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This paper documents that a large-scale government subsidy aimed at encouraging people to eat out in restaurants in the wake of the first 2020 COVID-19 wave in the United Kingdom has had a significant causal impact on new cases, accelerating the subsequent second COVID-19 wave. The scheme subsidised 50% off the cost of food and non-alcoholic drinks for an unlimited number of visits in participating restaurants on Mondays–Wednesdays from 3–31 August 2020. Areas with higher take-up saw both a notable increase in new COVID-19 infection clusters within a week of the scheme starting and a deceleration in infections within two weeks of the program ending. Similarly, areas that exhibited notable rainfall during the prime lunch and dinner hours on the days the scheme was active record lower infection incidence—a pattern that is also measurable in mobility data—and non-detectable on days during which the discount was not available or for rainfall outside the core lunch and dinner hours. [ABSTRACT FROM AUTHOR]

Background The dissemination of scientific data on coronavirus disease 2019 (COVID-19) continually builds but, in April 2020, could not keep up with the spread of the disease. Through technology, surgeons in Italy and the UK, representing both peak and pre-peak infective time zones, were able to communicate so that the urgent lessons on the huge expected demands of care learned in Italy could be brought to the UK in advance. This paper specifically discusses the issues related to paediatric surgery, currently under-reported in the literature. Methods The aim of this paper is to conjoin experience from the field to provide a framework for a safe assessment and treatment of paediatric patients by adopting a systemic approach aimed at reducing the risk of contamination. We reviewed the processes and good practices that were undertaken in contexts of emergency such as in Italy and the UK and then adapted them within the Systems Engineering Initiative for Patient Safety (SEIPS) framework to provide an assessment of how to reorganize the services in order to cope with an unexpected situation. The SEIPS model is the adopted theoretical framework, which allows to analyse the system in its main components with a human factors and ergonomics (HFE) perspective. Results The results introduce some of the good practices and recommendations developed during the emergency in the surgical scenario with a focus on the paediatric patients. They represent the lessons learned from the combination of the little existing evidence of literature and the experience from surgical teams who responded in an impromptu and unrehearsed way. Conclusions Lessons learned from the frontline 'on the fly' during COVID-19 emergency should be consolidated and taken into the future. In order to prepare proactively for the next phases and get ahead of the curve of these hospital accesses, there is a need for a risk assessment of the new clinical pathways with a multidisciplinary approach centred on HFE with the adoption of the SEIPS model and an involvement of all the surgical teams. [ABSTRACT FROM AUTHOR]

Background vaccination uptake in the UK and increased care home testing are likely affecting care home visitation. With scant scientific evidence to date, the aim of this longitudinal qualitative study was to explore the impact of both (vaccination and testing) on the conduct and experiences of care home visits. Methods family carers of care home residents with dementia and care home staff from across the UK took part in baseline (October/November 2020) and follow-up interviews (March 2021). Public advisers were involved in all elements of the research. Data were analysed using thematic analysis. Results across 62 baseline and follow-up interviews with family carers (n  = 26; 11) and care home staff (n  = 16; 9), five core themes were developed: delayed and inconsistent offers of face-to-face visits; procedures and facilitation of visits; variable uptake of the COVID-19 vaccine; misinformation, education and free choice; frustration and anger among family carers. The variable uptake in staff, compared to family carers, was a key factor seemingly influencing visitation, with a lack of clear guidance leading care homes to implement infection control measures and visitation rights differently. Conclusions we make five recommendations in this paper to enable improved care home visitation in the ongoing, and in future, pandemics. Visits need to be enabled and any changes to visiting rights must be used as a last resort, reviewed regularly in consultation with residents and carers and restored as soon as possible as a top priority, whilst more education needs to be provided surrounding vaccination for care home staff. [ABSTRACT FROM AUTHOR]

As soon as the scale of the coronavirus shock to the economy became clear, the UK government introduced three policies to protect directly household incomes: a Job Retention Scheme, to pay the wages of employees who were temporarily furloughed; a Self-Employment Income Support Scheme, to give grants to established self-employed people whose businesses had been affected; and a package of increases to entitlements to social security benefits, with Universal Credit at the core, that bolstered the UK's means-tested 'safety net'. This paper analyses the design and beneficiaries of these policies and, given the distributional pattern of the labour market shock, considers the emerging overall impact on living standards, particularly of low-income households. [ABSTRACT FROM AUTHOR]

How have differently institutionalized welfare regimes dealt with the Covid-19 crisis? In particular, how have they confronted the social and economic inequalities exposed by the virus? Taking three European countries--Germany, Sweden, and the UK, corresponding broadly to conservative-continental, social democratic, and liberal regime types--this paper tracks the virus response in the areas of income and employment protection and health and residential care. With attention paid to issues of "capacity" and the institutional arrangements in each case, we find that institutional histories in Germany and Sweden permitted a certain recidivistic reliance on established practices in the areas of employment and social protection. In sum, certain social and economic inequalities were mitigated as these countries set aside recent trends toward "liberalization" and mobilized longer-standing institutional capacities to protect some groups, although by no means all. Evidence of this trend is less clear in the health and residential care sectors, where Germany had existing capacity, allowing its older population to weather the crisis in better order than its counterparts in Sweden and the UK. In the UK, welfare liberalization has led to increased social and economic inequalities and funding reductions in health and residential care--all of which have reduced the country's ability to deal with severe crisis. The Covid response in this case was agile, but also chaotic, with little being done to ameliorate the positions of the most vulnerable groups. [ABSTRACT FROM AUTHOR]

The article discussed COVID-19 pandemic responses among select ASEAN countries. Topics discussed include actions that helped save lives in UK during Covid-19, vaccination detail of ASEAN countries with Singapore vaccinating 28.8% of its people, followed by Cambodia at 10.6%, and importance of plan-do-study-act (PDSA) cycle for countries with developing economies to strategically prepare and craft response plans for future disease outbreaks.

The article discusses excess deaths that were not correctly diagnosed and reported during Covid-19 in Philippines. Topics discussed include WHO estimates of undercount of total deaths directly and indirectly attributed to COVID-19, The Economist report on Malaysia, Thailand and the Philippines showing negative excess mortality, fewer deaths than normal days, and importance of, accurate and timely data in public health decision-making.

The nature and scale of the shocks to the demand for, and the supply of, home childcare during the COVID-19 pandemic provide a unique opportunity to increase our understanding of the division of home labour and the determinants of specialization within the household. We collected real-time data on daily lives to document the impact of measures to control COVID-19 on UK families with children under the age of 12. We document that these families have been doing the equivalent of a working week in childcare, with mothers bearing most of the burden. The additional hours of childcare done by women are less sensitive to their employment than they are for men, leaving many women juggling work and (a lot more) childcare, with likely adverse effects on their mental health and future careers. However, some households, those in which men have not been working, have taken greater steps towards an equal allocation, offering the prospect of sharing the burden of childcare more equally in the future. [ABSTRACT FROM AUTHOR]

We use high-quality UK panel data to document the extent that pre-existing labour market and financial inequalities were exacerbated by the pandemic between April 2020 and September 2021. Some inequalities worsened, others did not, and in some cases, initial widening of labour market inequalities was subsequently reversed. We find no evidence of an overall divergence in labour market outcomes by gender. Initial changes for ethnic minorities and the young were largely reversed by March 2021. Those in the top third of the long-run income distribution experienced income falls, but also increased saving. Net wealth increased not for only the affluent, but also for middle deciles of the long-run income distribution. These deciles were most protected by the furlough scheme. Those at the bottom of the income distribution were more likely to report a decline in net wealth over the year. [ABSTRACT FROM AUTHOR]

In an editorial, the editors note how crucial the role is of public health activism in enforcing efficient and effective public health management. The government is the lead institution in any national response to the pandemic and to ensure transparency on its end, it is important for any network of health organizations and associations not to shy away from embracing an activist role. In this correspondence, the author explores the case of the Alliance of Health Workers, a union of government and private health workers, and its advocacy towards an empowered status of healthcare professionals in the Philippines. [ABSTRACT FROM AUTHOR]

Background Concerns have been raised that angiotensin-converting enzyme-inhibitors (ACE-I) and angiotensin receptor blockers (ARBs) might facilitate transmission of severe acute respiratory syndrome coronavirus 2 leading to more severe coronavirus disease (COVID-19) disease and an increased risk of mortality. We aimed to investigate the association between ACE-I/ARB treatment and risk of death amongst people with COVID-19 in the first 6 months of the pandemic. Methods We identified a cohort of adults diagnosed with either confirmed or probable COVID-19 (from 1 January to 21 June 2020) using computerized medical records from the Oxford-Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) primary care database. This comprised 465 general practices in England, United Kingdom with a nationally representative population of 3.7 million people. We constructed mixed-effects logistic regression models to quantify the association between ACE-I/ARBs and all-cause mortality among people with COVID-19, adjusted for sociodemographic factors, comorbidities, concurrent medication, smoking status, practice clustering, and household number. Results There were 9,586 COVID-19 cases in the sample and 1,463 (15.3%) died during the study period between 1 January 2020 and 21 June 2020. In adjusted analysis ACE-I and ARBs were not associated with all-cause mortality (adjusted odds ratio [OR] 1.02, 95% confidence interval [CI] 0.85–1.21 and OR 0.84, 95% CI 0.67–1.07, respectively). Conclusion Use of ACE-I/ARB, which are commonly used drugs, did not alter the odds of all-cause mortality amongst people diagnosed with COVID-19. Our findings should inform patient and prescriber decisions concerning continued use of these medications during the pandemic. [ABSTRACT FROM AUTHOR]

Background Twice weekly lateral flow tests (LFTs) for secondary school children was UK Government policy from 8 March 2021. We evaluate use of LFTs (both supervised at test centres, and home test kits) in school-aged children in Cheshire and Merseyside. Methods We report (i) number of LFT positives (ii) proportion of LFT positive with confirmatory reverse transcription polymerase chain reaction (PCR) test within 2 days, and (iii) agreement between LFT-positive and confirmatory PCR, and dependence of (i–iii) on COVID-19 prevalence. Findings 1 248 468 LFTs were taken by 211 255 12–18 years old, and 163 914 by 52 116 5–11 years old between 6 November 2020 and 31 July 2021. Five thousand three hundred and fourteen (2.5%) 12–18 years old and 1996 (3.8%) 5–11 years old returned LFT positives, with 3829 (72.1%) and 1535 (76.9%) confirmatory PCRs, and 3357 (87.7%) and 1383 (90.1%) confirmatory PCR-positives, respectively. Monthly proportions of LFT positive with PCR negative varied between 4.7% and 35.3% in 12–18 years old (corresponding proportion of all tests positive: 9.7% and 0.3%). Deprivation and non-White ethnicity were associated with reduced uptake of confirmatory PCR. Interpretation Substantial inequalities in confirmatory testing need more attention to avoid further disadvantage through education loss. When prevalence is low additional measures, including confirmatory testing, are needed. Local Directors of Public Health taking more control over schools testing may be needed. Funding DHSC, MRC, NIHR, EPSRC. [ABSTRACT FROM AUTHOR]

Background Non-random selection of analytic subsamples could introduce selection bias in observational studies. We explored the potential presence and impact of selection in studies of SARS-CoV-2 infection and COVID-19 prognosis. Methods We tested the association of a broad range of characteristics with selection into COVID-19 analytic subsamples in the Avon Longitudinal Study of Parents and Children (ALSPAC) and UK Biobank (UKB). We then conducted empirical analyses and simulations to explore the potential presence, direction and magnitude of bias due to this selection (relative to our defined UK-based adult target populations) when estimating the association of body mass index (BMI) with SARS-CoV-2 infection and death-with-COVID-19. Results In both cohorts, a broad range of characteristics was related to selection, sometimes in opposite directions (e.g. more-educated people were more likely to have data on SARS-CoV-2 infection in ALSPAC, but less likely in UKB). Higher BMI was associated with higher odds of SARS-CoV-2 infection and death-with-COVID-19. We found non-negligible bias in many simulated scenarios. Conclusions Analyses using COVID-19 self-reported or national registry data may be biased due to selection. The magnitude and direction of this bias depend on the outcome definition, the true effect of the risk factor and the assumed selection mechanism; these are likely to differ between studies with different target populations. Bias due to sample selection is a key concern in COVID-19 research based on national registry data, especially as countries end free mass testing. The framework we have used can be applied by other researchers assessing the extent to which their results may be biased for their research question of interest. [ABSTRACT FROM AUTHOR]

Along with age and race, sex has historically been a core stratification and control variable in epidemiologic research. While in recent decades research guidelines and institutionalized requirements have incorporated an approach differentiating biological sex from social gender, neither sex nor gender is itself a unidimensional construct. The conflation of dimensions within and between sex and gender presents a validity issue wherein proxy measures are used for dimensions of interest, often without explicit acknowledgement or evaluation. Here, individual-level dimensions of sex and gender are outlined as a guide for epidemiologists, and 2 case studies are presented. The first case study demonstrates how unacknowledged use of a sex/gender proxy for a sexed dimension of interest (uterine status) resulted in decades of cancer research misestimating risks, racial disparities, and age trends. The second illustrates how a multidimensional sex and gender framework may be applied to strengthen research on coronavirus disease 2019 incidence, diagnosis, morbidity, and mortality. Considerations are outlined, including: 1) addressing the match between measures and theory, and explicitly acknowledging and evaluating proxy use; 2) improving measurement across dimensions and social ecological levels; 3) incorporating multidimensionality into research objectives; and 4) interpreting sex, gender, and their effects as biopsychosocial. [ABSTRACT FROM AUTHOR]

Objective To establish the demographic characteristics, laboratory findings and clinical outcomes in patients with autoimmune disease (AD) compared with a propensity-matched cohort of patients without AD admitted with COVID-19 to hospitals in the UK. Methods This is a multicentre observational study across 26 NHS Trusts. Data were collected both retrospectively and prospectively using a predesigned standardized case record form. Adult patients (≥18 years) admitted between 1 April 2020 and 31 July 2020 were included. Results Overall, 6288 patients were included to the study. Of these, 394 patients had AD prior to admission with COVID-19. Of 394 patients, 80 patients with SLE, RA or aPL syndrome were classified as severe rheumatologic AD. A higher proportion of those with AD had anaemia [240 (60.91%) vs 206 (52.28%), P  = 0.015], elevated LDH [150 (38.08%) vs 43 (10.92%), P  < 0.001] and raised creatinine [122 (30.96%) vs 86 (21.83%), P  = 0.01], respectively. A significantly higher proportion of patients with severe rheumatologic AD had elevated CRP [77 (96.25%) vs 70 (87.5%), P  = 0.044] and LDH [20 (25%) vs 6 (7.5%), P  = 0.021]. Patients with severe rheumatologic AD had significantly higher mortality [32/80 (40%)] compared with propensity matched cohort of patients without AD [20/80 (25%), P  = 0.043]. However, there was no difference in 180-day mortality between propensity-matched cohorts of patients with or without AD in general (P  = 0.47). Conclusions Patients with severe rheumatologic AD had significantly higher mortality. Anaemia, renal impairment and elevated LDH were more frequent in patients with any AD while elevated CRP and LDH were more frequent in patients with severe rheumatologic AD both of which have been shown to associate with increased mortality in patients with COVID-19. [ABSTRACT FROM AUTHOR]

We compared the performance of prognostic tools for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) using parameters fitted either at the time of hospital admission or across all time points of an admission. This cohort study used clinical data to model the dynamic change in prognosis of SARS-CoV-2 at a single hospital center in the United Kingdom, including all patients admitted from February 1, 2020, to December 31, 2020, and then followed up for 60 days for intensive care unit (ICU) admission, death, or discharge from the hospital. We incorporated clinical observations and blood tests into 2 time-varying Cox proportional hazards models predicting daily 24- to 48-hour risk of admission to the ICU for those eligible for escalation of care or death for those ineligible for escalation. In developing the model, 491 patients were eligible for ICU escalation and 769 were ineligible for escalation. Our model had good discrimination of daily risk of ICU admission in the validation cohort (n  = 1,141; C statistic: C  = 0.91, 95% confidence interval: 0.89, 0.94) and our score performed better than other scores (National Early Warning Score 2, International Severe Acute Respiratory and Emerging Infection Comprehensive Clinical Characterisation Collaboration score) calculated using only parameters measured on admission, but it overestimated the risk of escalation (calibration slope = 0.7). A bespoke daily SARS-CoV-2 escalation risk prediction score can predict the need for clinical escalation better than a generic early warning score or a single estimation of risk calculated at admission. [ABSTRACT FROM AUTHOR]

Context: A sex discordance in COVID exists, with males disproportionatel y affected. Although sex steroids may play a role in this discordance, no definitive genetic data exist to su pport androgen-mediated immune suppression neither for viral susceptibility nor for adrenally produced androgens. Objective: The common adrenal-permissive missense-encoding variant HSD3B1(1245C) that enables androgen synthesis from adrenal precursors and that has been linked to suppression of inflammation in severe asthma was investigated in COVID susceptibility and outcomes reported in the UK Biobank. Methods: The UK Biobank is a long-term study with detailed medical information and health outcomes for over 500 000 genotyped individuals. We obtained COVID test results, inpa tient hospital records, and death records and tested for associations between COVID susceptibility or outcomes and HSD3B1(1245A/C) genotype. Primary analyses were performed on the UK Biobank Caucasian cohort. The outcomes were identification as a COVID case among all subjects, COVID positivity among COVID-tested subjects, and mortality amo ng subjects identified as COVID cases. Results: Adrenal-permissive HSD3B1(1245C) genotype was associated with identification as a COVID c ase (odds ratio (OR): 1.11 per C allele, 95% CI: 1.04-1.18, P = 0.0013) and COVID-test positivity (OR: 1.09, 95% CI: 1.02-1.17, P = 0.011) in older (=70 years of age) women. In women identified as COVID cases, ther e was a positive linear relationship between age and 1245C allele frequency (P < 0.0001). No associations were found between genotype and morta lity or between genotype and circulating sex hormone levels. Conclusion: Our study suggests that a common androgen synthesis variant reg ulates immune susceptibility to COVID infection in women, with increasingly strong effects as women ag e. [ABSTRACT FROM AUTHOR]

Background COVID-19 lockdown measures may have led to more, and increasingly severe, domestic abuse. This study examines police referrals to a specialist domestic abuse service in Wales, UK before and during the first lockdown. Methods Routine data relating to 2292 police referrals for female adult victim-survivors from December 2019 until July 2020 were analysed and presented in the form of descriptive statistics to monitor changes in referral rates and the profile of those referrals. Results There was little increase in the overall volume of police referrals during lockdown, but the proportion assessed as high risk increased, and children became the primary source of third-party referrals, with a higher proportion of reports made by other third parties as restrictions eased. Police reports for cases of Child/Adolescent to Parent Violence (C/APV) occurred almost exclusively during lockdown. Conclusions The increase in risk level despite less clear increase in volume may suggest unmet need, with victims less likely to seek help during lockdown other than for more severe instances. Increased reports by children suggest increased exposure of children to domestic abuse during school closure. Unmet need for women and children may have been made visible to services, and acquaintances, as measures began to ease. [ABSTRACT FROM AUTHOR]

Background defining features of the COVID-19 pandemic in many countries were the tragic extent to which care home residents were affected and the difficulty in preventing the introduction and subsequent spread of infection. Management of risk in care homes requires good evidence on the most important transmission pathways. One hypothesised route at the start of the pandemic, prior to widespread testing, was the transfer of patients from hospitals that were experiencing high levels of nosocomial events. Methods we tested the hypothesis that hospital discharge events increased the intensity of care home cases using a national individually linked health record cohort in Wales, UK. We monitored 186,772 hospital discharge events over the period from March to July 2020, tracking individuals to 923 care homes and recording the daily case rate in the homes populated by 15,772 residents. We estimated the risk of an increase in case rates following exposure to a hospital discharge using multi-level hierarchical logistic regression and a novel stochastic Hawkes process outbreak model. Findings in regression analysis, after adjusting for care home size, we found no significant association between hospital discharge and subsequent increases in care home case numbers (odds ratio: 0.99, 95% CI: 0.82, 1.90). Risk factors for increased cases included care home size, care home resident density and provision of nursing care. Using our outbreak model, we found a significant effect of hospital discharge on the subsequent intensity of cases. However, the effect was small and considerably less than the effect of care home size, suggesting the highest risk of introduction came from interaction with the community. We estimated that approximately 1.8% of hospital discharged patients may have been infected. Interpretation there is growing evidence in the UK that the risk of transfer of COVID-19 from the high-risk hospital setting to the high-risk care home setting during the early stages of the pandemic was relatively small. Although access to testing was limited to initial symptomatic cases in each care home at this time, our results suggest that reduced numbers of discharges, selection of patients and action taken within care homes following transfer all may have contributed to the mitigation. The precise key transmission routes from the community remain to be quantified. [ABSTRACT FROM AUTHOR]

The COVID-19 pandemic resulted in catastrophic levels of morbidity and mortality for care home residents. Despite this, research platforms for COVID-19 in care homes arrived late in the pandemic compared with other care settings. The Prophylactic Therapy in Care Homes Trial (PROTECT-CH) was established to provide a platform to deliver multi-centre cluster-randomized clinical trials of investigational medicinal products for COVID-19 prophylaxis in UK care homes. Commencing set-up in January 2021, this involved the design and development of novel infrastructure for contracting and recruitment, remote consent, staff training, research insurance, eligibility screening, prescribing, dispensing and adverse event reporting; such infrastructure being previously absent. By the time this infrastructure was in place, the widespread uptake of vaccination in care homes had changed the epidemiology of COVID-19 rendering the trial unfeasible. While some of the resources developed through PROTECT-CH will enable the future establishment of care home platform research, the near absence of care home trial infrastructure and nationally linked databases involving the care home sector will continue to significantly hamper progress. These issues are replicated in most other countries. Beyond COVID-19, there are many other research questions that require addressing to provide better care to people living in care homes. PROTECT-CH has exposed a clear need for research funders to invest in, and legislate for, an effective care home research infrastructure as part of national pandemic preparedness planning. Doing so would also invigorate care home research in the interim, leading to improved healthcare delivery specific to those living in this sector. [ABSTRACT FROM AUTHOR]

In this brief communication, we discuss the confusion of mortality with fatality in the interpretation of evidence in the coronavirus disease 2019 (COVID-19) pandemic, and how this confusion affects the translation of science into policy and practice. We discuss how this confusion has influenced COVID-19 policy in France, Sweden, and the United Kingdom and discuss the implications for decision-making about COVID-19 vaccine distribution. We also discuss how this confusion is an example of a more general statistical fallacy we term the "Missing Link Fallacy." [ABSTRACT FROM AUTHOR]

Introduction Care homes have been severely affected by the SARS-CoV-2 pandemic. Rapid antigen testing could identify most SARS-CoV-2 infected staff and visitors before they enter homes. We explored implementation of staff and visitor testing protocols using lateral flow devices (LFDs). Methods An evaluation of a SARS-CoV-2 LFD-based testing protocol in 11 care homes in Liverpool, UK, including staff and visitor testing, plus a qualitative exploratory study in nine of these homes. The proportion of pilot homes with outbreaks, and outbreak size, were compared to non-pilot homes in Liverpool. Adherence to testing protocols was evaluated. Fifteen staff were interviewed, and transcript data were thematically coded using an iterative analysis to identify and categorize factors influencing testing implementation. Results In total, 1,638 LFD rapid tests were performed on 407 staff. Protocol adherence was poor with 8.6% of staff achieving >75% protocol adherence, and 25.3% achieving |$\ge$| 50%. Six care homes had outbreaks during the study. Compared to non-pilot care homes, there was no evidence of significant difference in the proportion of homes with outbreaks, or the size of outbreaks. Qualitative data showed difficulty implementing testing strategies due to excessive work burden. Factors influencing adherence related to test integration and procedural factors, socio-economic factors, cognitive overload and the emotional value of testing. Conclusion Implementation of staff and visitor care home LFD testing protocols was poorly adhered to and consequently did not reduce the number or scale of COVID-19 outbreaks. More focus is needed on the contextual and behavioural factors that influence protocol adherence. [ABSTRACT FROM AUTHOR]

Background informal carers provide the majority of the support for persons with dementia living at home. Restrictions imposed due to COVID-19 have had a profound impact on the daily life of the entire population. This study provides insight into the impact of these restrictions on carers of people with dementia living at home. Design qualitative semi-structured interviews. Participants purposive sample of carers who provide at least 10 hours of care a week for the person with dementia living at home. Setting UK. Results twenty-three carers were interviewed, and thematic analysis identified three main themes—Changes to daily life, impact on carer health and wellbeing and reduced support from health and social support networks. The results highlight the impact of restrictions imposed on daily life and routines due to the pandemic, wellbeing of carers, reduced social support, lack of access to health and care professionals and respite for carers. The restrictions have had negative consequences on carers' wellbeing, and they have experienced difficulties in accessing formal care services and respite care. Conclusion carers attempt to continue to provide physical, emotional and practical support for persons with dementia in the community throughout the COVID-19 restrictions. To prevent a future carer crisis, carers need better support systems including formal carer services, telecare solutions that work for them and additional support for respite, as the restrictions from this pandemic continue. [ABSTRACT FROM AUTHOR]

Background Seroprevalence studies are essential to understand the epidemiology of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Various technologies, including laboratory assays and point-of-care self-tests, are available for antibody testing. The interpretation of seroprevalence studies requires comparative data on the performance of antibody tests. Methods In June 2020, current and former members of the United Kingdom police forces and fire service performed a self-test lateral flow immunoassay (LFIA), had a nurse-performed LFIA, and provided a venous blood sample for enzyme-linked immunosorbent assay (ELISA). We present the prevalence of antibodies to SARS-CoV-2 and the acceptability and usability of self-test LFIAs, and we determine the sensitivity and specificity of LFIAs compared with laboratory ELISA. Results In this cohort of 5189 current and former members of the police service and 263 members of the fire service, 7.4% (396 of 5348; 95% confidence interval [CI], 6.7–8.1) were antibody positive. Seroprevalence was 8.9% (95% CI, 6.9–11.4) in those under 40 years, 11.5% (95% CI, 8.8–15.0) in those of nonwhite ethnicity, and 7.8% (95% CI, 7.1–8.7) in those currently working. Self-test LFIA had an acceptability of 97.7% and a usability of 90.0%. There was substantial agreement between within-participant LFIA results (kappa 0.80; 95% CI, 0.77–0.83). The LFIAs had a similar performance: compared with ELISA, sensitivity was 82.1% (95% CI, 77.7–86.0) self-test and 76.4% (95% CI, 71.9–80.5) nurse-performed with specificity of 97.8% (95% CI, 97.3–98.2) and 98.5% (95% CI, 98.1–98.8), respectively. Conclusions A greater proportion of this nonhealthcare key worker cohort showed evidence of previous infection with SARS-CoV-2 than the general population at 6.0% (95% CI, 5.8–6.1) after the first wave in England. The high acceptability and usability reported by participants and similar performance of self-test and nurse-performed LFIAs indicate that the self-test LFIA is fit for purpose for home testing in occupational and community prevalence studies. [ABSTRACT FROM AUTHOR]

Background epidemiological data on COVID-19 infection in care homes are scarce. We analysed data from a large provider of long-term care for older people to investigate infection and mortality during the first wave of the pandemic. Methods cohort study of 179 UK care homes with 9,339 residents and 11,604 staff. We used manager-reported daily tallies to estimate the incidence of suspected and confirmed infection and mortality in staff and residents. Individual-level electronic health records from 8,713 residents were used to model risk factors for confirmed infection, mortality and estimate attributable mortality. Results 2,075/9,339 residents developed COVID-19 symptoms (22.2% [95% confidence interval: 21.4%; 23.1%]), while 951 residents (10.2% [9.6%; 10.8%]) and 585 staff (5.0% [4.7%; 5.5%]) had laboratory-confirmed infections. The incidence of confirmed infection was 152.6 [143.1; 162.6] and 62.3 [57.3; 67.5] per 100,000 person-days in residents and staff, respectively. Sixty-eight percent (121/179) of care homes had at least one COVID-19 infection or COVID-19-related death. Lower staffing ratios and higher occupancy rates were independent risk factors for infection. Out of 607 residents with confirmed infection, 217 died (case fatality rate: 35.7% [31.9%; 39.7%]). Mortality in residents with no direct evidence of infection was twofold higher in care homes with outbreaks versus those without (adjusted hazard ratio: 2.2 [1.8; 2.6]). Conclusions findings suggest many deaths occurred in people who were infected with COVID-19, but not tested. Higher occupancy and lower staffing levels were independently associated with risks of infection. Protecting staff and residents from infection requires regular testing for COVID-19 and fundamental changes to staffing and care home occupancy. [ABSTRACT FROM AUTHOR]

Background In responding to Covid-19, governments have tried to balance protecting health while minimizing gross domestic product (GDP) losses. We compare health-related net benefit (HRNB) and GDP losses associated with government responses of the UK, Ireland, Germany, Spain and Sweden from UK healthcare payer perspective. Methods We compared observed cases, hospitalizations and deaths under 'mitigation' to modelled events under 'no mitigation' to 20 July 2020. We thus calculated healthcare costs, quality adjusted life years (QALYs), and HRNB at £20,000/QALY saved by each country. On per population (i.e. per capita) basis, we compared HRNB with forecast reductions in 2020 GDP growth (overall or compared with Sweden as minimal mitigation country) and qualitatively and quantitatively described government responses. Results The UK saved 3.17 (0.32–3.65) million QALYs, £33 (8–38) billion healthcare costs and £1416 (220–1637) HRNB per capita at £20,000/QALY. Per capita, this is comparable to £1455 GDP loss using Sweden as comparator and offsets 46.1 (7.1–53.2)% of total £3075 GDP loss. Germany, Spain, and Sweden had greater HRNB per capita. These also offset a greater percentage of total GDP losses per capita. Ireland fared worst on both measures. Countries with more mask wearing, testing, and population susceptibility had better outcomes. Highest stringency responses did not appear to have best outcomes. Conclusions Our exploratory analysis indicates the benefit of government Covid-19 responses may outweigh their economic costs. The extent that HRNB offset economic losses appears to relate to population characteristics, testing levels, and mask wearing, rather than response stringency. [ABSTRACT FROM AUTHOR]

Objective: Several recent observational studies have linked metabolic comorbidities to an increased risk from COVID19. Here we investigated whether women with PCOS are at an increased risk of COVID-19 infection. Design: Population-based closed cohort study between 31 January 2020 and 22 July 2020 in the setting of a UK primary care database (The Health Improvement Network, THIN). Methods: The main outcome was the incidence of COVID-19 coded as suspected or confirmed by the primary care provider. We used Cox proportional hazards regression model with stepwise inclusion of explanatory variables (age, BMI, impaired glucose regulation, androgen excess, anovulation, vitamin D deficiency, hypertension, and cardiovascular disease) to provide unadjusted and adjusted hazard risks (HR) of COVID-19 infection among women with PCOS compared to women without PCOS. Results: We identified 21 292 women with a coded diagnosis of PCO/PCOS and randomly selected 78 310 aged and general practice matched control women. The crude COVID-19 incidence was 18.1 and 11.9 per 1000 person-years among women with and without PCOS, respectively. Age-adjusted Cox regression analysis suggested a 51% higher risk of COVID-19 among women with PCOS compared to women without PCOS (HR: 1.51 (95% CI: 1.27–1.80), P < 0.001). After adjusting for age and BMI, HR reduced to 1.36 (1.14–1.63)], P = 0.001. In the fully adjusted model, women with PCOS had a 28% increased risk of COVID-19 (aHR: 1.28 (1.05–1.56), P = 0.015). Conclusion: Women with PCOS are at an increased risk of COVID-19 infection and should be specifically encouraged to adhere to infection control measures during the COVID-19 pandemic. Significance statement: Women with polycystic ovary syndrome (PCOS) have an increased risk of cardio-metabolic disease, which have been identified as a risk factor for COVID-19. To investigate whether the increased metabolic risk in PCOS translates into an increased risk of COVID-19 infection, we carried out a population-based closed cohort study in the UK during its first wave of the SARS-CoV-2 pandemic (January to July 2020), including 21 292 women with PCOS and 78 310 controls matched for sex, age and general practice location. Results revealed a 52% increased risk of COVID-19 infection in women with PCOS, which remained increased at 28% above controls after adjustment for age, BMI, impaired glucose regulation and other explanatory variables. [ABSTRACT FROM AUTHOR]

Objectives We aimed to estimate what proportion of people with SLE attending UK rheumatology clinics would be categorized as being at high risk from coronavirus disease 2019 (COVID-19) and therefore asked to shield, and explore what implications this has for rheumatology clinical practice. Methods We used data from the British Society for Rheumatology multicentre audit of SLE, which included a large, representative cross-sectional sample of patients attending UK Rheumatology clinics with SLE. We calculated who would receive shielding advice using the British Society for Rheumatology's risk stratification guidance and accompanying scoring grid, and assessed whether ethnicity and history of nephritis were over-represented in the shielding group. Results The audit included 1003 patients from 51 centres across all 4 nations of the UK. Overall 344 (34.3%) patients had a shielding score ≥3 and would have been advised to shield. People with previous or current LN were 2.6 (1.9–3.4) times more likely to be in the shielding group than people with no previous LN (P  < 0.001). Ethnicity was not evenly distributed between the groups (chi-squared P  < 0.001). Compared with White people, people of Black ethnicity were 1.9 (1.3–2.8) and Asian 1.9 (1.3–2.7) times more likely to be in the shielding group. Increased risk persisted after controlling for LN. Conclusion Our study demonstrates the large number of people with SLE who are likely to be shielding. Implications for clinical practice include considering communication across language and cultural differences, and ways to conduct renal assessment including urinalysis, during telephone and video consultations for patients who are shielding. [ABSTRACT FROM AUTHOR]

The care and support of older people residing in long-term care facilities during the COVID-19 pandemic has created new and unanticipated uncertainties for staff. In this short report, we present our analyses of the uncertainties of care home managers and staff expressed in a self-formed closed WhatsApp™ discussion group during the first stages of the pandemic in the UK. We categorised their wide-ranging questions to understand what information would address these uncertainties and provide support. We have been able to demonstrate that almost one-third of these uncertainties could have been tackled immediately through timely, responsive and unambiguous fact-based guidance. The other uncertainties require appraisal, synthesis and summary of existing evidence, commissioning or provision of a sector- informed research agenda for medium to long term. The questions represent wider internationally relevant care home pandemic-related uncertainties. [ABSTRACT FROM AUTHOR]

Background The adequacy of personal protective equipment (PPE) and infection prevention and control (IPC) training in UK medical students and interim Foundation Year 1 (FiY1) doctors during the COVID-19 pandemic is unknown, as is its impact on COVID-19-related anxiety. Methods Cross-sectional, multi-centre study analysing self-reported adequacy of PPE and IPC training and correlation to a modified pandemic anxiety scale. Participants were current medical students and FiY1 doctors in the UK. Data were collected by an online survey. Results Participants reported that they received insufficient PPE information (43%) and IPC training (56%). Significantly, fewer participants identifying as women or BAME/mixed ethnicity reported receiving sufficient PPE information, compared with those identifying as men and White British/White Other, respectively. COVID-19-related anxiety was significantly higher in those without sufficient reported PPE or IPC training, in women compared with men, and in FiY1 doctors compared with medical students. Conclusions With medical students currently volunteering in and imminently returning to hospitals in an educational capacity, levels of self-reported PPE and IPC training are sub-optimal. Better training is paramount to avoid harm to patients and healthcare professionals and to reduce COVID-19-related anxiety among medical students and FiY1 doctors. [ABSTRACT FROM AUTHOR]

Reports of Guillain-Barré syndrome (GBS) have emerged during the Coronavirus disease 2019 (COVID-19) pandemic. This epidemiological and cohort study sought to investigate any causative association between COVID-19 infection and GBS. The epidemiology of GBS cases reported to the UK National Immunoglobulin Database was studied from 2016 to 2019 and compared to cases reported during the COVID-19 pandemic. Data were stratified by hospital trust and region, with numbers of reported cases per month. UK population data for COVID-19 infection were collated from UK public health bodies. In parallel, but separately, members of the British Peripheral Nerve Society prospectively reported incident cases of GBS during the pandemic at their hospitals to a central register. The clinical features, investigation findings and outcomes of COVID-19 (definite or probable) and non-COVID-19 associated GBS cases in this cohort were compared. The incidence of GBS treated in UK hospitals from 2016 to 2019 was 1.65-1.88 per 100 000 individuals per year. GBS incidence fell between March and May 2020 compared to the same months of 2016-19. GBS and COVID-19 incidences during the pandemic also varied between regions and did not correlate with one another (r = 0.06, 95% confidence interval: -0.56 to 0.63, P = 0.86). In the independent cohort study, 47 GBS cases were reported (COVID-19 status: 13 definite, 12 probable, 22 non-COVID-19). There were no significant differences in the pattern of weakness, time to nadir, neurophysiology, CSF findings or outcome between these groups. Intubation was more frequent in the COVID-19 affected cohort (7/13, 54% versus 5/22, 23% in COVID-19-negative) attributed to COVID-19 pulmonary involvement. Although it is not possible to entirely rule out the possibility of a link, this study finds no epidemiological or phenotypic clues of SARS-CoV-2 being causative of GBS. GBS incidence has fallen during the pandemic, which may be the influence of lockdown measures reducing transmission of GBS inducing pathogens such as Campylobacter jejuni and respiratory viruses. [ABSTRACT FROM AUTHOR]

Background: COVID-19 pandemic has had a major impact globally, with older people living in aged care homes suffering high death rates.Objectives: We aimed to compare the impact of initial government policies on this vulnerable older population between the UK and Australia during the first wave of attack.Methods: We searched websites of governments in the UK and Australia and media outlets. We examined the key policies including the national lockdown dates and the distribution of some important resources (personal protective equipment and testing) and the effects of these initial policies on the mortality rates in the aged care homes during the first wave of attack of COVID-19.Results: We found that both countries had prioritized resources to hospitals over aged care homes during the first wave of attack. Both countries had lower priority for aged care residents in hospitals (e.g. discharging without testing for COVID-19 or discouraging admissions). However, deaths in aged care homes were 270 times higher in the UK than in Australia as on 7 May 2020 (despite UK having a population only 2.5 times larger than Australia). The lower fatality rate in Australia may have been due to the earlier lockdown strategy when the total daily cases were low in Australia (118) compared to the UK (over 1000), as well as the better community viral testing regime in Australia.Conclusion: In conclusion, the public health policy in Australia aimed towards earlier intervention with earlier national lockdown and more viral testing to prevent new cases. This primary prevention could have resulted in more lives being saved. In contrast, the initial policy in the UK focussed mainly on protecting resources for hospitals, and there was a delay in national lockdown intervention and lower viral testing rate, resulting in more lives lost in the aged care sector. [ABSTRACT FROM AUTHOR]

In the COVID-19 pandemic, patients who are older and residents of long-term care facilities (LTCF) are at greatest risk of worse clinical outcomes. We reviewed discharge criteria for hospitalised COVID-19 patients from 10 countries with the highest incidence of COVID-19 cases as of 26 July 2020. Five countries (Brazil, Mexico, Peru, Chile and Iran) had no discharge criteria; the remaining five (USA, India, Russia, South Africa and the UK) had discharge guidelines with large inter-country variability. India and Russia recommend discharge for a clinically recovered patient with two negative reverse transcription polymerase chain reaction (RT-PCR) tests 24 h apart; the USA offers either a symptom based strategy—clinical recovery and 10 days after symptom onset, or the same test-based strategy. The UK suggests that patients can be discharged when patients have clinically recovered; South Africa recommends discharge 14 days after symptom onset if clinically stable. We recommend a unified, simpler discharge criteria, based on current studies which suggest that most SARS-CoV-2 loses its infectivity by 10 days post-symptom onset. In asymptomatic cases, this can be taken as 10 days after the first positive PCR result. Additional days of isolation beyond this should be left to the discretion of individual clinician. This represents a practical compromise between unnecessarily prolonged admissions and returning highly infectious patients back to their care facilities, and is of particular importance in older patients discharged to LTCFs, residents of which may be at greatest risk of transmission and worse clinical outcomes. [ABSTRACT FROM AUTHOR]

This article considers policy responses to the COVID-19 crisis as they affect the labour market, how these policies are evolving and some of the design issues they face. The concentration is on the UK, but other countries are also discussed for comparative purposes. The Job Retention Scheme is a successful innovation to keep temporarily stopped workers attached to their employers. However, since economic recovery will be slow, it is not sustainable in its current form. A sustained rise in unemployment is inevitable and alternative policies to mitigate this and the dangers of scarring are discussed. The structure of output will change, as therefore will the composition of jobs. A comprehensive active manpower policy will be needed to efficiently match job seekers to available jobs. The young are likely to suffer disproportionately from the recession and this makes it essential to introduce radical policies to boost work-based training and to enhance the contribution made by further and higher education institutions. [ABSTRACT FROM AUTHOR]

Introduction During the UK Covid-19 lockdown, video consultations (telemedicine) were encouraged. The extent of usage, and to which concerns to earlier implementation were set aside, is unknown; this is worthy of exploration as data becomes available. Sources of data Sources of data are as follows: published case studies, editorials, news articles and government guidance. Areas of agreement Video can be clinically effective, especially where patients cannot attend due to illness or infection risk. Patients are positive, and they can benefit from savings in time and money. Adoption of telemedicine is hindered by a range of known barriers including clinician resistance due to technological problems, disrupted routines, increased workload, decreased work satisfaction and organizational readiness. Areas of controversy Despite policy impetus and successful pilots, telemedicine has not been adopted at scale. Growing points Increased use of telemedicine during the Covid-19 crisis presents opportunities to obtain robust evidence of issues and create service transformation effectively. Areas timely for developing research Examination of telemedicine use during the Covid-19 crisis to ensure that the benefits and usage continue into the post-lockdown, 'new normal' world. [ABSTRACT FROM AUTHOR]

Background We examined whether the greater severity of coronavirus disease 2019 (COVID-19) amongst men and Black, Asian and Minority Ethnic (BAME) individuals is explained by cardiometabolic, socio-economic or behavioural factors. Methods We studied 4510 UK Biobank participants tested for COVID-19 (positive, n  = 1326). Multivariate logistic regression models including age, sex and ethnicity were used to test whether addition of (1) cardiometabolic factors [diabetes, hypertension, high cholesterol, prior myocardial infarction, smoking and body mass index (BMI)]; (2) 25(OH)-vitamin D; (3) poor diet; (4) Townsend deprivation score; (5) housing (home type, overcrowding) or (6) behavioural factors (sociability, risk taking) attenuated sex/ethnicity associations with COVID-19 status. Results There was over-representation of men and BAME ethnicities in the COVID-19 positive group. BAME individuals had, on average, poorer cardiometabolic profile, lower 25(OH)-vitamin D, greater material deprivation, and were more likely to live in larger households and in flats/apartments. Male sex, BAME ethnicity, higher BMI, higher Townsend deprivation score and household overcrowding were independently associated with significantly greater odds of COVID-19. The pattern of association was consistent for men and women; cardiometabolic, socio-demographic and behavioural factors did not attenuate sex/ethnicity associations. Conclusions In this study, sex and ethnicity differential pattern of COVID-19 was not adequately explained by variations in cardiometabolic factors, 25(OH)-vitamin D levels or socio-economic factors. Factors which underlie ethnic differences in COVID-19 may not be easily captured, and so investigation of alternative biological and genetic susceptibilities as well as more comprehensive assessment of the complex economic, social and behavioural differences should be prioritised. [ABSTRACT FROM AUTHOR]

I would like to comment on those suggestions During the UK-India Telemedicine Project, junior doctors managed the patinets in some satellite Covid-19 centres as their workforce capacity was stretched to the limit by an influx of many patients. These junior doctors presented cases (by maintaining patient confidentiality) to a panel of UK Consultants in a virtual ward round. All the UK clinicians involved in this project are full-time National Health Service (NHS) doctors and they contributed to this project in their free time. [Extracted from the article]