Achieving global mortality reduction targets and universal health coverage: The impact of COVID-19

Wenhui Mao and coauthors discuss possible implications of the COVID-19 pandemic for health aspirations in low- and middle-income countries.

Summary points

• The Coronavirus Disease 2019 (COVID-19) pandemic threatens progress toward a “grand convergence” in global health—universal reduction in deaths from infections and maternal and child health conditions to low levels—and toward achieving universal health coverage (UHC).
• Our analysis suggests that COVID-19 will exacerbate the difficulty of achieving grand convergence targets for tuberculosis (TB), maternal mortality, and, probably, for under-5 mortality. HIV targets are likely to be met.
• By 2035, our analysis suggests that the public sectors of low-income countries (LICs) would only be able to finance about a third of the costs of a package of 120 essential non-COVID-19 health interventions through domestic sources, unless the country increases significantly the priority assigned to the health sector; lower middle-income countries (LMICs) would likewise only be able to finance a little less than half.
• The likelihood of getting back on track for reaching grand convergence and UHC will depend on (i) how quickly COVID-19 vaccines can be deployed in LICs and LMICs; (ii) how much additional public sector health financing can be mobilized from external and domestic sources; and (iii) whether countries can rapidly strengthen and focus their health delivery systems.

     

Evaluation of progress toward universal health coverage in Myanmar: A national and subnational analysis

BackgroundUniversal health coverage (UHC) encompasses 2 main components: access to essential healthcare services and protection from financial hardship when using healthcare. This study examines Myanmar’s efforts to achieve UHC on a national and subnational level. It is a primer of studying the concept of UHC on a subnational level, and it also establishes a baseline for assessing future progress toward reaching UHC in Myanmar.Methods and findingsThe study uses the Demographic and Health Survey (2015) and the Myanmar Living Conditions Survey (MLCS; 2017) and adapts a previously developed UHC index to provide insights into the main barriers preventing the country’s progress toward UHC. We find a negative correlation between the UHC index and the state/region poverty levels. The equity of access analysis reveals significant pro-rich inequity in access to all essential healthcare services. Socioeconomic status and limited availability of healthcare infrastructure are the main driving forces behind the unequal access to interventions that are crucial to achieving UHC by 2030. Finally, financial risk protection analysis shows that the poor are less likely to use healthcare services, and, once they do, they are at a greater risk of suffering financial catastrophe. Limitations of this study revolve around its correlational, rather than causal, nature.ConclusionsWe suggest a 2-pronged approach to help Myanmar achieve UHC: Government and state authorities should reduce the financial burden of seeking healthcare, and, coupled with this, significant investment in and expansion of health infrastructure and the health workforce should be made, particularly in the poorer and more remote states.

Zlatko Nikoloski and colleagues provide analytical insight into Myanmar’s efforts to achieve universal health coverage on a national and sub-national level.     

Transcatheter aortic valve implantation amid the COVID-19 pandemic: a nationwide analysis of the first COVID-19 wave in the Netherlands

IntroductionThe coronavirus disease 2019 (COVID-19) pandemic has put tremendous pressure on healthcare systems. Most transcatheter aortic valve implantation (TAVI) centres have adopted different triage systems and procedural strategies to serve highest-risk patients first and to minimise the burden on hospital logistics and personnel. We therefore assessed the impact of the COVID-19 pandemic on patient selection, type of anaesthesia and outcomes after TAVI.MethodsWe used data from the Netherlands Heart Registration to examine all patients who underwent TAVI between March 2020 and July 2020 (COVID cohort), and between March 2019 and July 2019 (pre-COVID cohort). We compared patient characteristics, procedural characteristics and clinical outcomes.ResultsWe examined 2131 patients who underwent TAVI (1020 patients in COVID cohort, 1111 patients in pre-COVID cohort). EuroSCORE II was comparable between cohorts (COVID 4.5 ± 4.0 vs pre-COVID 4.6 ± 4.2, p = 0.356). The number of TAVI procedures under general anaesthesia was lower in the COVID cohort (35.2% vs 46.5%, p < 0.001). Incidences of stroke (COVID 2.7% vs pre-COVID 1.7%, p = 0.134), major vascular complications (2.3% vs 3.4%, p = 0.170) and permanent pacemaker implantation (10.0% vs 9.4%, p = 0.634) did not differ between cohorts. Thirty-day and 150-day mortality were comparable (2.8% vs 2.2%, p = 0.359 and 5.2% vs 5.2%, p = 0.993, respectively).ConclusionsDuring the COVID-19 pandemic, patient characteristics and outcomes after TAVI were not different than before the pandemic. This highlights the fact that TAVI procedures can be safely performed during the COVID-19 pandemic, without an increased risk of complications or mortality.Supplementary InformationThe online version of this article (10.1007/s12471-022-01704-9) contains supplementary material, which is available to authorized users.     

Understanding COVID-19 vaccine demand and hesitancy: A nationwide online survey in China

BackgroundThis study attempts to understand coronavirus disease 2019 (COVID-19) vaccine demand and hesitancy by assessing the public’s vaccination intention and willingness-to-pay (WTP). Confidence in COVID-19 vaccines produced in China and preference for domestically-made or foreign-made vaccines was also investigated.MethodsA nationwide cross-sectional, self-administered online survey was conducted on 1–19 May 2020. The health belief model (HBM) was used as a theoretical framework for understanding COVID-19 vaccination intent and WTP.ResultsA total of 3,541 complete responses were received. The majority reported a probably yes intent (54.6%), followed by a definite yes intent (28.7%). The perception that vaccination decreases the chances of getting COVID-19 under the perceived benefit construct (OR = 3.14, 95% CI 2.05–4.83) and not being concerned about the efficacy of new COVID-19 vaccines under the perceived barriers construct (OR = 1.65, 95% CI 1.31–2.09) were found to have the highest significant odds of a definite intention to take the COVID-19 vaccine. The median (interquartile range [IQR]) of WTP for COVID-19 vaccine was CNY¥200/US$28 (IQR CNY¥100–500/USD$14–72). The highest marginal WTP for the vaccine was influenced by socio-economic factors. The majority were confident (48.7%) and completely confident (46.1%) in domestically-made COVID-19 vaccine. 64.2% reported a preference for a domestically-made over foreign-made COVID-19 vaccine.ConclusionsThe findings demonstrate the utility of HBM constructs in understanding COVID-19 vaccination intent and WTP. It is important to improve health promotion and reduce the barriers to COVID-19 vaccination.     

Uptake of infant and preschool immunisations in Scotland and England during the COVID-19 pandemic: An observational study of routinely collected data

BackgroundIn 2020, the SARS-CoV-2 (COVID-19) pandemic and lockdown control measures threatened to disrupt routine childhood immunisation programmes with early reports suggesting uptake would fall. In response, public health bodies in Scotland and England collected national data for childhood immunisations on a weekly or monthly basis to allow for rapid analysis of trends. The aim of this study was to use these data to assess the impact of different phases of the pandemic on infant and preschool immunisation uptake rates.Methods and findingsWe conducted an observational study using routinely collected data for the year prior to the pandemic (2019) and immediately before (22 January to March 2020), during (23 March to 26 July), and after (27 July to 4 October) the first UK “lockdown”. Data were obtained for Scotland from the Public Health Scotland “COVID19 wider impacts on the health care system” dashboard and for England from ImmForm.Five vaccinations delivered at different ages were evaluated; 3 doses of “6-in-1” diphtheria, tetanus, pertussis, polio, Haemophilus influenzae type b, and hepatitis B vaccine (DTaP/IPV/Hib/HepB) and 2 doses of measles, mumps, and rubella (MMR) vaccine. This represented 439,754 invitations to be vaccinated in Scotland and 4.1 million for England. Uptake during the 2020 periods was compared to the previous year (2019) using binary logistic regression analysis. For Scotland, uptake within 4 weeks of a child becoming eligible by age was analysed along with geographical region and indices of deprivation. For Scotland and England, we assessed whether immunisations were up-to-date at approximately 6 months (all doses 6-in-1) and 16 to 18 months (first MMR) of age.We found that uptake within 4 weeks of eligibility in Scotland for all the 5 vaccines was higher during lockdown than in 2019. Differences ranged from 1.3% for first dose 6-in-1 vaccine (95.3 versus 94%, odds ratio [OR] compared to 2019 1.28, 95% confidence intervals [CIs] 1.18 to 1.39) to 14.3% for second MMR dose (66.1 versus 51.8%, OR compared to 2019 1.8, 95% CI 1.74 to 1.87). Significant increases in uptake were seen across all deprivation levels.In England, fewer children due to receive their immunisations during the lockdown period were up to date at 6 months (6-in-1) or 18 months (first dose MMR). The fall in percentage uptake ranged from 0.5% for first 6-in-1 (95.8 versus 96.3%, OR compared to 2019 0.89, 95% CI 0.86– to 0.91) to 2.1% for third 6-in-1 (86.6 versus 88.7%, OR compared to 2019 0.82, 95% CI 0.81 to 0.83).The use of routinely collected data used in this study was a limiting factor as detailed information on potential confounding factors were not available and we were unable to eliminate the possibility of seasonal trends in immunisation uptake.ConclusionsIn this study, we observed that the national lockdown in Scotland was associated with an increase in timely childhood immunisation uptake; however, in England, uptake fell slightly. Reasons for the improved uptake in Scotland may include active measures taken to promote immunisation at local and national levels during this period and should be explored further. Promoting immunisation uptake and addressing potential vaccine hesitancy is particularly important given the ongoing pandemic and COVID-19 vaccination campaigns.

Fiona McQuaid and colleagues assess the uptake of infant and pre-school immunisations in Scotland and England during the COVID-19 pandemic.     

Factors associated with the unwillingness of Jordanians,Palestinians and Syrians to be vaccinated against COVID-19

BackgroundThe COVID-19 pandemic is expected to continue to inflect immense burdens of morbidity and mortality, not to mention the sever disruption of societies and economies worldwide. One of the major challenges to managing COVID-19 pandemic is the negative attitudes towards vaccines and the uncertainty or unwillingness to receive vaccinations. We evaluated the predictors and factors behind the negative attitudes towards COVID-19 vaccines in 3 countries in the Middle East.MethodsA cross-sectional, self-administered survey was conducted between the 1^st and the 25^th of December, 2020. Representative sample of 8619 adults residing in Jordan, West Bank, and Syria, completed the survey via the Web or via telephone interview. The survey intended to assess intent to be vaccinated against COVID-19 and to identify predictors of and reasons among participants unwilling/hesitant to get vaccinated.ResultsThe total of the 8619 participants included in this study were the ones who answered the question on the intent to be vaccinated. Overall, 32.2% of participants (n = 2772) intended to be vaccinated, 41.6% (n = 3589) didn’t intend to get vaccinated, and 26.2% (n = 2258) were not sure. The main factors associated with the willingness to take the vaccine (yes responses) included females, 18–35 years old, Syrians and Jordanians, a large family size, and having received a flu vaccine last year. Reasons for vaccine hesitancy included the lack of rigorous evaluation of the vaccine by the FDA and the possible long-term health risks associated with the vaccines (the wait-and-see approach).ConclusionThis survey, conducted in December when the number of cases and deaths per day due to COVID-19 were at or near peak levels of the initial surge in the three regions under investigation. The survey revealed that most of survey’s participants (67.8%) were unwilling/hesitant to get vaccinated against COVID-19 with the lack of trust in the approval process of the vaccine being the main concern; the two main characteristics of those participants were more than 35 years old and participants holding a Bachelor’s degree or higher. Targeted and multi-pronged efforts will be needed to increase acceptance of COVID-19 vaccine in Jordan, West Bank and Syria.     

Did Equity of Reproductive and Maternal Health Service Coverage Increase during the MDG Era? An Analysis of Trends and Determinants across 74 Low- and Middle-Income Countries

Introduction

Despite widespread gains toward the 5^th Millennium Development Goal (MDG), pro-rich inequalities in reproductive health (RH) and maternal health (MH) are pervasive throughout the world. As countries enter the post-MDG era and strive toward UHC, it will be important to monitor the extent to which countries are achieving equity of RH and MH service coverage. This study explores how equity of service coverage differs across countries, and explores what policy factors are associated with a country’s progress, or lack thereof, toward more equitable RH and MH service coverage.

Methods

We used RH and MH service coverage data from Demographic and Health Surveys (DHS) for 74 countries to examine trends in equity between countries and over time from 1990 to 2014. We examined trends in both relative and absolute equity, and measured relative equity using a concentration index of coverage data grouped by wealth quintile. Through multivariate analysis we examined the relative importance of policy factors, such as political commitment to health, governance, and the level of prepayment, in determining countries’ progress toward greater equity in RH and MH service coverage.

Results

Relative equity for the coverage of RH and MH services has continually increased across all countries over the past quarter century; however, inequities in coverage persist, in some countries more than others. Multivariate analysis shows that higher education and greater political commitment (measured as the share of government spending allocated to health) were significantly associated with higher equity of service coverage. Neither country income, i.e., GDP per capita, nor better governance were significantly associated with equity.

Conclusion

Equity in RH and MH service coverage has improved but varies considerably across countries and over time. Even among the subset of countries that are close to achieving the MDGs, progress made on equity varies considerably across countries. Enduring disparities in access and outcomes underpin mounting support for targeted reforms within the broader context of universal health coverage (UHC).     

Prevalence and characteristics of malaria among COVID-19 individuals: A systematic review,meta-analysis,and analysis of case reports

BackgroundThe world population is currently at a very high risk of Coronavirus disease-2019 (COVID-19), caused by the severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2). People who live in malaria-endemic areas and get infected by SARS-CoV-2 may be at increased risk of severe COVID-19 or unfavorable disease outcomes if they ignore their malaria status. Therefore, the present study aimed to synthesize, qualitatively and quantitatively, information on the prevalence and characteristics of malaria infection among COVID-19-infected individuals. The findings will help us better understand this particular comorbidity during the COVID-19 pandemic.MethodsThe systematic review protocol was registered at the International Prospective Register of Systematic Reviews (PROSPERO) with the identification number: CRD42021247521. We searched for studies reporting on the coinfection of COVID-19 and malaria in PubMed, Web of Science, and Scopus from inception to March 27, 2021 using Medical Subject Headings (MeSH) terms. The study’s methodological quality in the search output was assessed using the Joanna Briggs Institute (JBI) Critical Appraisal Tools for cross-sectional study. The pooled prevalence of Plasmodium spp. infection among patients infected with COVID-19 was estimated using the random effect model and then graphically presented as forest plots. The heterogeneity among the included studies was assessed using Cochrane Q and I² statistics. The characteristics of patients co-infected with COVID-19 and malaria were derived from case reports and series and were formally analyzed using simple statistics.ResultsTwelve of 1,207 studies reporting the coinfection of COVID-19 and malaria were selected for further analysis. Results of quantitative synthesis show that the pooled prevalence of Plasmodium spp. infection (364 cases) among COVID–19 individuals (1,126 cases) is 11%, with a high degree of heterogeneity (95% CI: 4%–18%, I²: 97.07%, 5 studies). Most of the coinfections were reported in Nigeria (336 cases), India (27 cases), and the Democratic Republic of Congo (1 case). Results of qualitative synthesis indicate that patients with coinfection are typically symptomatic at presentation with mild or moderate parasitemia. An analysis of case reports and series indicates that co-infected individuals often display thrombocytopenia, lymphopenia, and elevated bilirubin levels. Among four patients (30%) who required treatment with intravenous artesunate, one experienced worsened clinical status after administering the drug. One serious outcome of coinfection involved a pregnant woman who experienced fetal abortion due to the initial misdiagnosis of malaria.ConclusionsAll individuals in malaria-endemic regions who are febrile or display symptoms of COVID-19 should be evaluated for malaria to avoid serious complications. Further prospective studies are required to investigate the burden and outcomes of COVID-19 in malaria-endemic regions. Prompt management is required to prevent serious outcomes in individuals co-infected with COVID-19 and malaria.     

COVID-19, media coverage of bats and related Web searches: a turning point for bat conservation?

1. SARS-CoV-2, the virus that caused the COVID-19 pandemic, is genomically similar to a SARS-like beta-coronavirus found in Asian rhinolophid bats. This evolutionary relationship impressed the global media, which then emphasised bats as key actors in the spillover that resulted in the pandemic. In this study, we highlight changes in the traditional and new media coverage of bats and in Internet search volumes that occurred since the beginning of the COVID-19 pandemic in 2020.
2. We analysed Google and Wikipedia searches for bats and coronaviruses in 21 countries and eight languages, as well as television broadcasts in the USA, some of which have global coverage, between January 2016 and December 2020. In January 2020, the amount of television news about bats boomed, and news associated with the term ‘bat’ shifted to COVID-19-related topics. A nearly identical pattern was observed in Google searches during 2020 at the global scale. The daily time series of television coverage and Internet search volumes on bats and coronavirus in the USA covaried in the first quarter of 2020, in line with the existence of a media bubble. Time-series analysis revealed that both the Google Trends index and visits to Wikipedia pages about bats boomed in early 2020, despite the fact that this time of year is usually characterised by low search volumes.
3. Media coverage emphasised, correctly or not, the role of bats in the COVID-19 pandemic and amplified public interest in bats worldwide. The public image of these mammals, in many cases threatened and important ecosystem service providers, was seriously compromised. We therefore recommend that policymakers and journalists prioritise scientifically accurate communication campaigns about bats, which would help counteract the surge in bat persecution, and leverage interest towards positive human–bat interactions.

     

Learning from the COVID-19 pandemic to strengthen routine immunization systems

Kate Causey and Jonathan F Mosser discuss what can be learnt from the observed impacts of the COVID-19 pandemic on routine immunisation systems.

In the final months of 2021, deaths due to the Coronavirus Disease 2019 (COVID-19) surpassed 5 million globally [1]. Available data suggest that even this staggering figure may be a substantial underestimate of the true toll of the pandemic [2]. Beyond mortality, it may take years to fully quantify the direct and indirect impacts of the COVID-19 pandemic such as disruptions in preventive care services. In an accompanying research study in PLOS Medicine, McQuaid and colleagues report on the uptake of routine childhood immunizations in 2020 in Scotland and England during major pandemic-related lockdowns [3]. This adds to a growing body of literature quantifying the impact of the COVID-19 pandemic on routine health services and childhood immunization [4,5], which provides important opportunities to learn from early pandemic experiences as immunization systems face ongoing challenges.McQuaid and colleagues compared weekly or monthly data on vaccine uptake in Scotland and England from January to December of 2020 to the rates observed in 2019 to estimate the changes in uptake before, during, and after COVID-19 pandemic lockdowns in each country. The authors included 2 different preschool immunizations, each with multiple doses. They found significantly increased uptake within 4 weeks of eligibility during the lockdown and postlockdown periods in Scotland for all 5 vaccine dose combinations examined: During lockdown, percentage point increases ranged from 1.3% to 14.3%. In England, there were significant declines in uptake during the prelockdown, lockdown, and postlockdown periods for all 4 vaccine dose combinations examined. However, declines during lockdown were small, with percentage point decreases ranging from −0.5% to −2.1%. Due to the nature of the data available, the authors were unable to account for possible seasonal variation in vaccine delivery, control for important individual-level confounders or effect modifiers such as child sex and parental educational attainment, or directly compare outcomes across the 2 countries.These findings stand in contrast to the documented experience of many other countries, where available data suggest historic disruptions in routine childhood vaccination coverage, particularly during the first months of pandemic-related lockdowns [5,6]. Supply side limitations such as delayed shipments of vaccines and supplies [7], inadequate personal protective equipment [8], staff shortages [9], and delayed or canceled campaigns and introductions [9] threatened vaccine delivery. Furthermore, fear of exposure to COVID-19 at vaccination centers [10], misinformation about vaccine safety [8], and lockdown-related limitations on travel to facilities [9,10] reduced demand. In polls of country experts conducted by WHO, UNICEF, and Gavi, the Vaccine Alliance throughout the second quarter of 2020, 126 of 170 countries reported at least some disruption to routine immunization programs [10,11]. Global estimates suggest that millions more children missed doses of important vaccines than would have in the absence of the COVID-19 pandemic [5,6]. While many vaccine programs showed remarkable resilience in the second half of 2020, with rates of vaccination returning to or even exceeding prepandemic levels [5,6], disruptions to immunization services persisted into 2021 in many countries [12].As the authors discuss, it is critical to pinpoint the specific program policies and strategies that contributed to increased uptake in Scotland and only small declines in England and, more broadly, to the rapid recovery of vaccination rates observed in many other countries. McQuaid and colleagues cite work suggesting that increased flexibility in parental working patterns during lockdowns, providing mobile services or public transport to vaccine centers, and sending phone- and mail-based reminders are strategies that may have improved uptake of timely vaccination in Scotland during this period [13]. Similarly, immunization programs around the world have employed a broad range of strategies to maintain or increase vaccination during the pandemic. Leaders in Senegal, Paraguay, and Sri Lanka designed and conducted media campaigns to emphasize the importance of childhood immunization even during lockdown [8,14,15]. Although many programs delayed mass campaigns in the spring of 2020, multiple countries were able to implement campaigns by the summer of 2020 [8,16–20]. In each of these examples, leaders responded quickly to meet the unique challenges presented by the COVID-19 pandemic in their communities.Increased data collection and tracking systems are essential for efficient and effective responses as delivery programs face challenges. When concern arose for pandemic-related disruptions to immunization services, public health decision-makers in Scotland and England responded by increasing the frequency and level of detail in reports of vaccine uptake and by making these data available for planning and research. The potential for robust data systems to inform real-time decision-making is not limited to high-income countries. For instance, the Nigerian National Health Management Information System released an extensive online dashboard shortly after the onset of the pandemic, documenting the impact of COVID-19 on dozens of indicators of health service uptake, including 16 related to immunization [21]. Vaccination data systems that track individual children and doses, such as the reminder system in Scotland, allow for highly targeted responses. Similarly, in Senegal, Ghana, and in Karachi, Pakistan, healthcare workers have relied on existing or newly implemented tracking systems to identify children who have missed doses and provide text message and/or phone call reminders [8,22,23]. Investing in robust routine data systems allows for rapid scale-up of data collection, targeted services to those who miss doses, and a more informed response when vaccine delivery challenges arise.Policy and program decision-makers must learn from the observed impacts of the COVID-19 pandemic on health systems and vaccine delivery. The study by McQuaid and colleagues provides further evidence that vaccination programs in England and Scotland leveraged existing strengths and identified novel strategies to mitigate disruptions and deliver vaccines in the early stages of the pandemic. However, the challenges posed by the pandemic to routine immunization services continue. To mitigate the risk of outbreaks of measles and other vaccine-preventable diseases, strategies are needed to maintain and increase coverage, while ensuring that children who missed vaccines during the pandemic are quickly caught up. The accompanying research study provides important insights into 2 countries where services were preserved—and even increased—in the early pandemic. To meet present and future challenges, we must learn from early pandemic successes such as those in Scotland and England, tailor solutions to improve vaccine uptake, and strengthen data systems to support improved decision-making.     

Obstetrical outcomes and maternal morbidities associated with COVID-19 in pregnant women in France: A national retrospective cohort study

BackgroundTo the best of our knowledge, no study has exhaustively evaluated the association between maternal morbidities and Coronavirus Disease 2019 (COVID-19) during the first wave of the pandemic in pregnant women. We investigated, in natural conceptions and assisted reproductive technique (ART) pregnancies, whether maternal morbidities were more frequent in pregnant women with COVID-19 diagnosis compared to pregnant women without COVID-19 diagnosis during the first wave of the COVID-19 pandemic.Methods and findingsWe conducted a retrospective analysis of prospectively collected data in a national cohort of all hospitalizations for births ≥22 weeks of gestation in France from January to June 2020 using the French national hospitalization database (PMSI). Pregnant women with COVID-19 were identified if they had been recorded in the database using the ICD-10 (International Classification of Disease) code for presence of a hospitalization for COVID-19. A total of 244,645 births were included, of which 874 (0.36%) in the COVID-19 group. Maternal morbidities and adverse obstetrical outcomes among those with or without COVID-19 were analyzed with a multivariable logistic regression model adjusted on patient characteristics. Among pregnant women, older age (31.1 (±5.9) years old versus 30.5 (±5.4) years old, respectively, p < 0.001), obesity (0.7% versus 0.3%, respectively, p < 0.001), multiple pregnancy (0.7% versus 0.4%, respectively, p < 0.001), and history of hypertension (0.9% versus 0.3%, respectively, p < 0.001) were more frequent with COVID-19 diagnosis. Active smoking (0.2% versus 0.4%, respectively, p < 0.001) and primiparity (0.3% versus 0.4%, respectively, p < 0.03) were less frequent with COVID-19 diagnosis. Frequency of ART conception was not different between those with and without COVID-19 diagnosis (p = 0.28).When compared to the non-COVID-19 group, women in the COVID-19 group had a higher frequency of admission to ICU (5.9% versus 0.1%, p < 0.001), mortality (0.2% versus 0.005%, p < 0.001), preeclampsia/eclampsia (4.8% versus 2.2%, p < 0.001), gestational hypertension (2.3% versus 1.3%, p < 0.03), postpartum hemorrhage (10.0% versus 5.7%, p < 0.001), preterm birth at <37 weeks of gestation (16.7% versus 7.1%, p < 0.001), <32 weeks of gestation (2.2% versus 0.8%, p < 0.001), <28 weeks of gestation (2.4% versus 0.8%, p < 0.001), induced preterm birth (5.4% versus 1.4%, p < 0.001), spontaneous preterm birth (11.3% versus 5.7%, p < 0.001), fetal distress (33.0% versus 26.0%, p < 0.001), and cesarean section (33.0% versus 20.2%, p < 0.001). Rates of pregnancy terminations ≥22 weeks of gestation, stillbirths, gestational diabetes, placenta praevia, and placenta abruption were not significantly different between the COVID-19 and non-COVID-19 groups. The number of venous thromboembolic events was too low to perform statistical analysis. A limitation of this study relies in the possibility that asymptomatic infected women were not systematically detected.ConclusionsWe observed an increased frequency of pregnant women with maternal morbidities and diagnosis of COVID-19 compared to pregnant women without COVID-19. It appears essential to be aware of this, notably in populations at known risk of developing a more severe form of infection or obstetrical morbidities and in order for obstetrical units to better inform pregnant women and provide the best care. Although causality cannot be determined from these associations, these results may be in line with recent recommendations in favor of vaccination for pregnant women.

In a national retrospective study, Sylvie Epelboin and colleagues investigate obstetrical outcomes and maternal morbidities among pregnant women with a COVID-19 diagnosis in France.     

COVID-19 pandemic and patients with cancer: The protocol of a Clinical Oncology center in Tehran,Iran

AimTo provide recommendations for the management of patients with cancer in the COVID-19 era.BackgroundThe current global pandemic of COVID-19 has severely impacted global healthcare systems. Several groups of people are considered high-risk for SARS-CoV-2 infection, including patients with cancer. Therefore, protocols for the better management of these patients during this viral pandemic are necessary. So far, several protocols have been presented regarding the management of patients with cancer during the COVID-19 pandemic. However, none of them points to a developing country with limited logistics and facilities.MethodsIn this review, we have provided a summary of recommendations on the management of patients with cancer during the COVID-19 pandemic based on our experience in Shohada-e Tajrish Hospital, Iran.ResultsWe recommend that patients with cancer should be managed in an individualized manner during the COVID-19 pandemic.ConclusionsOur recommendation provides a guide for oncology centers of developing countries for better management of cancer.     

COVID-19 and indirect health implications in Africa: Impact,mitigation measures,and lessons learned for improved disease control

Seth Inzaule and co-authors discuss implications of the COVID-19 pandemic for health in African countries.

Summary points

• Coronavirus Disease 2019 (COVID-19) and the mitigation measures taken to limit its spread have significantly disrupted other essential health services in Africa. This disruption has threatened the control of major high-burden diseases such as HIV, tuberculosis (TB), and malaria as well as the prevention of maternal and child mortality.
• While the 2020 WHO global reports for HIV, TB, and malaria show progress in control of these diseases in African countries, there are still significant gaps in meeting the global targets. Similarly, modeling studies predict that most African countries are unlikely to meet the Sustainable Development Goals (SDGs) 2030 targets for reductions in maternal and child mortality under the current rate of progress.
• Prediction models and emerging empirical data indicate that the implemented mitigation measures against COVID-19 such as travel restrictions and lockdowns as well as the repurposing of health resources and suspension of prevention programs such as immunizations will lead to an increase in new infections and deaths, significantly reversing the gains achieved in the control of these health challenges.
• A more comprehensive COVID-19 response that minimizes indirect deaths is therefore warranted in Africa. These include implementing WHO recommendations that limit contact with the clinic where possible, such as multimonths drug dispensing, self-testing, virtual platforms for case management, community- and home-based prevention, and care services such as home distribution of test kits, vaccines, treatment, and mosquito nets.
• This is in addition to ensuring effective implementation of COVID-19 infection prevention and control measures in healthcare facilities including providing healthcare workers with personal protective equipment and prioritizing them for COVID-19 immunization.
• There is also a need to incorporate aggressive recovery plans to reverse the lost gains in disease control efforts and put African countries back on course toward achieving the global targets. This includes leveraging on the wider COVID-19 response enablements such as the increased political will and global solidarity funding efforts to support a more comprehensive response that accounts for the indirect public health effects of the pandemic.

     

Colonoscopy screening and surveillance disparities during the COVID-19 pandemic

BackgroundThe COVID-19 pandemic has increased barriers to accessing preventive healthcare. This study identifies populations disproportionately underrepresented in screening and surveillance colonoscopies during the COVID-19 pandemic.MethodsIn this single-center cohort study, colonoscopy procedures were reviewed during 6-month intervals before the pandemic (July 1, 2019 - December 31, 2019) and during the pandemic (July 1, 2020 - December 31, 2020 and January 1, 2021 - June 30, 2021). 7095 patients were categorized based on procedure indication, demographics, Charlson Comorbidity Index and Social Vulnerability Index (SVI). Statistics performed using VassarStats.Results2387 (2019) colonoscopies pre-pandemic and 2585 (2020) and 2123 (2021) during the pandemic were identified. There was a decrease in colonoscopies performed during months when COVID-19 cases peaked. The total number of average CRC risk patients presenting for first colonoscopy declined during the pandemic: 232 (10 %) pre-pandemic to 190 (7 %) in 2020, 145 (7 %) in 2021 (p < 0.001). Fewer of these patients presented from highly vulnerable communities, SVI > 0.8, during the pandemic, 39 in 2019 vs 16 in 2020 and 22 in 2021. Of all screening and surveillance patients, fewer presented from communities with SVI > 0.8 during the pandemic, 106 in 2019 versus 67 in 2020 and 77 in 2021.ConclusionIt is important to address the decline in CRC preventive care during this pandemic among average CRC risk first-time screeners and vulnerable community patients. An emphasis on addressing social determinants of health and establishing patients in gastroenterology clinics is imperative to promote future health in these populations.     

The impact of COVID-19 on clinical research for Neglected Tropical Diseases (NTDs): A case study of bubonic plague

BackgroundAmong the many collaterals of the COVID-19 pandemic is the disruption of health services and vital clinical research. COVID-19 has magnified the challenges faced in research and threatens to slow research for urgently needed therapeutics for Neglected Tropical Diseases (NTDs) and diseases affecting the most vulnerable populations. Here we explore the impact of the pandemic on a clinical trial for plague therapeutics and strategies that have been considered to ensure research efforts continue.MethodsTo understand the impact of the COVID-19 pandemic on the trial accrual rate, we documented changes in patterns of all-cause consultations that took place before and during the pandemic at health centres in two districts of the Amoron’I Mania region of Madagascar where the trial is underway. We also considered trends in plague reporting and other external factors that may have contributed to slow recruitment.ResultsDuring the pandemic, we found a 27% decrease in consultations at the referral hospital, compared to an 11% increase at peripheral health centres, as well as an overall drop during the months of lockdown. We also found a nation-wide trend towards reduced number of reported plague cases.DiscussionCOVID-19 outbreaks are unlikely to dissipate in the near future. Declining NTD case numbers recorded during the pandemic period should not be viewed in isolation or taken as a marker of things to come. It is vitally important that researchers are prepared for a rebound in cases and, most importantly, that research continues to avoid NTDs becoming even more neglected.     

Global human security in the post–COVID-19 era: The rising role of East Asia

Kenji Shibuya and coauthors discuss the potential contribution of East Asian countries to global health in the light of COVID-19.

Summary points

• East Asia, comprising the 10 ASEAN countries, China, Japan, and the countries of the Korean peninsula, has achieved comparatively good outcomes during the ongoing Coronavirus Disease 2019 (COVID-19) pandemic.
• This can be explained by sociological imprinting of and learning from past outbreaks, as well as competent governance.
• Concomitantly, East Asian nations have also been expanding capacity in global health development and diplomatic outreach, although there is as yet no coherent regional bloc vision, shared strategy, or a common set of operating principles, thus limiting synergistic impact.
• We believe that concrete next steps to bolster cooperation and extend influence could include the establishment of an East Asian Center for Disease Control, joint work in health and human security by the Asian Development Bank (ADB) and Asian Infrastructure and Investment Bank, and a region-wide research funding programme.
• Much, however, depends on evolving geopolitics writ large, notably the instability and reorientation of global alliances, which have the potential to adversely affect relations between neighbouring East Asian member states.
• Health diplomacy for global human security has the potential to become a stabilising influence and can be a topic around which all actors can more comfortably rally.

While the constituent countries of East Asia share common elements of history and culture, there is great diversity and rapid transition in social systems, economic development, demography, and epidemiological profiles (S1 Table). These factors fundamentally lead to the full range of major global health challenges, including those concerning epidemics and pandemics of novel and reemerging pathogens.Here, in the light of Coronavirus Disease 2019 (COVID-19), we discuss East Asia’s experience in this and past major outbreaks, its capacity and willingness to share best practice and support global health development, and the regional bloc’s potential in reshaping the global architecture for human security.Geographically and ethnoculturally, East Asia has conventionally referred to the region comprising China, Japan, Republic of Korea (South Korea), Democratic People’s Republic of Korea (North Korea), and Mongolia. More recently, the term has been broadened to encompass Southeast Asia (viz the 10 member states of ASEAN, the Association of South East Asian Nations), largely due to expanded regional economic cooperation and latterly for geopolitical reasons.     

Overall and cause-specific hospitalisation and death after COVID-19 hospitalisation in England: A cohort study using linked primary care,secondary care,and death registration data in the OpenSAFELY platform

BackgroundThere is concern about medium to long-term adverse outcomes following acute Coronavirus Disease 2019 (COVID-19), but little relevant evidence exists. We aimed to investigate whether risks of hospital admission and death, overall and by specific cause, are raised following discharge from a COVID-19 hospitalisation.Methods and findingsWith the approval of NHS-England, we conducted a cohort study, using linked primary care and hospital data in OpenSAFELY to compare risks of hospital admission and death, overall and by specific cause, between people discharged from COVID-19 hospitalisation (February to December 2020) and surviving at least 1 week, and (i) demographically matched controls from the 2019 general population; and (ii) people discharged from influenza hospitalisation in 2017 to 2019. We used Cox regression adjusted for age, sex, ethnicity, obesity, smoking status, deprivation, and comorbidities considered potential risk factors for severe COVID-19 outcomes.We included 24,673 postdischarge COVID-19 patients, 123,362 general population controls, and 16,058 influenza controls, followed for ≤315 days. COVID-19 patients had median age of 66 years, 13,733 (56%) were male, and 19,061 (77%) were of white ethnicity. Overall risk of hospitalisation or death (30,968 events) was higher in the COVID-19 group than general population controls (fully adjusted hazard ratio [aHR] 2.22, 2.14 to 2.30, p < 0.001) but slightly lower than the influenza group (aHR 0.95, 0.91 to 0.98, p = 0.004). All-cause mortality (7,439 events) was highest in the COVID-19 group (aHR 4.82, 4.48 to 5.19 versus general population controls [p < 0.001] and 1.74, 1.61 to 1.88 versus influenza controls [p < 0.001]). Risks for cause-specific outcomes were higher in COVID-19 survivors than in general population controls and largely similar or lower in COVID-19 compared with influenza patients. However, COVID-19 patients were more likely than influenza patients to be readmitted or die due to their initial infection or other lower respiratory tract infection (aHR 1.37, 1.22 to 1.54, p < 0.001) and to experience mental health or cognitive-related admission or death (aHR 1.37, 1.02 to 1.84, p = 0.039); in particular, COVID-19 survivors with preexisting dementia had higher risk of dementia hospitalisation or death (age- and sex-adjusted HR 2.47, 1.37 to 4.44, p = 0.002). Limitations of our study were that reasons for hospitalisation or death may have been misclassified in some cases due to inconsistent use of codes, and we did not have data to distinguish COVID-19 variants.ConclusionsIn this study, we observed that people discharged from a COVID-19 hospital admission had markedly higher risks for rehospitalisation and death than the general population, suggesting a substantial extra burden on healthcare. Most risks were similar to those observed after influenza hospitalisations, but COVID-19 patients had higher risks of all-cause mortality, readmission or death due to the initial infection, and dementia death, highlighting the importance of postdischarge monitoring.

Krishnan Bhaskaran and co-workers study health outcomes after admission with COVID-19 and subsequent discharge.     

Deep learning representations to support COVID-19 diagnosis on CT slices

Introduction: The coronavirus disease 2019 (COVID-19) has become a significant public health problem worldwide. In this context, CT-scan automatic analysis has emerged as a COVID-19 complementary diagnosis tool allowing for radiological finding characterization, patient categorization, and disease follow-up. However, this analysis depends on the radiologist’s expertise, which may result in subjective evaluations.Objective: To explore deep learning representations, trained from thoracic CT-slices, to automatically distinguish COVID-19 disease from control samples.Materials and methods: Two datasets were used: SARS-CoV-2 CT Scan (Set-1) and FOSCAL clinic’s dataset (Set-2). The deep representations took advantage of supervised learning models previously trained on the natural image domain, which were adjusted following a transfer learning scheme. The deep classification was carried out: (a) via an end-to-end deep learning approach and (b) via random forest and support vector machine classifiers by feeding the deep representation embedding vectors into these classifiers.Results: The end-to-end classification achieved an average accuracy of 92.33% (89.70% precision) for Set-1 and 96.99% (96.62% precision) for Set-2. The deep feature embedding with a support vector machine achieved an average accuracy of 91.40% (95.77% precision) and 96.00% (94.74% precision) for Set-1 and Set-2, respectively.Conclusion: Deep representations have achieved outstanding performance in the identification of COVID-19 cases on CT scans demonstrating good characterization of the COVID-19 radiological patterns. These representations could potentially support the COVID-19 diagnosis in clinical settings.     

Impact of COVID-19 outbreak on hospital admissions and outcome of acute coronary syndromes in a single high-volume centre in southeastern Europe

BackgroundAs coronavirus disease 2019 (COVID-19) has reached pandemic status, authors from the most severely affected countries have reported reduced rates of hospital admissions for patients with acute coronary syndrome (ACS).AimThe aim of the present study was to investigate the influence of the COVID-19 outbreak on hospital admissions and outcomes in ACS patients in a single high-volume centre in southeastern Europe.MethodsThis retrospective observational study aimed to investigate the number of hospital admissions for ACS, clinical findings at admission, length of hospitalisation, major complications and in-hospital mortality during the COVID-19 outbreak and to compare the data with the same parameters during an equivalent time frame in 2019. For the ST-elevated myocardial infarction (STEMI) subgroup of patients, changes in ischaemic times were analysed as well.ResultsThere was a significant reduction of 44.3% in the number of patients admitted for ACS during the COVID-19 outbreak when compared with the same period in 2019 (151 vs 271; 95% confidence interval 38.4–50.2, p < 0.01) with a higher mortality rate (13.2% vs 7.2%, p = 0.03). In 2020, patients with non-ST-elevated myocardial infarction presented more often with acute heart failure (3.3% vs 0.7%, p = 0.04). During the COVID-19 outbreak, we observed increases in the total ischaemic time (303 ± 163.4 vs 200.8 ± 156.8 min, p < 0.05) and door-to-balloon time (69.2 ± 58.4 vs 50.5 ± 31.3 min, p < 0.01) in STEMI patients.ConclusionsThese findings should increase the awareness of morbidity and mortality related to missed or delayed treatment of ACS among the public and the healthcare services.