Projected health-care resource needs for an effective response to COVID-19 in 73 low-income and middle-income countries: a modelling study

An epidemiological modeling framework to inform institutional-level response to infectious disease outbreaks: a Covid-19 case study

Institutions have an enhanced ability to implement tailored mitigation measures during infectious disease outbreaks. However, macro-level predictive models are inefficient for guiding institutional decision-making due to uncertainty in local-level model input parameters. We present an institutional-level modeling toolkit used to inform prediction, resource procurement and allocation, and policy implementation at Clemson University throughout the Covid-19 pandemic. Through incorporating real-time estimation of disease surveillance and epidemiological measures based on institutional data, we argue this approach helps minimize uncertainties in input parameters presented in the broader literature and increases prediction accuracy. We demonstrate this through case studies at Clemson and other university settings during the Omicron BA.1 and BA.4/BA.5 variant surges. The input parameters of our toolkit are easily adaptable to other institutional settings during future health emergencies. This methodological approach has potential to improve public health response through increasing the capability of institutions to make data-informed decisions that better prioritize the health and safety of their communities while minimizing operational disruptions.

Investigating the spatiotemporal characteristics and medical response during the initial COVID-19 epidemic in six Chinese cities

In the future, novel and highly pathogenic viruses may re-emerge, leading to a surge in healthcare demand. It is essential for urban epidemic control to investigate different cities' spatiotemporal spread characteristics and medical carrying capacity during the early stages of COVID-19. This study employed textual analysis, mathematical statistics, and spatial analysis methods to examine the situation in six highly affected Chinese cities. The findings reveal that these cities experienced three phases during the initial outbreak of COVID-19: "unknown-origin incubation", "Wuhan-related outbreak", and "local exposure outbreak". Cities with a high number of confirmed cases exhibited a multicore pattern, while those with fewer cases displayed a single-core pattern. The cores were distributed hierarchically in the central built-up areas of cities' economic, political, or transportation centers. The radii of these cores shrank as the central built-up area's level decreased, indicating a hierarchical decay and a core-edge structure. It suggests that decentralized built environments (non-clustered economies and populations) are less likely to facilitate large-scale epidemic clusters. Additionally, the deployment of designated hospitals in these cities was consistent with the spatial distribution of the epidemic; however, their carrying capacity requires urgent improvement. Ultimately, the essence of prevention and control is the governance of human activities and the efficient management of limited resources about individuals, places, and materials through leveraging IT and GIS technologies to address supply-demand contradictions.

Estimating the return on investment of selected infection prevention and control interventions in healthcare settings for preparing against novel respiratory viruses: modelling the experience from SARS-CoV-2 among health workers

Background

Insufficient infection prevention and control (IPC) practices in healthcare settings increase the SARS-CoV-2 infection risk among health workers. This study aimed to examine the level of preparedness for future outbreaks.

Methods

We modelled the experience from the COVID-19 pandemic and assessed the return on investment on a global scale of three IPC interventions to prevent SARS-CoV-2 infections among health workers: enhancing hand hygiene; increasing access to personal protective equipment (PPE); and combining PPE, with a scale-up of IPC training and education (PPE+). Our analysis covered seven geographic regions, representing a combination of World Health Organization (WHO) regions and the Organisation for Economic Co-operation and Development (OECD) countries. Across all regions, we focused on the first 180 days of the pandemic in 2020 between January 1st and June 30th. We used an extended version of a susceptible-infectious-recovered compartmental model to measure the level of IPC preparedness. Data were sourced from the WHO COVID-19 Detailed Surveillance Database.

Findings

In all regions, the PPE + intervention would have averted the highest number of new SARS-CoV-2 infections compared to the other two interventions, ranging from 6562 (95% CI 4873-8779) to 38,170 (95% CI 33,853-41,901) new infections per 100,000 health workers in OECD countries and in the South-East Asia region, respectively. Countries in the South-East Asia region and non-OECD countries in the Western Pacific region were poised to achieve the highest level of savings by scaling up the PPE + intervention.

Interpretation

Our results not only support efforts to make an economic case for continuing investments in IPC interventions to halt the COVID-19 pandemic and protect health workers, but could also contribute to efforts to improve preparedness for future outbreaks.

Funding

This work was funded by WHO, with support by the German Federal Ministry of Health for the WHOResearch and Development Blueprint for COVID-19.

An epidemiological modeling framework to inform institutional-level response to infectious disease outbreaks: A Covid-19 case study

Institutions have an enhanced ability to implement tailored mitigation measures during infectious disease outbreaks. However, macro-level predictive models are inefficient for guiding institutional decision-making due to uncertainty in local-level model input parameters. We present an institutional-level modeling toolkit used to inform prediction, resource procurement and allocation, and policy implementation at Clemson University throughout the Covid-19 pandemic. Through incorporating real-time estimation of disease surveillance and epidemiological measures based on institutional data, we argue this approach helps minimize uncertainties in input parameters presented in the broader literature and increases prediction accuracy. We demonstrate this through case studies at Clemson and other university settings during the Omicron BA.1 and BA.4/BA.5 variant surges. The input parameters of our toolkit are easily adaptable to other institutional settings during future health emergencies. This methodological approach has potential to improve public health response through increasing the capability of institutions to make data-informed decisions that better prioritize the health and safety of their communities while minimizing operational disruptions.

A global perspective on the intrinsic dimensionality of COVID-19 data

We develop a novel global perspective of the complexity of the relationships between three COVID-19 datasets, the standardised per-capita growth rate of COVID-19 cases and deaths, and the Oxford Coronavirus Government Response Tracker COVID-19 Stringency Index (CSI) which is a measure describing a country's stringency of lockdown policies. We use a state-of-the-art heterogeneous intrinsic dimension estimator implemented as a Bayesian mixture model, called Hidalgo. Our findings suggest that these highly popular COVID-19 statistics may project onto two low-dimensional manifolds without significant information loss, suggesting that COVID-19 data dynamics are generated from a latent mechanism characterised by a few important variables. The low dimensionality imply a strong dependency among the standardised growth rates of cases and deaths per capita and the CSI for countries over 2020-2021. Importantly, we identify spatial autocorrelation in the intrinsic dimension distribution worldwide. The results show how high-income countries are more prone to lie on low-dimensional manifolds, likely arising from aging populations, comorbidities, and increased per capita mortality burden from COVID-19. Finally, the temporal stratification of the dataset allows the examination of the intrinsic dimension at a more granular level throughout the pandemic.

The positive impact of COVID-19 on critical care: from unprecedented challenges to transformative changes, from the perspective of young intensivists

Over the past 2 years, SARS-CoV-2 infection has resulted in numerous hospitalizations and deaths worldwide. As young intensivists, we have been at the forefront of the fight against the COVID-19 pandemic and it has been an intense learning experience affecting all aspects of our specialty. Critical care was put forward as a priority and managed to adapt to the influx of patients and the growing demand for beds, financial and material resources, thereby highlighting its flexibility and central role in the healthcare system. Intensivists assumed an essential and unprecedented role in public life, which was important when claiming for indispensable material and human investments. Physicians and researchers around the world worked hand-in-hand to advance research and better manage this disease by integrating a rapidly growing body of evidence into guidelines. Our daily ethical practices and communication with families were challenged by the massive influx of patients and restricted visitation policies, forcing us to improve our collaboration with other specialties and innovate with new communication channels. However, the picture was not all bright, and some of these achievements are already fading over time despite the ongoing pandemic and hospital crisis. In addition, the pandemic has demonstrated the need to improve the working conditions and well-being of critical care workers to cope with the current shortage of human resources. Despite the gloomy atmosphere, we remain optimistic. In this ten-key points review, we outline our vision on how to capitalize on the lasting impact of the pandemic to face future challenges and foster transformative changes of critical care for the better.

Relevance of prediction scores derived from the SARS-CoV-2 first wave, in the evolving UK COVID-19 second wave, for safe early discharge and mortality: a PREDICT COVID-19 UK prospective observational cohort study

OBJECTIVE

Prospectively validate prognostication scores, SOARS and 4C Mortality Score, derived from the COVID-19 first wave, for mortality and safe early discharge in the evolving pandemic with SARS-CoV-2 variants (B.1.1.7 replacing D614) and healthcare responses altering patient demographic and mortality.

DESIGN

Protocol-based prospective observational cohort study.

SETTING

Single site PREDICT and multisite ISARIC (International Severe Acute Respiratory and Emerging Infections Consortium) cohorts in UK COVID-19 second wave, October 2020 to January 2021.

PARTICIPANTS

1383 PREDICT and 20 595 ISARIC SARS-CoV-2 patients.

PRIMARY OUTCOME MEASURES

Relevance of SOARS and 4C Mortality Score determining in-hospital mortality and safe early discharge in the evolving UK COVID-19 second wave.

RESULTS

1383 (median age 67 years, IQR 52-82; mortality 24.7%) PREDICT and 20 595 (mortality 19.4%) ISARIC patient cohorts showed SOARS had area under the curve (AUC) of 0.8 and 0.74, while 4C Mortality Score had AUC of 0.83 and 0.91 for hospital mortality, in the PREDICT and ISARIC cohorts respectively, therefore, effective in evaluating safe discharge and in-hospital mortality. 19.3% (231/1195, PREDICT cohort) and 16.7% (2550/14992, ISARIC cohort) with SOARS of 0-1 were candidates for safe discharge to a virtual hospital (VH) model. SOARS implementation in the VH pathway resulted in low readmission, 11.8% (27/229) and low mortality, 0.9% (2/229). Use to prevent admission is still suboptimal, as 8.1% in the PREDICT cohort and 9.5% in the ISARIC cohort were admitted despite SOARS score of 0-1.

CONCLUSIONS

SOARS and 4C Mortality Score remains valid, transforming complex clinical presentations into tangible numbers, aiding objective decision making, despite SARS-CoV-2 variants and healthcare responses altering patient demographic and mortality. Both scores, easily implemented within urgent care pathways for safe early discharge, allocate hospital resources appropriately to the pandemic's needs while enabling normal healthcare services resumption.

Construction and Immunogenicity of a Recombinant Pseudorabies Virus Expressing SARS-CoV-2-S and SARS-CoV-2-N

Coronavirus (CoV) is an important pathogen of humans and animals, which can infect humans or animals through the respiratory mucosal route. Syndrome coronavirus 2 (SARS-CoV-2) is quite similar to syndrome coronavirus (SARS-CoV) with the same receptor, angiotensin-converting enzyme 2 (ACE2). The S and N proteins are the most important protective antigens of the SARS-CoV-2. The S protein on the viral membrane mediates the virus attachment with the host cells, and the N protein is the most abundant expression during infection. In this study, the recombinant viruses expressing the S and N proteins of SARS-CoV-2 were successfully constructed by Red/ET recombinant technology using Pseudorabies virus (PRV) strain Bartha-K61 as a vector. Genetic stability and growth kinetics analysis showed that the recombinant viruses rPRV-SARS-CoV-2-S and rPRV-SARS-CoV-2-N had similar genetic stability and proliferation characteristics to the parental PRV. The immunoassay results showed that mice immunized with recombinant viruses could produce total IgG antibodies. Therefore, PRV is feasible and promising as a viral vector to express SARS-CoV-2-S and SARS-CoV-2-N genes. This study can provide a reference for future research on live vector vaccines for domestic animals, pets, and wild animals.

Lessons from the frontline: The COVID-19 pandemic emergency care experience from a human resource perspective in the Pacific region

Background

This study explores emergency care (EC) and other frontline healthcare worker (HCW) experiences responding to the COVID-19 pandemic in the Pacific region. The crisis has reinforced the crucial role well-trained, resourced, and supported EC providers play in supporting vital health systems and services in all global regions not only during 'business as usual' periods, but in times of tremendous stress and surge.

Methods

Qualitative data were collected from EC providers and relevant stakeholders in three research phases in 2020 and 2021. Data on the World Health Organization's (WHO) Human Resources Building Block, adapted for the Pacific EC context, was thematically analysed. Key findings were further analysed to identify enablers and barriers to effective EC pandemic management.

Findings

116 participants from across the Pacific region participated in this study. Five themes emerged: (1) EC providers performed multiple pandemic roles; (2) Importance of authorities' valuing frontline HCWs; (3) HCW mental health and exhaustion; (4) HCW tension managing stigma, personal/professional expectations, and chronic health needs; and (5) Building health and human resource capacity.

Interpretation

This study significantly contributes to the limited scientific literature on HCW experiences responding to COVID-19 across the Pacific. Recommendations arising out of this research align with consensus priorities and standards that were identified pre-pandemic by health stakeholders across the Pacific for enhancing EC system development. With limited HCWs available for many Pacific nations, it is imperative the dignity and welfare of local HCWs is genuinely prioritised.

Funding

Epidemic Ethics/WHO, Foreign, Commonwealth and Development Office/Wellcome Grant 214711/Z/18/Z. Co-funding: Australasian College for Emergency Medicine Foundation, International Development Fund Grant.

Visualizing the Knowledge Base and Research Hotspot of Public Health Emergency Management: A Science Mapping Analysis-Based Study

Public health emergency management has been one of the main challenges of social sustainable development since the beginning of the 21st century. Research on public health emergency management is becoming a common focus of scholars. In recent years, the literature associated with public health emergency management has grown rapidly, but few studies have used a bibliometric analysis and visualization approach to conduct deep mining and explore the characteristics of the public health emergency management research field. To better understand the present status and development of public health emergency management research, and to explore the knowledge base and research hotspots, the bibliometric method and science mapping technology were adopted to visually evaluate the knowledge structure and research trends in the field of public health emergency management studies. From 2000 to 2020, a total of 3723 papers related to public health emergency management research were collected from the Web of Science Core Collection as research data. The five main research directions formed are child prevention, mortality from public health events, public health emergency preparedness, public health emergency management, and coronavirus disease 2019 (COVID-19). The current research hotspots and frontiers are climate change, COVID-19 and related coronaviruses. Further research is needed to focus on the COVID-19 and related coronaviruses. This study intends to contribute inclusive support to related academia and industry in the aspects of public health emergency management and public safety research, as well as research hotspots and future research directions.

Rapid, application-based survey to characterise the impacts of COVID-19 on LGBTQ+ communities around the world: an observational study

INTRODUCTION

Emerging evidence indicates that the COVID-19 pandemic, and the responses it has generated, have had disproportionate impacts on lesbian, gay, bisexual, transgender and queer (LGBTQ+) communities. This study seeks to build on existing information and provide regional insight.

METHODS

In response, a cross-sectional survey was administered to a global sample of LGBTQ+ individuals (n=13 358) between 16 April and 20 May 2020 via the social networking application Hornet. The survey contained questions that characterise the impact of COVID-19 and associated mitigation strategies on economics, employment, mental health and access to healthcare.

RESULTS

5191 (43.9%) individuals indicated they were somewhat, slightly or unable to meet basic needs with their current income, while 2827 (24.1%) and 4710 (40.1%) felt physically or emotionally unsafe in their living environment, respectively. 2202 individuals (24.7%) stated they are at risk for losing health insurance coverage. 2685 (22.7%) persons reported having skipped or cut meals as there was not enough money.

CONCLUSION

Many LGBTQ+persons who responded reported adverse consequences to mental health, economics, interruptions to care and lack of support from their government. This data is part of ongoing analyses but accentuates the unique needs of LGBTQ+ communities that will require targeted, ameliorative approaches.

Estimating the cost of achieving basic water, sanitation, hygiene, and waste management services in public health-care facilities in the 46 UN designated least-developed countries: a modelling study

Background

An alarming number of public health-care facilities in low-income and middle-income countries lack basic water, sanitation, hygiene (WASH), and waste management services. This study estimates the costs of achieving full coverage of basic WASH and waste services in existing public health facilities in the 46 UN designated least-developed countries (LDCs).

Methods

In this modelling study, in-need facilities were quantified by combining published counts of public facilities with estimated basic WASH and waste service coverage. Country-specific per-facility capital and recurrent costs to deliver basic services were collected via survey of country WASH experts and officials between Sept 24 and Dec 24, 2020. Baseline cost estimates were modelled and discounted by 5% per year. Key assumptions were adjusted to produce lower and upper estimates, including adjusting the discount rate to 8% and 3% per year, respectively.

Findings

An estimated US$6·5 billion to $9·6 billion from 2021 to 2030 is needed to achieve full coverage of basic WASH and waste services in public health facilities in LDCs. Capital costs are $2·9 billion to $4·8 billion and recurrent costs are $3·6 billion to $4·8 billion over this time period. A mean of $0·24–0·40 per capita in capital investment is needed each year, and annual operations and maintenance costs are expected to increase from $0·10 in 2021 to $0·39–0·60 in 2030. Waste management accounts for the greatest share of costs, requiring $3·7 billion (46·6% of the total) in the baseline estimates, followed by $1·8 billion (23·1%) for sanitation, $1·5 billion (19·5%) for water, and $845 million (10·7%) for hygiene. Needs are greatest for non-hospital facilities ($7·4 billion [94%] of $7·9 billion) and for facilities in rural areas ($5·3 billion [68%]).

Interpretation

Investment will need to increase to reach full coverage of basic WASH and waste services in public health facilities. Financial needs are modest compared with current overall health and WASH spending, and better service coverage will yield substantial health benefits. To sustain services and prevent degradation and early replacement, countries will need to routinely budget for operations and maintenance of WASH and waste management assets.

Funding

WHO (including underlying grants from the governments of Japan, the Netherlands, and the UK), World Bank (including an underlying grant from the Global Water Security and Sanitation Partnership), and UNICEF.

Translations

For the Arabic, French and Portuguese translations of the abstract see Supplementary Materials section.

Japan's development assistance for health: Historical trends and prospects for a new era

The year 2020 marked an important turning point in Japan's global health policy. While the global health community has been suffering serious damage to sustainable health financing due to the COVID-19 pandemic, an independent commission on Japan's Strategy on Development Assistance for Health (DAH) launched an ambitious policy recommendation to double the amount of Japan's DAH during the post-COVID-19 era. This paper examines historical trends in DAH in Japan over the past 30 years based on published literature and comprehensive DAH tracking data and highlights priority areas for discussion on how DAH can be advanced to ensure equitable and efficient use of limited resources to support the achievement of the Sustainable Development Goals, including universal health coverage and pandemic preparedness, in low- and middle-income countries. Priority areas for discussion include: how and where to focus DAH for equitable health gains; how to provide DAH to support health system strengthening, including pandemic preparedness; and clarifying the role of DAH in global health functions.

Informed Consent and Protection of Personal Data in Genetic Research on COVID-19

The particular characteristics of COVID-19 demand the careful biomedical study of samples from patients who have shown different symptomatology, in order to understand the genetic foundations of its phenotypic expression. Research on genetic material from COVID-19 patients is indispensable for understanding the biological bases for its varied clinical manifestations. The issue of “informed consent” constitutes the crux of the problem in regulating research biobanks, because it concerns the relationship between the person and the parts separated from the body. There are several consensus models that can be adopted, varying from quite restricted models of specific informed consent to forms that allow very broad authorization (open consent). Our current understanding of COVID-19 is incomplete. Thus, we cannot plan, with precision, the research to be conducted on biological samples that have been, or will be, collected from patients infected by the novel coronavirus. Therefore, we suggest utilizing the “participation pact” between researchers and donors, based on a new form of participation in research, which offers a choice based on the principles of solidarity and reciprocity, which represent the communication of “values”. In the last part of this paper, the general data protection regulation concerning the matter is discussed. The treatment of personal data must be performed with explicit goals, and donors must be provided with a clear, transparent explanation of the methods, goals and time of storage. The data must not be provided to unauthorized subjects. In conclusion, open informed consent forms will be necessary for research on individual patients and on populations.

Cost estimates of COVID-19 clinical management in Myanmar

Objective

This study aims to estimate the cost of clinical management of COVID-19 infected patients based on their severity by exploring the resources used in health care provision in Myanmar.

Methods

A multicenter retrospective cost analysis of COVID-19 patients was performed using the micro-costing approach from the perspective of the health system. It covered two cost components, namely direct and indirect cost of treating a patient. Input data and their quantities were obtained from COVID-19 Standard Treatment Guidelines of Ministry of Health and Sports, and administrative and financial records of resource utilization of three designated health facilities in Yangon Region. Valuation of these resources was based on the price list from the Procurement Section of the Ministry.

Results

This study estimated the unit cost of clinical management of COVID-19 infected patients with no symptom to be 953,552 MMK(717 USD), with mild-moderate symptoms to be 1,155,222 MMK(869 USD) and with severe-critically ill conditions to be 5,705,052 MMK(4290 USD). Average cost for a patient par day was 86,687 MMK(65 USD) for asymptomatic patients, 105,020 MMK(79 USD) for mild-moderate patients and 283,252 MMK(214 USD) for severe-critically ill patients. Since the first case detected till December 31, 2020, COVID-19 clinical management cost was accounted for 139 Billion MMK (104 Million USD) for total 124,630 confirmed cases.

Conclusions

COVID-19 pandemic has caused health systems to incur the significant health care expenses. Timely implementation of the sustainable, affordable and efficient policy for COVID-19 responses is of utmost important for every nation especially in the face of a pandemic. This study provides the fundamental inputs for strategic planning, for future economic evaluations of different policy interventions, and policy recommendations for health systems to remain resilient during and after the COVID-19 pandemic in Myanmar.

A three-layer system to win the war against COVID-19 and invest in health systems of the future

The COVID-19 pandemic taught us many lessons, most critically that its human and economic toll would have been significantly smaller if countries had in place strong layers of defence that would have either prevented the spillover of the SARS-CoV-2 into a human population in the first place, or, failing that, contained the outbreak to avert its global spread. Further, the brunt of COVID-19 impacts on some countries considered ‘most prepared’ for pandemics underscored the need for an integrated approach to ensure resilience to future epidemics. Consequently, as countries plan ahead to prevent future pandemics, they should give priority to investments that transform their systems, particularly in the precrises phase, to preparedness and response through a multilayered defence. We propose a three-layered approach for post-COVID-19 investments in public health functions and service delivery, particularly at the community and precrises levels. This framework highlights the interventions that enable countries to better prevent, detect and contain epidemic threats, and that strengthen the efficient use of limited resources towards high-impact precrises systems.

Stark choices: exploring health sector costs of policy responses to COVID-19 in low-income and middle-income countries

OBJECTIVES

COVID-19 has altered health sector capacity in low-income and middle-income countries (LMICs). Cost data to inform evidence-based priority setting are urgently needed. Consequently, in this paper, we calculate the full economic health sector costs of COVID-19 clinical management in 79 LMICs under different epidemiological scenarios.

METHODS

We used country-specific epidemiological projections from a dynamic transmission model to determine number of cases, hospitalisations and deaths over 1 year under four mitigation scenarios. We defined the health sector response for three base LMICs through guidelines and expert opinion. We calculated costs through local resource use and price data and extrapolated costs across 79 LMICs. Lastly, we compared cost estimates against gross domestic product (GDP) and total annual health expenditure in 76 LMICs.

RESULTS

COVID-19 clinical management costs vary greatly by country, ranging between <0.1%-12% of GDP and 0.4%-223% of total annual health expenditure (excluding out-of-pocket payments). Without mitigation policies, COVID-19 clinical management costs per capita range from US$43.39 to US$75.57; in 22 of 76 LMICs, these costs would surpass total annual health expenditure. In a scenario of stringent social distancing, costs per capita fall to US$1.10-US$1.32.

CONCLUSIONS

We present the first dataset of COVID-19 clinical management costs across LMICs. These costs can be used to inform decision-making on priority setting. Our results show that COVID-19 clinical management costs in LMICs are substantial, even in scenarios of moderate social distancing. Low-income countries are particularly vulnerable and some will struggle to cope with almost any epidemiological scenario. The choices facing LMICs are likely to remain stark and emergency financial support will be needed.

Understanding the Impact of Digital Health Strategies During the COVID-19 Outbreak in Saudi Arabia

BACKGROUND

The impact of COVID-19 has been analyzed from various aspects on the health care services management, accessibility and delivery of health care services. However, the COVID-19 pandemic has led to disruptions in health care services, which led to the increase in adoption of digital health technologies, mostly arising out of need and necessity.

OBJECTIVE

Focusing on the prevailing situations (increasing reliance on digital health services), this study investigates the impact of digital health technologies from the perspectives of policymakers and citizens.

METHODS

A mixed-methods approach was adopted. Twenty-seven semi-structured online interviews were conducted with experts and policymakers for assessing the impact from policymakers' perspectives. An online survey questionnaire instrument was used to collect the responses from 1698 Saudi Arabian citizens in relation to the various aspects of digital health applications.

RESULTS

Health care expenditures increased during the COVID-19 outbreak, resulting in launch of various digital health applications. While policymakers defended their stand in improving health care services and accessibility; citizens reflected inability to book medicines/personal medical equipment online (Mean=2.4) and suffered a lack of personalized care (Mean=2.9) through digital health applications. Moreover, disparities exist between the population groups with respect to the accessibility, utilization, and perceptions of digital health technologies.

CONCLUSION

Policymakers have to consider and address these differences in formulating digital health policies and implementing them.

Predicting Hospital Resource Use During COVID-19 Surges: A Simple but Flexible Discretely Integrated Condition Event Simulation of Individual Patient-Hospital Trajectories

OBJECTIVES

To assist with planning hospital resources, including critical care (CC) beds, for managing patients with COVID-19.

METHODS

An individual simulation was implemented in Microsoft Excel using a discretely integrated condition event simulation. Expected daily cases presented to the emergency department were modeled in terms of transitions to and from ward and CC and to discharge or death. The duration of stay in each location was selected from trajectory-specific distributions. Daily ward and CC bed occupancy and the number of discharges according to care needs were forecast for the period of interest. Face validity was ascertained by local experts and, for the case study, by comparing forecasts with actual data.

RESULTS

To illustrate the use of the model, a case study was developed for Guy's and St Thomas' Trust. They provided inputs for January 2020 to early April 2020, and local observed case numbers were fit to provide estimates of emergency department arrivals. A peak demand of 467 ward and 135 CC beds was forecast, with diminishing numbers through July. The model tended to predict higher occupancy in Level 1 than what was eventually observed, but the timing of peaks was quite close, especially for CC, where the model predicted at least 120 beds would be occupied from April 9, 2020, to April 17, 2020, compared with April 7, 2020, to April 19, 2020, in reality. The care needs on discharge varied greatly from day to day.

CONCLUSIONS

The DICE simulation of hospital trajectories of patients with COVID-19 provides forecasts of resources needed with only a few local inputs. This should help planners understand their expected resource needs.

Tracking development assistance for health and for COVID-19: a review of development assistance, government, out-of-pocket, and other private spending on health for 204 countries and territories, 1990-2050

BACKGROUND

The rapid spread of COVID-19 renewed the focus on how health systems across the globe are financed, especially during public health emergencies. Development assistance is an important source of health financing in many low-income countries, yet little is known about how much of this funding was disbursed for COVID-19. We aimed to put development assistance for health for COVID-19 in the context of broader trends in global health financing, and to estimate total health spending from 1995 to 2050 and development assistance for COVID-19 in 2020.

METHODS

We estimated domestic health spending and development assistance for health to generate total health-sector spending estimates for 204 countries and territories. We leveraged data from the WHO Global Health Expenditure Database to produce estimates of domestic health spending. To generate estimates for development assistance for health, we relied on project-level disbursement data from the major international development agencies' online databases and annual financial statements and reports for information on income sources. To adjust our estimates for 2020 to include disbursements related to COVID-19, we extracted project data on commitments and disbursements from a broader set of databases (because not all of the data sources used to estimate the historical series extend to 2020), including the UN Office of Humanitarian Assistance Financial Tracking Service and the International Aid Transparency Initiative. We reported all the historic and future spending estimates in inflation-adjusted 2020 US$, 2020 US$ per capita, purchasing-power parity-adjusted US$ per capita, and as a proportion of gross domestic product. We used various models to generate future health spending to 2050.

FINDINGS

In 2019, health spending globally reached $8·8 trillion (95% uncertainty interval [UI] 8·7-8·8) or $1132 (1119-1143) per person. Spending on health varied within and across income groups and geographical regions. Of this total, $40·4 billion (0·5%, 95% UI 0·5-0·5) was development assistance for health provided to low-income and middle-income countries, which made up 24·6% (UI 24·0-25·1) of total spending in low-income countries. We estimate that $54·8 billion in development assistance for health was disbursed in 2020. Of this, $13·7 billion was targeted toward the COVID-19 health response. $12·3 billion was newly committed and $1·4 billion was repurposed from existing health projects. $3·1 billion (22·4%) of the funds focused on country-level coordination and $2·4 billion (17·9%) was for supply chain and logistics. Only $714·4 million (7·7%) of COVID-19 development assistance for health went to Latin America, despite this region reporting 34·3% of total recorded COVID-19 deaths in low-income or middle-income countries in 2020. Spending on health is expected to rise to $1519 (1448-1591) per person in 2050, although spending across countries is expected to remain varied.

INTERPRETATION

Global health spending is expected to continue to grow, but remain unequally distributed between countries. We estimate that development organisations substantially increased the amount of development assistance for health provided in 2020. Continued efforts are needed to raise sufficient resources to mitigate the pandemic for the most vulnerable, and to help curtail the pandemic for all.

FUNDING

Bill & Melinda Gates Foundation.

Effective vaccine allocation strategies, balancing economy with infection control against COVID-19 in Japan

Due to COVID-19, many countries including Japan have implemented a suspension of economic activities for infection control. It has contributed to reduce the transmission of COVID-19 but caused severe economic losses. Today, several promising vaccines have been developed and are already being distributed in some countries. Therefore, we evaluated various vaccine and intensive countermeasure strategies with constraint of economic loss using SEIR model to obtain knowledge of how to balance economy with infection control in Japan. Our main results were that the vaccination strategy that prioritized younger generation was better in terms of deaths when a linear relationship between lockdown intensity and acceptable economic loss was assumed. On the other hand, when a non-linearity relationship was introduced, implying that the strong lockdown with small economic loss was possible, the old first strategies were best in the settings of small basic reproduction number. These results indicated a high potential of remote work when prioritizing vaccination for the old generation. When focusing on only the old first strategies as the Japanese government has decided to do, the strategy vaccinating the young next to the old was superior to the others when a non-linear relationship was assumed due to sufficient reduction of contact with small economic loss.

A worldwide assessment of changes in adherence to COVID-19 protective behaviours and hypothesized pandemic fatigue

As the COVID-19 pandemic lingers, the possibility of 'pandemic fatigue' has raised worldwide concerns. Here, we examine whether there was a gradual reduction in adherence to protective behaviours against COVID-19 from March through December 2020, as hypothesized in expectations of fatigue. We considered self-report behaviours from representative samples of the populations of 14 countries (N = 238,797), as well as mobility and policy data for 124 countries. Our results show that changes in adherence were empirically meaningful and geographically widespread. While a low-cost and habituating behaviour (mask wearing) exhibited a linear rise in adherence, high-cost and sensitizing behaviours (physical distancing) declined, but this decline decelerated over time, with small rebounds seen in later months. Reductions in adherence to physical distancing showed little difference across societal groups, but were less intense in countries with high interpersonal trust. Alternative underlying mechanisms and policy implications are discussed.

A worldwide assessment of changes in adherence to COVID-19 protective behaviours and hypothesized pandemic fatigue

As the COVID-19 pandemic lingers, the possibility of 'pandemic fatigue' has raised worldwide concerns. Here, we examine whether there was a gradual reduction in adherence to protective behaviours against COVID-19 from March through December 2020, as hypothesized in expectations of fatigue. We considered self-report behaviours from representative samples of the populations of 14 countries (N = 238,797), as well as mobility and policy data for 124 countries. Our results show that changes in adherence were empirically meaningful and geographically widespread. While a low-cost and habituating behaviour (mask wearing) exhibited a linear rise in adherence, high-cost and sensitizing behaviours (physical distancing) declined, but this decline decelerated over time, with small rebounds seen in later months. Reductions in adherence to physical distancing showed little difference across societal groups, but were less intense in countries with high interpersonal trust. Alternative underlying mechanisms and policy implications are discussed.

Nonintensivist Training to Increase the Staff Capacity of Intensive Care Units During COVID-19 Pandemic Surge in Argentina

OBJECTIVE

The aim of this study was to report the results of a nationwide critical-care course for non-intensivists to increase staff capacity of intensive care units (ICUs) during the coronavirus disease 2019 (COVID-19) pandemic in Argentina.

METHODS

Three academic organizations, with special funding from 55 private companies, developed a short virtual course comprised of Web-based videos, virtual tutorials, and a forum chat. Each state assigned scholarships to non-ICU staff from public hospitals. Students received active follow-up for the completion of the course and took a survey upon course completion.

RESULTS

After 4 m, there were 10,123 students registered from 661 hospitals in 328 cities. Of these, 67.8% passed the course, 29.1% were still ongoing, and 3.1% were inactive. Most students were female (74.2%) with a median of 37 y old (IQR 31-44). The group was composed of 56.5% nurses, 36.2% physicians, and 7.4% physiotherapists, of whom 48.3% did not have any experience in critical care. Mean overall satisfaction was 4.4/5 (standard deviation, 0.9), and 90.7% considered they were able to apply the contents to their practice.

CONCLUSIONS

This course was effective for rapid training of non-ICU personnel. The assignment strategy, the educational techniques, and the close follow-up led to low dropout and high success rates and satisfaction.

Cost-effectiveness Analysis of Current Varicose Veins Treatments

OBJECTIVE

To analyze the effectiveness and cost-effectiveness of technologies for treatment of varicose veins over 5 years - conservative care (CONS), surgery (HL/S), ultrasound guided foam sclerotherapy (UGFS), endovenous laser ablation (EVLA), and radiofrequency ablation (RFA), mechanochemical ablation (MOCA) and cyanoacrylate glue occlusion (CAE).

METHODS

A systematic review was updated and used to construct a Markov decision model. Outcomes were re-intervention on the truncal vein, re-treatment of residual varicosities and quality-adjusted life years (QALY) and costs over five years.

RESULTS

UGFS has a significantly greater re-intervention rate than other procedures, while there is no significant difference between the other procedures. The cost per QALY of EVLA versus UGFS in our base-case model is £16966 ($23700) per QALY, which is considered cost-effective in the UK. RFA, MOCA and CAE have greater procedure costs than EVLA with no evidence of greater benefit for patients.

CONCLUSIONS

EVLA is the most cost-effective therapeutic option, with RFA a close second, in adult patients requiring treatment in the upper leg for incompetence of the GSV. MOCA, UGFS, CAE, CONS and HL/S are not cost-effective at current prices in the UK National Health Service. MOCA and CAE appear promising but further evidence on effectiveness, re-interventions and health-related quality of life is needed, as well as how cost-effectiveness may vary across settings and reimbursement systems.

The benefits and costs of social distancing in high- and low-income countries

BACKGROUND

Widespread social distancing and lockdowns of everyday activity have been the primary policy prescription across many countries throughout the coronavirus disease 2019 (COVID-19) pandemic. Despite their uniformity, these measures may be differentially valuable for different countries.

METHODS

We use a compartmental epidemiological model to project the spread of COVID-19 across policy scenarios in high- and low-income countries. We embed estimates of the welfare value of disease avoidance into the epidemiological projections to estimate the return to more stringent lockdown policies.

RESULTS

Social distancing measures that 'flatten the curve' of the disease provide immense welfare value in upper-income countries. However, social distancing policies deliver significantly less value in lower-income countries that have younger populations, which are less vulnerable to COVID-19. Equally important, social distancing mandates a trade-off between disease risk and economic activity. Poorer people are less able to make those economic sacrifices.

CONCLUSIONS

The epidemiological and welfare value of social distancing is smaller in lower-income countries and such policies may exact a heavy toll on the poorest and most vulnerable. Workers in the informal sector often lack the resources and social protections that enable them to isolate themselves until the virus passes. By limiting these households' ability to earn a living, social distancing can lead to an increase in hunger, deprivation, and related mortality and morbidity.

What determines city's resilience against epidemic outbreak: evidence from China's COVID-19 experience

By employing the city-level data from China during the spring of 2020, this study investigates the relationship between city-level resilience against the outbreak of COVID-19 pandemics and its affecting factors, including the inflow risk pressure of COVID-19 virus (population inflow from the epicenter), city agglomeration characteristics (urban population density and city size), healthcare resource adequacy, among others. The results reveal that, while managing COVID-19 inflow risk pressure plays a critical role in the city's pandemic disaster resilience, city agglomeration characteristics also matters. To be exact, we find that large and high-density cities with high inter and intra-city mobility flows have more difficulties in containing the epidemic spread, but improving healthcare infrastructure adequacy and urban governance capacity can increase time efficacy of pandemic control and then improve the city's resilience against pandemic. Although our analysis is based on the performance of Chinese cities in the case of COVID-19, the research framework can be applied in understanding COVID-19 control performance of cities in other countries and the findings can be useful for improving health-related urban resilience and sustainability.

Multi-Period Multi-Criteria Decision Making under Uncertainty: A Renewable Energy Transition Case from Germany

Methods of multi-criteria decision making (MCDM) from operations research have been applied to provide information for making long-term decisions in the energy sector, and energy policy. For example, in sustainability evaluations, multiple conflicting criteria can be considered. While most MCDM approaches have been applied to evaluate energy systems in a single period, the multi-criteria evaluation of energy system evolution over time has received less attention. To evaluate such transition paths, multi-period MCDM approaches can be used. Because of long-term planning horizons, deep uncertainties need to be considered. Based on prior multi-period MCDM approaches, this paper provides an extension of the outranking approach preference ranking and organization method for enrichment evaluations (PROMETHEE) for multi-period evaluations in deep uncertainty settings. In order to adequately address the consideration of uncertainties and to obtain an additional level of information, a multi-period PROMETHEE approach and scenario planning are combined. In an illustrative example, this method is applied to a case study from the German energy sector regarding a renewable energy transition. This highlights the potential interactions of a multi-period perspective and the consideration of external scenarios in the decision-making process.

Hitting the diagnostic sweet spot: Point-of-care SARS-CoV-2 salivary antigen testing with an off-the-shelf glucometer

Significant barriers to the diagnosis of latent and acute SARS-CoV-2 infection continue to hamper population-based screening efforts required to contain the COVID-19 pandemic in the absence of widely available antiviral therapeutics or vaccines. We report an aptamer-based SARS-CoV-2 salivary antigen assay employing only low-cost reagents ($3.20/test) and an off-the-shelf glucometer. The test was engineered around a glucometer as it is quantitative, easy to use, and the most prevalent piece of diagnostic equipment globally, making the test highly scalable with an infrastructure that is already in place. Furthermore, many glucometers connect to smartphones, providing an opportunity to integrate with contact tracing apps, medical providers, and electronic health records. In clinical testing, the developed assay detected SARS-CoV-2 infection in patient saliva across a range of viral loads - as benchmarked by RT-qPCR - within 1 h, with 100% sensitivity (positive percent agreement) and distinguished infected specimens from off-target antigens in uninfected controls with 100% specificity (negative percent agreement). We propose that this approach provides an inexpensive, rapid, and accurate diagnostic for distributed screening of SARS-CoV-2 infection at scale.

Leveraging community mortality indicators to infer COVID-19 mortality and transmission dynamics in Damascus, Syria

The COVID-19 pandemic has resulted in substantial mortality worldwide. However, to date, countries in the Middle East and Africa have reported considerably lower mortality rates than in Europe and the Americas. Motivated by reports of an overwhelmed health system, we estimate the likely under-ascertainment of COVID-19 mortality in Damascus, Syria. Using all-cause mortality data, we fit a mathematical model of COVID-19 transmission to reported mortality, estimating that 1.25% of COVID-19 deaths (sensitivity range 1.00% - 3.00%) have been reported as of 2 September 2020. By 2 September, we estimate that 4,380 (95% CI: 3,250 - 5,550) COVID-19 deaths in Damascus may have been missed, with 39.0% (95% CI: 32.5% - 45.0%) of the population in Damascus estimated to have been infected. Accounting for under-ascertainment corroborates reports of exceeded hospital bed capacity and is validated by community-uploaded obituary notifications, which confirm extensive unreported mortality in Damascus.

Inhaled budesonide in the treatment of early COVID-19 (STOIC): a phase 2, open-label, randomised controlled trial

Background

Multiple early reports of patients admitted to hospital with COVID-19 showed that patients with chronic respiratory disease were significantly under-represented in these cohorts. We hypothesised that the widespread use of inhaled glucocorticoids among these patients was responsible for this finding, and tested if inhaled glucocorticoids would be an effective treatment for early COVID-19.

Methods

We performed an open-label, parallel-group, phase 2, randomised controlled trial (Steroids in COVID-19; STOIC) of inhaled budesonide, compared with usual care, in adults within 7 days of the onset of mild COVID-19 symptoms. The trial was done in the community in Oxfordshire, UK. Participants were randomly assigned to inhaled budsonide or usual care stratified for age (≤40 years or >40 years), sex (male or female), and number of comorbidities (≤1 and ≥2). Randomisation was done using random sequence generation in block randomisation in a 1:1 ratio. Budesonide dry powder was delivered using a turbohaler at a dose of 400 μg per actuation. Participants were asked to take two inhalations twice a day until symptom resolution. The primary endpoint was COVID-19-related urgent care visit, including emergency department assessment or hospitalisation, analysed for both the per-protocol and intention-to-treat (ITT) populations. The secondary outcomes were self-reported clinical recovery (symptom resolution), viral symptoms measured using the Common Cold Questionnare (CCQ) and the InFLUenza Patient Reported Outcome Questionnaire (FLUPro), body temperature, blood oxygen saturations, and SARS-CoV-2 viral load. The trial was stopped early after independent statistical review concluded that study outcome would not change with further participant enrolment. This trial is registered with ClinicalTrials.gov, NCT04416399.

Findings

From July 16 to Dec 9, 2020, 167 participants were recruited and assessed for eligibility. 21 did not meet eligibility criteria and were excluded. 146 participants were randomly assigned—73 to usual care and 73 to budesonide. For the per-protocol population (n=139), the primary outcome occurred in ten (14%) of 70 participants in the usual care group and one (1%) of 69 participants in the budesonide group (difference in proportions 0·131, 95% CI 0·043 to 0·218; p=0·004). For the ITT population, the primary outcome occurred in 11 (15%) participants in the usual care group and two (3%) participants in the budesonide group (difference in proportions 0·123, 95% CI 0·033 to 0·213; p=0·009). The number needed to treat with inhaled budesonide to reduce COVID-19 deterioration was eight. Clinical recovery was 1 day shorter in the budesonide group compared with the usual care group (median 7 days [95% CI 6 to 9] in the budesonide group vs 8 days [7 to 11] in the usual care group; log-rank test p=0·007). The mean proportion of days with a fever in the first 14 days was lower in the budesonide group (2%, SD 6) than the usual care group (8%, SD 18; Wilcoxon test p=0·051) and the proportion of participants with at least 1 day of fever was lower in the budesonide group when compared with the usual care group. As-needed antipyretic medication was required for fewer proportion of days in the budesonide group compared with the usual care group (27% [IQR 0–50] vs 50% [15–71]; p=0·025) Fewer participants randomly assigned to budesonide had persistent symptoms at days 14 and 28 compared with participants receiving usual care (difference in proportions 0·204, 95% CI 0·075 to 0·334; p=0·003). The mean total score change in the CCQ and FLUPro over 14 days was significantly better in the budesonide group compared with the usual care group (CCQ mean difference −0·12, 95% CI −0·21 to −0·02 [p=0·016]; FLUPro mean difference −0·10, 95% CI −0·21 to −0·00 [p=0·044]). Blood oxygen saturations and SARS-CoV-2 load, measured by cycle threshold, were not different between the groups. Budesonide was safe, with only five (7%) participants reporting self-limiting adverse events.

Interpretation

Early administration of inhaled budesonide reduced the likelihood of needing urgent medical care and reduced time to recovery after early COVID-19.

Funding

National Institute for Health Research Biomedical Research Centre and AstraZeneca.

The Impact of COVID-19 on Primary Care General Practice Consultations in a Teaching Hospital in Shanghai, China

Background: The COVID-19 (2019 novel coronavirus disease) pandemic is deeply concerning because of its massive mortality and morbidity, creating adverse perceptions among patients likely to impact on their overall medical care. Thus, we evaluated the impact of the COVID-19 pandemic on the pattern of primary care consultations within a Shanghai health district.

Methods: A retrospective observational cohort study was performed, with data analyzed concerning the pattern of patient visits to general practitioners within the Tongren Hospital network (the sole provider of general practice to the population of 700,000). Data from all general practice consultations for adults were collected for the first 6 months of 2020, which included a 60-day lockdown period (January 24–March 24, 2020) and compared to corresponding data from the first 6 months of 2019. We evaluated changes to the numbers and patterns of primary care consultations, including subgroup analysis based on age, sex, and primary diagnosis.

Results: A substantial reduction in patient visits, associated with increased median age, was observed during the first wave of the pandemic in the first 6 months of 2020, compared to the same interval during 2019. Additionally, reduced reappointments and waiting times, but increased costs per visit were observed. When analyzed by primary disease diagnosis, patient visits were reduced for all the major systems. The most striking visit reductions were in cardiovascular, respiratory, endocrine, and gastrointestinal diseases. However, psychological disorders were increased following lockdown, but there was also a dramatic fall in consultations for depression. Reduced monthly patient numbers correlated with both rate of reappointment and average waiting time during the first 6 months of both 2019 and 2020, but an inverse correlation was observed between cost per visit and monthly patient numbers. Specifically during the lockdown period, there was ~50% reduced patient visits.

Conclusions: The lockdown has had a serious impact on patients' physical and psychological health. Our analysis provides objective health-related data that may inform the current controversy concerning the balance between the detrimental effects of the use of lockdown vs. the use of a more targeted approach to eliminate viral transmission. These data may improve decision-making in medical practice, policy, and education.

A global panel database of pandemic policies (Oxford COVID-19 Government Response Tracker)

COVID-19 has prompted unprecedented government action around the world. We introduce the Oxford COVID-19 Government Response Tracker (OxCGRT), a dataset that addresses the need for continuously updated, readily usable and comparable information on policy measures. From 1 January 2020, the data capture government policies related to closure and containment, health and economic policy for more than 180 countries, plus several countries' subnational jurisdictions. Policy responses are recorded on ordinal or continuous scales for 19 policy areas, capturing variation in degree of response. We present two motivating applications of the data, highlighting patterns in the timing of policy adoption and subsequent policy easing and reimposition, and illustrating how the data can be combined with behavioural and epidemiological indicators. This database enables researchers and policymakers to explore the empirical effects of policy responses on the spread of COVID-19 cases and deaths, as well as on economic and social welfare.

Impact of novel coronavirus Disease-19 (COVID-19) pandemic in Italian pediatric emergency departments: a national survey

BACKGROUND

Coronavirus Disease-19 (COVID-19) has rapidly become a pandemic emergency, distressing health systems in each affected country. Preparation strategies for managing this pandemic have been keys to face the COVID-19 surge all over the world and all levels of care.

MATERIALS AND METHODS

During the epidemic, the Italian society of pediatric emergency-urgency (SIMEUP) promoted a national survey aiming to evaluate preparedness and response of pediatric emergency departments (PED) critical in ensuring optimal management of COVID-19 cases.

RESULTS

Our results suggest that Italian PED have promptly set a proactive approach to the present emergency. 98.9% of the hospitals have defined special pathways and assistive protocols concerning the management of pediatric COVID-19 cases. The highest percentage of application of the measures for preventive and protective for COVID-19 concerned the use of personal protective equipments.

CONCLUSIONS

Results show that the following measures for pediatric patients, admitted in PED, have been promptly implemented throughout the whole country: eg. use of protective devices, pre-triage of patients accessing the hospital. Despite COVID-19 being a new threat, we have shown that by developing an easy-to-follow decision algorithm and clear plans for the interventional platform teams, we can ensure optimal health care workers and patients' safety.