemic on Rheumatology and Health Equity

Although the public health emergency associated with the COVID-19 pandemic has ended, challenges remain, especially for individuals with rheumatic diseases. We aimed to assess the historical and ongoing effects of COVID-19 on individuals with rheumatic diseases and rheumatology practices globally, with specific attention to vulnerable communities and lessons learned. We reviewed literature from several countries and regions, including Africa, Australia and New Zealand, China, Europe, Latin America, and the US. In this review, we summarize literature that not only examines the impact of the pandemic on individuals with rheumatic diseases, but also research that reports the lasting changes to rheumatology patient care and practice, and health service use. Across countries, challenges faced by individuals with rheumatic diseases during the pandemic included disruptions in health care and medication supply shortages. These challenges were associated with worse disease and mental health outcomes in some studies, particularly among those who had social vulnerabilities defined by socioeconomic, race, or rurality. Moreover, rheumatology practice was impacted in all regions, with the uptake of telemedicine and changes in health care utilization. While many regions developed rapid guidelines to disseminate scientific information, misinformation and disinformation remained widespread. Finally, vaccine uptake among individuals with rheumatic diseases has been uneven across the world. As the acute phase of the pandemic wanes, ongoing efforts are needed to improve health care access, stabilize rheumatology drug supplies, improve public health communication, and implement evidence-based vaccination practices to reduce COVID-19 morbidity and mortality among individuals with rheumatic diseases.

Having a real say: findings from first nations community panels on pandemic influenza vaccine distribution

BACKGROUND

Recent deliberations by Australian public health researchers and practitioners produced an ethical framework of how decisions should be made to distribute pandemic influenza vaccine. The outcome of the deliberations was that the population should be considered in two categories, Level 1 and Level 2, with Level 1 groups being offered access to the pandemic influenza vaccine before other groups. However, the public health researchers and practitioners recognised the importance of making space for public opinion and sought to understand citizens values and preferences, especially First Nations peoples.

METHODS

We conducted First Nations Community Panels in two Australian locations in 2019 to assess First Nations people's informed views through a deliberative process on pandemic influenza vaccination distribution strategies. Panels were asked to make decisions on priority levels, coverage and vaccine doses.

RESULTS

Two panels were conducted with eighteen First Nations participants from a range of ages who were purposively recruited through local community networks. Panels heard presentations from public health experts, cross-examined expert presenters and deliberated on the issues. Both panels agreed that First Nations peoples be assigned Level 1 priority, be offered pandemic influenza vaccination before other groups, and be offered two doses of vaccine. Reasons for this decision included First Nations people's lives, culture and families are important; are at-risk of severe health outcomes; and experience barriers and challenges to accessing safe, quality and culturally appropriate healthcare. We found that communication strategies, utilising and upskilling the First Nations health workforce, and targeted vaccination strategies are important elements in pandemic preparedness and response with First Nations peoples.

CONCLUSIONS

First Nations Community Panels supported prioritising First Nations peoples for pandemic influenza vaccination distribution and offering greater protection by using a two-dose full course to fewer people if there are initial supply limitations, instead of one dose to more people, during the initial phase of the vaccine roll out. The methodology and findings can help inform efforts in planning for future pandemic vaccination strategies for First Nations peoples in Australia.

Lessons learned from behaviors of the employees in Iranian banks during the Covid-19 pandemic crisis: A phenomenological study

The aim of this research is to analyze the experiences of employees during the Covid-19 pandemic cri-sis and conceptualize the lessons learned to deal with similar crises in the future. To achieve this, a qualitative approach with a phenomenological strategy was conducted through semi-structured, in-depth interviews with 16 front-line employees of Bank Melli, the largest state bank in Iran. The study found that employee behavior plays a critical role in crisis management, with functional behaviors such as preventive measures, stress management, and sharing valid information being essential. Dysfunctional behaviors such as resistance to change and inconsistent behaviors were also identified. The prevention of infection and stress management were identified as key behaviors to cope with the crisis, while media literacy and acceptance of change were crucial for correct information analysis and crisis management. Overall, the study highlights the challenges faced by employees during the Covid-19 crisis and provides valuable lessons from a behavioral perspective for managers in the banking industry to manage disruptions caused by current and future pandemics. The study emphasizes the importance of learning from the lessons of the Covid-19 crisis to reduce negative effects on physical and mental health.

Psychological impact of COVID-19 and determinants among Spanish university students

Background

University students are a vulnerable population and faced a significant psychological impact from the COVID-19 pandemic. Therefore, this study aimed to determine the level of fear of COVID-19 among university students and to evaluate the possible relationship between fear of COVID-19 and socio-demographic, health-related determinants, variables related to the COVID-19 and variables related to the psychological impact of the COVID-19 pandemic.

Methods

We conducted a cross-sectional study between December 2020 and December 2021 on a sample of 950 university students from two universities in southern Spain. Participants completed a form that collected socio-demographic, health-related and COVID-related variables, a validated questionnaire related to the psychological impact of the COVID-19 pandemic and the fear of COVID Scale (FCV-19S). Descriptive, inferential, and multivariable linear regression analyzes were conducted.

Results

The mean FCV-19S score was 14.86 ± 5.16 points. The factors identified as predictors of FCV-19S were being female (p < 0.001), holding religious beliefs (p = 0.04), living in towns with over 10,000 inhabitants (p < 0.01), living with someone vulnerable to COVID-19 (p = 0.02), watching TV to keep informed about COVID-19 (p < 0.01), believing in a low probability of surviving if infected with COVID-19 (p < 0.001), having a higher level of death anxiety (p < 0.001) and suffering from insomnia (p < 0.001).

Conclusion

An average fear of COVID-19 score of 14.86 ± 5.16 points has been found among university students in Spain. These findings can aid in identifying specific factors contributing to fear of COVID-19 and in developing coping strategies to alleviate the stress of the pandemic.

Effectiveness of testing, contact tracing and isolation interventions among the general population on reducing transmission of SARS-CoV-2: a systematic review

We conducted a systematic literature review of general population testing, contact tracing, case isolation and contact quarantine interventions to assess their effectiveness in reducing SARS-CoV-2 transmission, as implemented in real-world settings. We designed a broad search strategy and aimed to identify peer-reviewed studies of any design provided there was a quantitative measure of effectiveness on a transmission outcome. Studies that assessed the effect of testing or diagnosis on disease outcomes via treatment, but did not assess a transmission outcome, were not included. We focused on interventions implemented among the general population rather than in specific settings; these were from anywhere in the world and published any time after 1 January 2020 until the end of 2022. From 26 720 titles and abstracts, 1181 were reviewed as full text, and 25 met our inclusion criteria. These 25 studies included one randomized control trial (RCT) and the remaining 24 analysed empirical data and made some attempt to control for confounding. Studies included were categorized by the type of intervention: contact tracing (seven studies); specific testing strategies (12 studies); strategies for isolating cases/contacts (four studies); and 'test, trace, isolate' (TTI) as a part of a package of interventions (two studies). None of the 25 studies were rated at low risk of bias and many were rated as serious risk of bias, particularly due to the likely presence of uncontrolled confounding factors, which was a major challenge in assessing the independent effects of TTI in observational studies. These confounding factors are to be expected from observational studies during an on-going pandemic, when the emphasis was on reducing the epidemic burden rather than trial design. Findings from these 25 studies suggested an important public health role for testing followed by isolation, especially where mass and serial testing was used to reduce transmission. Some of the most compelling analyses came from examining fine-grained within-country data on contact tracing; while broader studies which compared behaviour between countries also often found TTI led to reduced transmission and mortality, this was not universal. There was limited evidence for the benefit of isolation of cases/contacts away from the home environment. One study, an RCT, showed that daily testing of contacts could be a viable strategy to replace lengthy quarantine of contacts. Based on the scarcity of robust empirical evidence, we were not able to draw any firm quantitative conclusions about the quantitative impact of TTI interventions in different epidemic contexts. While the majority of studies found that testing, tracing and isolation reduced transmission, evidence for the scale of this impact is only available for specific scenarios and hence is not necessarily generalizable. Our review therefore emphasizes the need to conduct robust experimental studies that help inform the likely quantitative impact of different TTI interventions on transmission and their optimal design. Work is needed to support such studies in the context of future emerging epidemics, along with assessments of the cost-effectiveness of TTI interventions, which was beyond the scope of this review but will be critical to decision-making. This article is part of the theme issue 'The effectiveness of non-pharmaceutical interventions on the COVID-19 pandemic: the evidence'.

The response to COVID-19 in Timor-Leste: lessons learnt

The response to the COVID-19 pandemic in Timor-Leste offers lessons that may be useful for incorporating into future responses to infectious disease outbreaks in similar resource-limited settings. In this paper, we identify nine key areas for learning from Timor-Leste's experience of the COVID-19 pandemic: (1) the importance of prior preparation for health emergencies, (2) the establishment of effective leadership and governance structures, (3) the protective impact of early border restrictions, (4) the rapid expansion of diagnostic laboratory capacity, (5) the impact of effective health communications in supporting the vaccine roll-out, (6) the opportunity to build capacity for clinical care, (7) the use of public health interventions that were found to have limited public health impact, (8) the broader effects of the pandemic and the public health response and (9) translation of lessons from COVID-19 to other public health priorities.

Long-term monitoring of COVID-19 prevalence in raw and treated wastewater in Salvador, the largest capital of the Brazilian Northeast

Wastewater-based epidemiology (WBE) becomes an interesting epidemiological approach to monitoring the prevalence of SARS-CoV-2 broadly and non-invasively. Herein, we employ for the first time WBE, associated or not with the PEG 8000 precipitation method, for the detection of SARS-CoV-2 in samples of raw or treated wastewater from 22 municipal wastewater treatment stations (WWTPs) located in Salvador, the fourth most populous city in Brazil. Our results demonstrate the success of the application of WBE for detecting SARS-CoV-2 in both types of evaluated samples, regardless of the usage of PEG 8000 concentration procedure. Further, an increase in SARS-CoV-2 positivity rate was observed in samples collected in months that presented the highest number of confirmed COVID-19 cases (May/2021, June/2021 and January/2022). While PEG 8000 concentration step was found to significantly increase the positivity rate in treated wastewater samples (p < 0.005), a strong positive correlation (r: 0.84; p < 0.002) between non-concentrated raw wastewater samples with the number of new cases of COVID-19 (April/2021-February/2022) was observed. In general, the present results reinforce the efficiency of WBE approach to monitoring the presence of SARS-CoV-2 in either low- or high-capacity WWTPs. The successful usage of WBE even in raw wastewater samples makes it an interesting low-cost tool for epidemiological surveillance.

Communicating health and science to the public: a role for scientists and academic researchers

As seen through the COVID-19 pandemic, effective and impactful communications are the cornerstone to improved public health. Communications increase awareness about a health issue or solution and play a significant role in shifting social norms by influencing attitudes. However, scientists and academic researchers remain separate from the journalists and media that report to the wider community. We provide our perspective on the need to merge and weave the media and science worlds together for greater impact.

Evaluation of the Global Health Security Index as a predictor of COVID-19 excess mortality standardised for under-reporting and age structure

BACKGROUND

Previous studies have observed that countries with the strongest levels of pandemic preparedness capacities experience the greatest levels of COVID-19 burden. However, these analyses have been limited by cross-country differentials in surveillance system quality and demographics. Here, we address limitations of previous comparisons by exploring country-level relationships between pandemic preparedness measures and comparative mortality ratios (CMRs), a form of indirect age standardisation, of excess COVID-19 mortality.

METHODS

We indirectly age standardised excess COVID-19 mortality, from the Institute for Health Metrics and Evaluation modelling database, by comparing observed total excess mortality to an expected age-specific COVID-19 mortality rate from a reference country to derive CMRs. We then linked CMRs with data on country-level measures of pandemic preparedness from the Global Health Security (GHS) Index. These data were used as input into multivariable linear regression analyses that included income as a covariate and adjusted for multiple comparisons. We conducted a sensitivity analysis using excess mortality estimates from WHO and The Economist.

RESULTS

The GHS Index was negatively associated with excess COVID-19 CMRs (table 2; β= -0.21, 95% CI= -0.35 to -0.08). Greater capacities related to prevention (β= -0.11, 95% CI= -0.22 to -0.00), detection (β= -0.09, 95% CI= -0.19 to -0.00), response (β = -0.19, 95% CI= -0.36 to -0.01), international commitments (β= -0.17, 95% CI= -0.33 to -0.01) and risk environments (β= -0.30, 95% CI= -0.46 to -0.15) were each associated with lower CMRs. Results were not replicated using excess mortality models that rely more heavily on reported COVID-19 deaths (eg, WHO and The Economist).

CONCLUSION

The first direct comparison of COVID-19 excess mortality rates across countries accounting for under-reporting and age structure confirms that greater levels of preparedness were associated with lower excess COVID-19 mortality. Additional research is needed to confirm these relationships as more robust national-level data on COVID-19 impact become available.