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Whitfield, T., Fernandez, C., Davies, K., Defres, S., Griffiths, M., Hooper, C., Tangney, R., Burnside, G., Rosala- Hallas, A., Moore, P., Das, K., Zuckerman, M., Parkes, L., Keller, S., Roberts, N., Easton, A., Touati, S., Kneen, R., Stahl, J. P., Solomon, T.
BMJ Open, 22.07.2021
Tilføjet 22.07.2021
Introduction
Herpes simplex virus (HSV) encephalitis is a rare severe form of brain inflammation that commonly leaves survivors and their families with devastating long-term consequences. The virus particularly targets the temporal lobe of the brain causing debilitating problems in memory, especially verbal memory. It is postulated that immunomodulation with the corticosteroid, dexamethasone, could improve outcomes by reducing brain swelling. However, there are concerns (so far not observed) that such immunosuppression might facilitate increased viral replication with resultant worsening of disease. A previous trail closed early because of slow recruitment.
Method
DexEnceph is a pragmatic multicentre, randomised, controlled, open-label, observer-blind trial to determine whether adults with HSV encephalitis who receive dexamethasone alongside standard antiviral treatment with aciclovir for have improved clinical outcomes compared with those who receive standard treatment alone. Overall, 90 patients with HSV encephalitis are being recruited from a target of 45 recruiting sites; patients are randomised 1:1 to the dexamethasone or control arms of the study. The primary outcome measured is verbal memory as assessed by the Weschler Memory Scale fourth edition Auditory Memory Index at 26 weeks after randomisation. Secondary outcomes are measured up to 72 weeks include additional neuropsychological, clinical and functional outcomes as well as comparison of neuroimaging findings. Patient safety monitoring occurs throughout and includes the detection of HSV DNA in cerebrospinal fluid 2 weeks after randomisation, which is indicative of ongoing viral replication. Innovative methods are being used to ensure recrutiment targets are met for this rare disease.
Discussion
DexEnceph aims to be the first completed randomised controlled trial of corticosteroid therapy in HSV encephalitis. The results will provide evidence for future practice in managing adults with the condition and has the potential to improve outcomes .
Ethics and dissemination
The trial has ethical approval from the UK National Research Ethics Committee (Liverpool Central, REF: 15/NW/0545, 10 August 2015). Protocol V.2.1, July 2019. The results will be published and presented as soon as possible on completion.
Trial registration numbers
ISRCTN11774734, EUDRACT 2015-001609-16.
Læs mere Tjek på PubMedMangal, T., Whittaker, C., Nkhoma, D., Ng'ambi, W., Watson, O., Walker, P., Ghani, A., Revill, P., Colbourn, T., Phillips, A., Hallett, T., Mfutso-Bengo, J.
BMJ Open, 22.07.2021
Tilføjet 22.07.2021
Background
COVID-19 mitigation strategies have been challenging to implement in resource-limited settings due to the potential for widespread disruption to social and economic well-being. Here we predict the clinical severity of COVID-19 in Malawi, quantifying the potential impact of intervention strategies and increases in health system capacity.
Methods
The infection fatality ratios (IFR) were predicted by adjusting reported IFR for China, accounting for demography, the current prevalence of comorbidities and health system capacity. These estimates were input into an age-structured deterministic model, which simulated the epidemic trajectory with non-pharmaceutical interventions and increases in health system capacity.
Findings
The predicted population-level IFR in Malawi, adjusted for age and comorbidity prevalence, is lower than that estimated for China (0.26%, 95% uncertainty interval (UI) 0.12%–0.69%, compared with 0.60%, 95% CI 0.4% to 1.3% in China); however, the health system constraints increase the predicted IFR to 0.83%, 95% UI 0.49%–1.39%. The interventions implemented in January 2021 could potentially avert 54 400 deaths (95% UI 26 900–97 300) over the course of the epidemic compared with an unmitigated outbreak. Enhanced shielding of people aged ≥60 years could avert 40 200 further deaths (95% UI 25 300–69 700) and halve intensive care unit admissions at the peak of the outbreak. A novel therapeutic agent which reduces mortality by 0.65 and 0.8 for severe and critical cases, respectively, in combination with increasing hospital capacity, could reduce projected mortality to 2.5 deaths per 1000 population (95% UI 1.9–3.6).
Conclusion
We find the interventions currently used in Malawi are unlikely to effectively prevent SARS-CoV-2 transmission but will have a significant impact on mortality. Increases in health system capacity and the introduction of novel therapeutics are likely to further reduce the projected numbers of deaths.
Læs mere Tjek på PubMedWei, Q., Zhou, M., Liu, J., Zhang, S., Gao, F., Lin, H., Chen, Z.
BMJ Open, 22.07.2021
Tilføjet 22.07.2021
Introduction
Osteonecrosis (ON) is characterised by the destruction of the normal blood supply to the bone tissue. ON is the main cause of disability in patients with systemic lupus erythematosus (SLE). Studies have reported the existence of many risk factors for SLE complicated by ON, including the use of high-dose glucocorticoids and high disease activity. The correlation between antiphospholipid antibodies (aPLs) and ON in SLE has been controversial. We aim to conduct a systematic review of the literature related to SLE, aseptic ON and aPLs, to provide a reference for the clinical screening of high-risk patients and for early prevention.
Methods and analysis
The following six databases will be searched: MEDLINE/PubMed, Embase, Web of Science, Chinese Biomedical Literature Database, Wan-Fang Database and China National Knowledge Infrastructure. The database searches will not be restricted by date. Case–control studies, cohort studies or observational studies that compare aPLs between SLE patients with and without ON will be considered eligible. Articles published in English and Chinese will be included. Two researchers will independently perform the processes of study selection, data extraction and study quality assessment. The Newcastle–Ottawa Quality Assessment Scale will be used to assess the quality of the retrieved studies. A meta-analysis will be performed after screening the studies. Data will be analysed using ORs for dichotomous data.
Ethics and dissemination
Ethical approval is not required because this systematic review will use published data. The systematic review will be electronically disseminated through a peer-reviewed publication or conference presentations.
PROSPERO registration number
CRD42020209637.
Læs mere Tjek på PubMedIslam, S. J., Nayak, A., Hu, Y., Mehta, A., Dieppa, K., Almuwaqqat, Z., Ko, Y.-A., Patel, S. A., Goyal, A., Sullivan, S., Lewis, T. T., Vaccarino, V., Morris, A. A., Quyyumi, A. A.
BMJ Open, 22.07.2021
Tilføjet 22.07.2021
Background
The COVID-19 pandemic adversely affected the socially vulnerable and minority communities in the USA initially, but the temporal trends during the year-long pandemic remain unknown.
Objective
We examined the temporal association of county-level Social Vulnerability Index (SVI), a percentile-based measure of social vulnerability to disasters, its subcomponents and race/ethnic composition with COVID-19 incidence and mortality in the USA in the year starting in March 2020.
Methods
Counties (n=3091) with ≥50 COVID-19 cases by 6 March 2021 were included in the study. Associations between SVI (and its subcomponents) and county-level racial composition with incidence and death per capita were assessed by fitting a negative-binomial mixed-effects model. This model was also used to examine potential time-varying associations between weekly number of cases/deaths and SVI or racial composition. Data were adjusted for percentage of population aged ≥65 years, state-level testing rate, comorbidities using the average Hierarchical Condition Category score, and environmental factors including average fine particulate matter of diameter ≥2.5 μm, temperature and precipitation.
Results
Higher SVI, indicative of greater social vulnerability, was independently associated with higher COVID-19 incidence (adjusted incidence rate ratio per 10 percentile increase: 1.02, 95% CI 1.02 to 1.03, p<0.001) and death per capita (1.04, 95% CI 1.04 to 1.05, p<0.001). SVI became an independent predictor of incidence starting from March 2020, but this association became weak or insignificant by the winter, a period that coincided with a sharp increase in infection rates and mortality, and when counties with higher proportion of white residents were disproportionately represented (‘third wave’). By spring of 2021, SVI was again a predictor of COVID-19 outcomes. Counties with greater proportion of black residents also observed similar temporal trends in COVID-19-related adverse outcomes. Counties with greater proportion of Hispanic residents had worse outcomes throughout the duration of the analysis.
Conclusion
Except for the winter ‘third wave’, when majority of the white communities had the highest incidence of cases, counties with greater social vulnerability and proportionately higher minority populations experienced worse COVID-19 outcomes.
Læs mere Tjek på PubMedMathews, M., Spencer, S., Hedden, L., Marshall, E. G., Lukewich, J., Meredith, L., Ryan, D., Buote, R., Liu, T., Volpe, E., Gill, P. S., Ryan, B., Schacter, G., Wickett, J., Freeman, T. R., Sibbald, S. L., Wong, E., McKay, M., McCracken, R., Brown, J. B.
BMJ Open, 22.07.2021
Tilføjet 22.07.2021
Introduction
Given the recurrent risk of respiratory illness-based pandemics, and the important roles family physicians play during public health emergencies, the development of pandemic plans for primary care is imperative. Existing pandemic plans in Canada, however, do not adequately incorporate family physicians’ roles and perspectives. This policy and planning oversight has become increasingly evident with the emergence of the novel coronavirus disease, COVID-19, pandemic. This study is designed to inform the development of pandemic plans for primary care through evidence from four provinces in Canada: British Columbia, Newfoundland and Labrador, Nova Scotia, and Ontario.
Methods and analysis
We will employ a multiple-case study of regions in four provinces. Each case consists of a mixed methods design which comprises: (1) a chronology of family physician roles in the COVID-19 pandemic response; (2) a provincial policy analysis; and (3) qualitative interviews with family physicians. Relevant policy and guidance documents will be identified through targeted, snowball and general search strategies. Additionally, these policy documents will be analysed to identify gaps and/or emphases in existing policies and policy responses. Interviews will explore family physicians’ proposed, actual and potential roles during the pandemic, the facilitators and barriers they have encountered throughout and the influence of gender on their professional roles. Data will be thematically analysed using a content analysis framework, first at the regional level and then through cross-case analyses.
Ethics and dissemination
Approval for this study has been granted by the Research Ethics of British Columbia, the Health Research Ethics Board of Newfoundland and Labrador, the Nova Scotia Health Authority Research Ethics Board and the Western University Research Ethics Board. Findings will be disseminated via conferences and peer-reviewed publications. Evidence and lessons learnt will be used to develop tools for government ministries, public health units and family physicians for improved pandemic response plans for primary care.
Læs mere Tjek på PubMedOrtega, E., Corcoy, R., Gratacos, M., Cos Claramunt, F. X., Mata-Cases, M., Puig-Treserra, R., Real, J., Vlacho, B., Castelblanco, E., Domingo, P., Khunti, K., Franch-Nadal, J., Mauricio, D.
BMJ Open, 22.07.2021
Tilføjet 22.07.2021
Aim
This study’s objective was to assess the risk of severe in-hospital complications of patients admitted for COVID-19 and diabetes mellitus (DM).
Design
This was a cross-sectional study.
Settings
We used pseudonymised medical record data provided by six general hospitals from the HM Hospitales group in Spain.
Outcome measures
Multiple logistic regression analyses were used to identify variables associated with mortality and the composite of mortality or invasive mechanical ventilation (IMV) in the overall population, and stratified for the presence or absence of DM. Spline analysis was conducted on the entire population to investigate the relationship between glucose levels at admission and outcomes.
Results
Overall, 1621 individuals without DM and 448 with DM were identified in the database. Patients with DM were on average 5.1 years older than those without. The overall in-hospital mortality was 18.6% (N=301), and was higher among patients with DM than those without (26.3% vs 11.3%; p<0.001). DM was independently associated with death, and death or IMV (OR=2.33, 95% CI: 1.7 to 3.1 and OR=2.11, 95% CI: 1.6 to 2.8, respectively; p<0.001). In subjects with DM, the only variables independently associated with both outcomes were age >65 years, male sex and pre-existing chronic kidney disease. We observed a non-linear relationship between blood glucose levels at admission and risk of in-hospital mortality and death or IMV. The highest probability for each outcome (around 50%) was at random glucose of around 550 mg/dL (30.6 mmol/L), and the risks flattened above this value.
Conclusion
The results confirm the high burden associated with DM in patients hospitalised with COVID-19 infection, particularly among men, the elderly and those with impaired kidney function. Moreover, hyperglycaemia on admission was strongly associated with poor outcomes, suggesting that personalised optimisation could help to improve outcome during the hospital stay.
Læs mere Tjek på PubMedDun, Y., Ripley-Gonzalez, J. W., Zhou, N., You, B., Li, Q., Li, H., Zhang, W., Thomas, R. J., Olson, T. P., Liu, J., Dong, Y., Liu, S.
BMJ Open, 22.07.2021
Tilføjet 22.07.2021
Objectives
To observe the weight change in Chinese youth during a 4-month COVID-19 lockdown, and the association between weight change and mental health, physical activity and sedentary time changes, and dietary habits.
Design
A retrospective observational study.
Settings
Two universities located in Zhejiang and Hunan provinces, China.
Participants
This study enrolled 12 889 college students whose body weight was measured before the lockdown (1 December 2019–20 January 2020) at the two universities, and reported their weight measured at home or community after the end of the lockdown (1–23 May 2020) via an online follow-up questionnaire.
Primary and secondary outcome measures
The primary outcome was the weight change in Chinese youth during a 4-month lockdown resulting from the COVID-19 pandemic. The secondary outcomes were the relationships of weight change to COVID-19-related stress, depression, anxiety, physical activity and sedentary time changes, and dietary habits.
Results
Participants’ ages ranged from 17 to 27 years (M=19, SD=1) with 80.2% identified as female. The average absolute and relative changes in body weight were 2.6 (95% CI 2.0 to 3.2)) kg and 4.2% (95% CI 4.0% to 4.3%) for men, and 2.1 (1.9 to 2.4) kg and 4.2% (95% CI 3.9% to 4.4%) for women. An increase in overweight and obese individuals according to Asian cut-off points as a demographic percentage by 4.5% and 2.7% and 4.8% and 3.4% in men and women, respectively (P<0.001), was observed. Weight gain was significantly associated with increased sedentary time and an increase in COVID-19-related stress and depression score.
Conclusion
The present study’s results suggest that the risk of weight gain in Chinese youth during the lockdown increased and that strategies to decrease sedentary time and improve mental health may be warranted to mitigate weight gain during and after the COVID-19 pandemic.
Læs mere Tjek på PubMedBMC Infectious Diseases, 22.07.2021
Tilføjet 22.07.2021
Abstract
Background
Predicting hospital length of stay (LoS) for patients with COVID-19 infection is essential to ensure that adequate bed capacity can be provided without unnecessarily restricting care for patients with other conditions. Here, we demonstrate the utility of three complementary methods for predicting LoS using UK national- and hospital-level data.
Method
On a national scale, relevant patients were identified from the COVID-19 Hospitalisation in England Surveillance System (CHESS) reports. An Accelerated Failure Time (AFT) survival model and a truncation corrected method (TC), both with underlying Weibull distributions, were fitted to the data to estimate LoS from hospital admission date to an outcome (death or discharge) and from hospital admission date to Intensive Care Unit (ICU) admission date. In a second approach we fit a multi-state (MS) survival model to data directly from the Manchester University NHS Foundation Trust (MFT). We develop a planning tool that uses LoS estimates from these models to predict bed occupancy.
Results
All methods produced similar overall estimates of LoS for overall hospital stay, given a patient is not admitted to ICU (8.4, 9.1 and 8.0 days for AFT, TC and MS, respectively). Estimates differ more significantly between the local and national level when considering ICU. National estimates for ICU LoS from AFT and TC were 12.4 and 13.4 days, whereas in local data the MS method produced estimates of 18.9 days.
Conclusions
Given the complexity and partiality of different data sources and the rapidly evolving nature of the COVID-19 pandemic, it is most appropriate to use multiple analysis methods on multiple datasets. The AFT method accounts for censored cases, but does not allow for simultaneous consideration of different outcomes. The TC method does not include censored cases, instead correcting for truncation in the data, but does consider these different outcomes. The MS method can model complex pathways to different outcomes whilst accounting for censoring, but cannot handle non-random case missingness. Overall, we conclude that data-driven modelling approaches of LoS using these methods is useful in epidemic planning and management, and should be considered for widespread adoption throughout healthcare systems internationally where similar data resources exist.
Læs mere Tjek på PubMedDidem Görgün Hattatoğlu, Birsen Pınar Yıldız
Journal of Medical Virology, 21.07.2021
Tilføjet 22.07.2021
Tarun Kumar Suvvari, LV Simhachalam Kutikuppala, Christos Tsagkaris, Anna Chiara Corriero, Venkataramana Kandi
Journal of Medical Virology, 21.07.2021
Tilføjet 22.07.2021
Silvia Carbonell‐Sahuquillo, María Isabel Lázaro‐Carreño, Jorge Camacho, Ana Barrés‐Fernández, Eliseo Albert, Ignacio Torres, José Rafael Bretón‐Martínez, Cecilia Martínez‐Costa, David Navarro
Journal of Medical Virology, 21.07.2021
Tilføjet 22.07.2021
Olivier UWISHEMA, Baha Aldeen Abdalaziz Alshareif, Mohamed Yousif Elamin Yousif, Mohammed Eltahier Abdalla Omer, Alfredo Lorenzo Recio Sablay, Rabeet Tariq, Amirsaman Zahabioun, Rehema Mkamburi Mwazighe, Helen Onyeaka
Journal of Medical Virology, 21.07.2021
Tilføjet 22.07.2021
Olivier Uwishema, Ekene Mary Nnagha, Elie Chalhoub, Goodluck Nchasi, Rehema Mkamburi Mwazighe, Burak Talha Akin, Irem Adanur, Helen Onyeaka
Journal of Medical Virology, 21.07.2021
Tilføjet 22.07.2021
Philipp Sprengholz, Cornelia Betsch
Journal of Medical Virology, 21.07.2021
Tilføjet 22.07.2021
Ahmad M. Saad, Ahmed ES. Abdel‐Megied, Rizk A. Elbaz, Sobhy E. Hassab El‐Nabi, Rami M. Elshazli
Journal of Medical Virology, 21.07.2021
Tilføjet 22.07.2021
Jordan Z. Neises, Md Saddam Hossain, Rifat Sultana, Kevin N. Wanniarachchi, Jared W. Wollman, Eric Nelson, Bonny L. Specker, Adam D. Hoppe, Steven R. Lawson, Natalie W. Thiex
Journal of Medical Virology, 21.07.2021
Tilføjet 22.07.2021
Nicholas I. Paton, Joseph Musaazi, Cissy Kityo, Stephen Walimbwa, Anne Hoppe, Apolo Balyegisawa, Arvind Kaimal, Grace Mirembe, Phionah Tukamushabe, Gilbert Ategeka, James Hakim, Henry Mugerwa, Abraham Siika, Jesca Asienzo, Barbara Castelnuovo, Agnes Kiragga, Andrew Kambugu
New England Journal of Medicine, 21.07.2021
Tilføjet 22.07.2021
New England Journal of Medicine, Volume 385, Issue 4, Page 330-341, July 2021.
Læs mere Tjek på PubMedEric J. Rubin, Lindsey R. Baden, Katrina A. Armstrong, Stephen Morrissey
New England Journal of Medicine, 21.07.2021
Tilføjet 22.07.2021
Victoria T. Chu, Anna R. Yousaf, Karen Chang, Noah G. Schwartz, Clinton J. McDaniel, Scott H. Lee, Christine M. Szablewski, Marie Brown, Cherie L. Drenzek, Emilio Dirlikov, Dale A. Rose, Julie Villanueva, Alicia M. Fry, Aron J. Hall, Hannah L. Kirking, Jacqueline E. Tate, Tatiana M. Lanzieri, Rebekah J. Stewart
New England Journal of Medicine, 21.07.2021
Tilføjet 22.07.2021
New England Journal of Medicine, 21.07.2021
Tilføjet 22.07.2021
Stephen J.W. Evans, Nicholas P. Jewell
New England Journal of Medicine, 21.07.2021
Tilføjet 22.07.2021
Jamie Lopez Bernal, Nick Andrews, Charlotte Gower, Eileen Gallagher, Ruth Simmons, Simon Thelwall, Julia Stowe, Elise Tessier, Natalie Groves, Gavin Dabrera, Richard Myers, Colin N.J. Campbell, Gayatri Amirthalingam, Matt Edmunds, Maria Zambon, Kevin E. Brown, Susan Hopkins, Meera Chand, Mary Ramsay
New England Journal of Medicine, 21.07.2021
Tilføjet 22.07.2021
Garth Rapeport, Emma Smith, Anthony Gilbert, Andrew Catchpole, Helen McShane, Christopher Chiu
New England Journal of Medicine, 21.07.2021
Tilføjet 22.07.2021
Benjamas Chuaychoo, Kanokwan Rattanasaengloet, Run Banlengchit, Navin Horthongkham, Niracha Athipanyasilp, Kanyarat Totanarungroj, Nisa Muangman
International Journal of Infectious Diseases, 21.07.2021
Tilføjet 22.07.2021
Influenza virus is an important cause of adult hospitalization while respiratory syncytial virus (RSV) infection is increasingly recognized, especially in older adults with co-morbidities (Falsey et al. 2014; Lee et al. 2013; Olsen et al. 2010; Walker and Ison 2014). In studies from America, Europe, and Asia, RSV infection represented 2.3% to 13.0% of adult hospitalizations (Falsey et al. 2005; Falsey et al. 2014; Lee et al. 2013; Loubet et al. 2017; Malosh et al. 2017; Naorat et al. 2013; Olsen et al.
Læs mere Tjek på PubMedLijun Xu, Yufan Xu, Yanghao Zheng, Xiuming Peng, Zongxing Yang, Qing Cao, Dairong Xiang, Handan Zhao
Clinical & Experimental Immunology, 21.07.2021
Tilføjet 22.07.2021
Eric P. Caragata, Heverton L.C. Dutra, Pedro H.F. Sucupira, Alvaro G.A. Ferreira, Luciano A. Moreira
Trends in Parasitology, 21.07.2021
Tilføjet 22.07.2021
In this review we examine how exploiting the Wolbachia–mosquito relationship has become an increasingly popular strategy for controlling arbovirus transmission. Field deployments of Wolbachia-infected mosquitoes have led to significant decreases in dengue virus incidence via high levels of mosquito population suppression and replacement, emphasizing the success of Wolbachia approaches. Here, we examine how improved knowledge of Wolbachia–host interactions has provided key insight into the mechanisms of the essential phenotypes of pathogen blocking and cytoplasmic incompatibility.
Læs mere Tjek på PubMedNathella Pavan Kumar, Chandrasekaran Padmapriyadarsini, Anuradha Rajamanickam, Perumal Kannabiran Bhavani, Arul Nancy, Bharathi Jayadeepa, Nandhini Selvaraj, Dinesh Ashokan, Rachel Mariam Renji, Vijayalakshmi Venkataramani, Srikanth Tripathy, Subash Babu
International Journal of Infectious Diseases, 21.07.2021
Tilføjet 22.07.2021
Bacillus Calmette–Guérin (BCG) is a live-attenuated vaccine largely established to protect against childhood meningitis and disseminated tuberculosis (TB) (Foster et al., 2021) Several epidemiological findings suggest that BCG may increase the capacity of the immune system to fight against pathogens other than TB (Leentjens et al., 2015) and such non-specific responses augment both T cell–mediated adaptive and innate immune memory in a process called trained immunity and this could have important implications for improving vaccination strategies.
Læs mere Tjek på PubMedEmerging Infectious Diseases, 21.07.2021
Tilføjet 22.07.2021
Philipp Fervers, Jonathan Kottlors, Nils Große Hokamp, Johannes Bremm, David Maintz, Stephanie Tritt, Orkhan Safarov, Thorsten Persigehl, Nils Vollmar, Paul Martin Bansmann, Nuran Abdullayev
PLoS One Infectious Diseases, 21.07.2021
Tilføjet 22.07.2021
by Philipp Fervers, Jonathan Kottlors, Nils Große Hokamp, Johannes Bremm, David Maintz, Stephanie Tritt, Orkhan Safarov, Thorsten Persigehl, Nils Vollmar, Paul Martin Bansmann, Nuran Abdullayev
Purpose Cardiovascular comorbidity anticipates severe progression of COVID-19 and becomes evident by coronary artery calcification (CAC) on low-dose chest computed tomography (LDCT). The purpose of this study was to predict a patient’s obligation of intensive care treatment by evaluating the coronary calcium burden on the initial diagnostic LDCT.
Methods Eighty-nine consecutive patients with parallel LDCT and positive RT-PCR for SARS-CoV-2 were included from three centers. The primary endpoint was admission to ICU, tracheal intubation, or death in the 22-day follow-up period. CAC burden was represented by the Agatston score. Multivariate logistic regression was modeled for prediction of the primary endpoint by the independent variables “Agatston score > 0”, as well as the CT lung involvement score, patient sex, age, clinical predictors of severe COVID-19 progression (history of hypertension, diabetes, prior cardiovascular event, active smoking, or hyperlipidemia), and laboratory parameters (creatinine, C-reactive protein, leucocyte, as well as thrombocyte counts, relative lymphocyte count, d-dimer, and lactate dehydrogenase levels).
Results After excluding multicollinearity, “Agatston score >0” was an independent regressor within multivariate analysis for prediction of the primary endpoint (p<0.01). Further independent regressors were creatinine (p = 0.02) and leucocyte count (p = 0.04). The Agatston score was significantly higher for COVID-19 cases which completed the primary endpoint (64.2 [interquartile range 1.7–409.4] vs. 0 [interquartile range 0–0]).
Conclusion CAC scoring on LDCT might help to predict future obligation of intensive care treatment at the day of patient admission to the hospital.
Læs mere Tjek på PubMedEleanor E. Friedman, Samantha A. Devlin, Moira C. McNulty, Jessica P. Ridgway
PLoS One Infectious Diseases, 21.07.2021
Tilføjet 22.07.2021
by Eleanor E. Friedman, Samantha A. Devlin, Moira C. McNulty, Jessica P. Ridgway
Since the onset of the COVID-19 pandemic, it has been unclear how vulnerable people with HIV (PwH) are to SARS-CoV-2 infection. We sought to determine if PwH are more likely to test positive for SARS-CoV-2 than people without HIV, and to identify risk factors associated with SARS-CoV-2 positivity among PwH. We conducted a cross-sectional study in which we collected electronic medical record data for all patients who underwent SARS-CoV-2 PCR testing at an academic medical center. Presence of HIV and other chronic diseases were based on the presence of ICD-10 diagnosis codes. We calculated the percent positivity for SARS-CoV-2 among PwH and among people without HIV. Among PwH, we compared demographic factors, comorbidities, HIV viral load, CD4 T-cell count, and antiretroviral therapy (ART) regimens between those who tested positive for SARS-CoV-2 and those who tested negative. Comparisons were made using chi squared tests or Wilcoxon rank sum tests. Multivariate models were created using logistic regression. Among 69,763 people tested for SARS-CoV-2, 0.6% (431) were PwH. PwH were not significantly more likely to test positive for SARS-CoV-2 than people without HIV (7.2% (31/431) vs 8.4% (5820/69763), p = 0.35), but were more likely to be younger, Black, and male (p-values < .0001). There were no significant differences in HIV clinical factors, chronic diseases, or ART regimens among PwH testing positive for SARS-CoV-2 versus those testing negative. In our sample, PwH were not more likely to contract SARS-CoV-2, despite being more likely to be members of demographic groups known to be at higher risk for infection. Differences between PwH who tested positive for SARS-CoV-2 and those who tested negative were only seen in Hispanic/Latino ethnicity (non-Hispanic or Latino vs unknown Hispanic or Latino ethnicity (OR 0.2 95% CI (0.6, 0.9)) and site of testing(inpatient vs outpatient OR 3.1 95% CI (1.3, 7.4)).
Læs mere Tjek på PubMedFrank Trübner, Lisa Steigert, Fabian Echterdiek, Norma Jung, Kirsten Schmidt-Hellerau, Wolfram G. Zoller, Julia-Stefanie Frick, You-Shan Feng, Gregor Paul
PLoS One Infectious Diseases, 21.07.2021
Tilføjet 22.07.2021
by Frank Trübner, Lisa Steigert, Fabian Echterdiek, Norma Jung, Kirsten Schmidt-Hellerau, Wolfram G. Zoller, Julia-Stefanie Frick, You-Shan Feng, Gregor Paul
Background The objective of this study was to identify clinical risk factors for COVID-19 in a German outpatient fever clinic that allow distinction of SARS-CoV-2 infected patients from other patients with flu-like symptoms.
Methods This is a retrospective, single-centre cohort study. Patients were included visiting the fever clinic from 4th of April 2020 to 15th of May 2020. Symptoms, comorbidities, and socio-demographic factors were recorded in a standardized fashion. Multivariate logistic regression was used to identify risk factors of COVID-19, on the bases of those a model discrimination was assessed using area under the receiver operation curves (AUROC).
Results The final analysis included 930 patients, of which 74 (8%) had COVID-19. Anosmia (OR 10.71; CI 6.07–18.9) and ageusia (OR 9.3; CI 5.36–16.12) were strongly associated with COVID-19. High-risk exposure (OR 12.20; CI 6.80–21.90), especially in the same household (OR 4.14; CI 1.28–13.33), was also correlated; the more household members, especially with flu-like symptoms, the higher the risk of COVID-19. Working in an essential workplace was also associated with COVID-19 (OR 2.35; CI 1.40–3.96), whereas smoking was inversely correlated (OR 0.19; CI 0.08–0.44). A model that considered risk factors like anosmia, ageusia, concomitant of symptomatic household members and smoking well discriminated COVID-19 patients from other patients with flu-like symptoms (AUROC 0.84).
Conclusions We report a set of four readily available clinical parameters that allow the identification of high-risk individuals of COVID-19. Our study will not replace molecular testing but will help guide containment efforts while waiting for test results.
Læs mere Tjek på PubMedDevendra Raj Singh, Dev Ram Sunuwar, Sunil Kumar Shah, Lalita Kumari Sah, Kshitij Karki, Rajeeb Kumar Sah
PLoS One Infectious Diseases, 21.07.2021
Tilføjet 22.07.2021
by Devendra Raj Singh, Dev Ram Sunuwar, Sunil Kumar Shah, Lalita Kumari Sah, Kshitij Karki, Rajeeb Kumar Sah
Background Food insecurity is a serious social and public health problem which is exacerbated by the COVID-19 pandemic especially in resource-poor countries such as Nepal. However, there is a paucity of evidence at local levels. This study aims to explore food insecurity among people from the disadvantaged community and low-income families during the COVID-19 pandemic in Province-2 of Nepal.
Methods The semi-structured qualitative interviews were conducted virtually among purposively selected participants (n = 41) from both urban and rural areas in eight districts of Province 2 in Nepal. All the interviews were conducted in the local language between July and August 2020. The data analysis was performed using thematic network analysis in Nvivo 12 Pro software.
Results The results of this study are grouped into four global themes: i) Impact of COVID-19 on food security; ii) Food insecurity and coping strategies during the COVID-19 pandemic, iii) Food relief and emergency support during the COVID-19 pandemic, and iv) Impact of COVID-19 and food insecurity on health and wellbeing. Most participants in the study expressed that families from low socioeconomic backgrounds and disadvantaged communities such as those working on daily wages and who rely on remittance had experienced increased food insecurity during the COVID-19 pandemic. Participants used different forms of coping strategies to meet their food requirements during the pandemic. Community members experienced favouritism, nepotism, and partiality from local politicians and authorities during the distribution of food relief. The food insecurity among low-income and disadvantaged families has affected their health and wellbeing making them increasingly vulnerable to the COVID-19 infection.
Conclusion Food insecurity among low-income and disadvantaged families was found to be a serious problem during the COVID-19 pandemic. The study suggests that the relief support plan and policies should be focused on the implementation of immediate sustainable food security strategies to prevent hunger, malnutrition, and mental health problems among the most vulnerable groups in the community.
Læs mere Tjek på PubMedJonathan Salcedo, Monica Rosales, Jeniffer S. Kim, Daisy Nuno, Sze-chuan Suen, Alicia H. Chang
PLoS One Infectious Diseases, 21.07.2021
Tilføjet 22.07.2021
by Jonathan Salcedo, Monica Rosales, Jeniffer S. Kim, Daisy Nuno, Sze-chuan Suen, Alicia H. Chang
Background Tuberculosis (TB) incidence in Los Angeles County, California, USA (5.7 per 100,000) is significantly higher than the U.S. national average (2.9 per 100,000). Directly observed therapy (DOT) is the preferred strategy for active TB treatment but requires substantial resources. We partnered with the Los Angeles County Department of Public Health (LACDPH) to evaluate the cost-effectiveness of AiCure, an artificial intelligence (AI) platform that allows for automated treatment monitoring.
Methods We used a Markov model to compare DOT versus AiCure for active TB treatment in LA County. Each cohort transitioned between health states at rates estimated using data from a pilot study for AiCure (N = 43) and comparable historical controls for DOT (N = 71). We estimated total costs (2017, USD) and quality-adjusted life years (QALYs) over a 16-month horizon to calculate the incremental cost-effectiveness ratio (ICER) and net monetary benefits (NMB) of AiCure. To assess robustness, we conducted deterministic (DSA) and probabilistic sensitivity analyses (PSA).
Results For the average patient, AiCure was dominant over DOT. DOT treatment cost $4,894 and generated 1.03 QALYs over 16-months. AiCure treatment cost $2,668 for 1.05 QALYs. At willingness-to-pay threshold of $150K/QALY, incremental NMB per-patient under AiCure was $4,973. In univariate DSA, NMB were most sensitive to monthly doses and vocational nurse wage; however, AiCure remained dominant. In PSA, AiCure was dominant in 93.5% of 10,000 simulations (cost-effective in 96.4%).
Conclusions AiCure for treatment of active TB is cost-effective for patients in LA County, California. Increased use of AI platforms in other jurisdictions could facilitate the CDC’s vision of TB elimination.
Læs mere Tjek på PubMedRicardo Ramírez-Aldana, Juan Carlos Gomez-Verjan, Omar Yaxmehen Bello-Chavolla, Carmen García-Peña
PLoS One Infectious Diseases, 21.07.2021
Tilføjet 22.07.2021
by Ricardo Ramírez-Aldana, Juan Carlos Gomez-Verjan, Omar Yaxmehen Bello-Chavolla, Carmen García-Peña
COVID-19 is a respiratory disease caused by SARS-CoV-2, which has significantly impacted economic and public healthcare systems worldwide. SARS-CoV-2 is highly lethal in older adults (>65 years old) and in cases with underlying medical conditions, including chronic respiratory diseases, immunosuppression, and cardio-metabolic diseases, including severe obesity, diabetes, and hypertension. The course of the COVID-19 pandemic in Mexico has led to many fatal cases in younger patients attributable to cardio-metabolic conditions. Thus, in the present study, we aimed to perform an early spatial epidemiological analysis for the COVID-19 outbreak in Mexico. Firstly, to evaluate how mortality risk from COVID-19 among tested individuals (MRt) is geographically distributed and secondly, to analyze the association of spatial predictors of MRt across different states in Mexico, controlling for the severity of the disease. Among health-related variables, diabetes and obesity were positively associated with COVID-19 fatality. When analyzing Mexico as a whole, we identified that both the percentages of external and internal migration had positive associations with early COVID-19 mortality risk with external migration having the second-highest positive association. As an indirect measure of urbanicity, population density, and overcrowding in households, the physicians-to-population ratio has the highest positive association with MRt. In contrast, the percentage of individuals in the age group between 10 to 39 years had a negative association with MRt. Geographically, Quintana Roo, Baja California, Chihuahua, and Tabasco (until April 2020) had higher MRt and standardized mortality ratios, suggesting that risks in these states were above what was nationally expected. Additionally, the strength of the association between some spatial predictors and the COVID-19 fatality risk varied by zone.
Læs mere Tjek på PubMedAmna Tariq, Juan M. Banda, Pavel Skums, Sushma Dahal, Carlos Castillo-Garsow, Baltazar Espinoza, Noel G. Brizuela, Roberto A. Saenz, Alexander Kirpich, Ruiyan Luo, Anuj Srivastava, Humberto Gutierrez, Nestor Garcia Chan, Ana I. Bento, Maria-Eugenia Jimenez-Corona, Gerardo Chowell
PLoS One Infectious Diseases, 21.07.2021
Tilføjet 22.07.2021
by Amna Tariq, Juan M. Banda, Pavel Skums, Sushma Dahal, Carlos Castillo-Garsow, Baltazar Espinoza, Noel G. Brizuela, Roberto A. Saenz, Alexander Kirpich, Ruiyan Luo, Anuj Srivastava, Humberto Gutierrez, Nestor Garcia Chan, Ana I. Bento, Maria-Eugenia Jimenez-Corona, Gerardo Chowell
Mexico has experienced one of the highest COVID-19 mortality rates in the world. A delayed implementation of social distancing interventions in late March 2020 and a phased reopening of the country in June 2020 has facilitated sustained disease transmission in the region. In this study we systematically generate and compare 30-day ahead forecasts using previously validated growth models based on mortality trends from the Institute for Health Metrics and Evaluation for Mexico and Mexico City in near real-time. Moreover, we estimate reproduction numbers for SARS-CoV-2 based on the methods that rely on genomic data as well as case incidence data. Subsequently, functional data analysis techniques are utilized to analyze the shapes of COVID-19 growth rate curves at the state level to characterize the spatiotemporal transmission patterns of SARS-CoV-2. The early estimates of the reproduction number for Mexico were estimated between Rt ~1.1–1.3 from the genomic and case incidence data. Moreover, the mean estimate of Rt has fluctuated around ~1.0 from late July till end of September 2020. The spatial analysis characterizes the state-level dynamics of COVID-19 into four groups with distinct epidemic trajectories based on epidemic growth rates. Our results show that the sequential mortality forecasts from the GLM and Richards model predict a downward trend in the number of deaths for all thirteen forecast periods for Mexico and Mexico City. However, the sub-epidemic and IHME models perform better predicting a more realistic stable trajectory of COVID-19 mortality trends for the last three forecast periods (09/21-10/21, 09/28-10/27, 09/28-10/27) for Mexico and Mexico City. Our findings indicate that phenomenological models are useful tools for short-term epidemic forecasting albeit forecasts need to be interpreted with caution given the dynamic implementation and lifting of social distancing measures.
Læs mere Tjek på PubMedAnn M. Navar, Stacey N. Purinton, Qingjiang Hou, Robert J. Taylor, Eric D. Peterson
PLoS One Infectious Diseases, 21.07.2021
Tilføjet 22.07.2021
by Ann M. Navar, Stacey N. Purinton, Qingjiang Hou, Robert J. Taylor, Eric D. Peterson
Introduction At the population level, Black and Hispanic adults in the United States have increased risk of dying from COVID-19, yet whether race and ethnicity impact on risk of mortality among those hospitalized for COVID-19 is unclear.
Methods Retrospective cohort study using data on adults hospitalized with COVID-19 from the electronic health record from 52 health systems across the United States contributing data to Cerner Real World DataTM. In-hospital mortality was evaluated by race first in unadjusted analysis then sequentially adjusting for demographics and clinical characteristics using logistic regression.
Results Through August 2020, 19,584 patients with median age 52 years were hospitalized with COVID-19, including n = 4,215 (21.5%) Black and n = 5,761 (29.4%) Hispanic patients. Relative to white patients, crude mortality was slightly higher in Black adults [22.7% vs 20.8%, unadjusted OR 1.12 (95% CI 1.02–1.22)]. Mortality remained higher among Black adults after adjusting for demographic factors including age, sex, date, region, and insurance status (OR 1.13, 95% CI 1.01–1.27), but not after including comorbidities and body mass index (OR 1.07, 95% CI 0.93–1.23). Compared with non-Hispanic patients, Hispanic patients had lower mortality both in unadjusted and adjusted models [mortality 12.7 vs 25.0%, unadjusted OR 0.44(95% CI 0.40–0.48), fully adjusted OR 0.71 (95% CI 0.59–0.86)].
Discussion In this large, multicenter, EHR-based analysis, Black adults hospitalized with COVID-19 had higher observed mortality than white patients due to a higher burden of comorbidities in Black adults. In contrast, Hispanic ethnicity was associated with lower mortality, even in fully adjusted models.
Læs mere Tjek på PubMedSandip Das Sanyam, Sanjay Kumar Sah, Pankaj Chaudhary, Matthew J. Burton, Jeremy J. Hoffman
PLoS One Infectious Diseases, 21.07.2021
Tilføjet 22.07.2021
by Sandip Das Sanyam, Sanjay Kumar Sah, Pankaj Chaudhary, Matthew J. Burton, Jeremy J. Hoffman
Background Nepal was under a severe lockdown for several months in 2020 due to the COVID-19 pandemic. There were concerns regarding misinformation circulating on social media. This study aimed to analyse the knowledge and awareness of COVID-19 amongst eye care professionals in Nepal during the first wave of the pandemic.
Methodology We invited 600 participants from 12 ophthalmic centres across Nepal to complete a qualitative, anonymous online survey. Altogether, 25 questions (both open and closed-ended) were used. An overall performance score was calculated from the average of the 12 “Knowledge” questions for all the participants.
Results Of the 600 eye care professionals invited, 310 (51%) participated in the survey. The symptoms of COVID-19 were known to 94%, whilst only 49% of the participants were aware how the disease was transmitted, with 54% aware that anyone can be infected with SARS-CoV-2. Almost 98% of participants recognized the World Health Organization’s (WHO) awareness message, but surprisingly, 41% of participants felt that consumption of hot drinks helps to destroy the virus, in contradiction to WHO information. Importantly, 95% of the participants were aware of personal protective equipment (PPE) and what the acronym stands for. Social distancing was felt to be key to limiting the disease spread; whilst 41% disagreed that PPE should be mandatory for eye care practitioners. The mean overall “Knowledge” performance score was 69.65% (SD ± 22.81).
Conclusion There is still considerable scope to improve the knowledge of COVID-19 amongst ophthalmic professionals in Nepal. Opinion is also split on measures to prevent transmission, with misinformation potentially fuelling confusion. It is recommended to follow WHO and national guidelines, whilst seeking published scientific evidence behind any unofficial statements, to accurately inform one’s clinical practice.
Læs mere Tjek på PubMedFolake Temitope Fadare, Anthony Ifeanyi Okoh
PLoS One Infectious Diseases, 21.07.2021
Tilføjet 22.07.2021
by Folake Temitope Fadare, Anthony Ifeanyi Okoh
Globally, there is an increasing occurrence of multidrug-resistant (MDR) Enterobacteriaceae with extended-spectrum β-lactamases (ESBLs) and/or plasmid-encoded AmpC (pAmpC) β-lactamases in clinical and environmental settings of significant concern. Therefore, we aimed to evaluate the occurrence of ESBL/pAmpC genetic determinants, and some essential non-β-lactam genetic determinants in the MDR phenotypic antimicrobial resistance in Enterobacteriaceae isolates recovered from hospital wastewater. We collected samples from two hospitals in Amathole and Chris Hani District Municipalities in the Eastern Cape Province, South Africa, within October and November 2017. Using the matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF), we identified a total of 44 presumptive Enterobacteriaceae isolates. From this, 31 were identified as the targeted Enterobacteriaceae members. Thirty-six percent of these belonged to Klebsiella oxytoca, while 29% were Klebsiella pneumoniae. The other identified isolates included Citrobacter freundii and Escherichia coli (10%), Enterobacter asburiae (6%), Enterobacter amnigenus, Enterobacter hormaechei, and Enterobacter kobei (3%). We established the antibiotic susceptibility profiles of these identified bacterial isolates against a panel of 18 selected antibiotics belonging to 11 classes were established following established guidelines by the Clinical and Laboratory Standard Institute. All the bacterial species exhibited resistance phenotypically against at least four antibiotic classes and were classified as MDR. Notably, all the bacterial species displayed resistance against cefotaxime, ampicillin, nalidixic acid, and trimethoprim-sulfamethoxazole. The generated multiple antibiotic resistance indices ranged between 0.5 to 1.0, with the highest value seen in one K. oxytoca isolated. Molecular characterization via the Polymerase Chain Reaction uncovered various ESBLs, pAmpCs, and other non-β-lactam encoding genes. Of the phenotypically resistant isolates screened for each class of antibiotics, the ESBLs detected were blaCTX-M group (including groups 1, 2, and 9) [51.6% (16/31)], blaTEM [32.3% (10/31)], blaOXA-1-like [19.4% (6/31)], blaSHV [12.9% (4/31)], blaPER [6.5% (2/31)], blaVEB [3.2% (1/31)], blaOXA-48-like and blaVIM [15.4% (2/13)], and blaIMP [7.7% (1/13)]. The pAmpC resistance determinants detected were blaCIT [12.9% (4/31)], blaFOX [9.7% (3/31)], blaEBC [6.5% (2/31)], and blaDHA [3.2% (1/31)]. The frequencies of the non-β-lactam genes detected were catII [79.2% (19/24)], tetA [46.7% (14/30)], sulI and sulII [35.5% (11/31)], tetB [23.3% (7/30)], aadA [12.9% (4/31)], tetC [10% (3/30)], and tetD [3.3% (1/30)]. These results indicate that hospital wastewater is laden with potentially pathogenic MDR Enterobacteriaceae with various antibiotic resistance genes that can be spread to humans throughout the food chain, provided the wastewaters are not properly treated before eventual discharge into the environment.
Læs mere Tjek på PubMedMuhammad Adam Norrulashikin, Fadhilah Yusof, Nur Hanani Mohd Hanafiah, Siti Mariam Norrulashikin
PLoS One Infectious Diseases, 21.07.2021
Tilføjet 22.07.2021
by Muhammad Adam Norrulashikin, Fadhilah Yusof, Nur Hanani Mohd Hanafiah, Siti Mariam Norrulashikin
The increasing trend in the number new cases of influenza every year as reported by WHO is concerning, especially in Malaysia. To date, there is no local research under healthcare sector that implements the time series forecasting methods to predict future disease outbreak in Malaysia, specifically influenza. Addressing the problem could increase awareness of the disease and could help healthcare workers to be more prepared in preventing the widespread of the disease. This paper intends to perform a hybrid ARIMA-SVR approach in forecasting monthly influenza cases in Malaysia. Autoregressive Integrated Moving Average (ARIMA) model (using Box-Jenkins method) and Support Vector Regression (SVR) model were used to capture the linear and nonlinear components in the monthly influenza cases, respectively. It was forecasted that the performance of the hybrid model would improve. The data from World Health Organization (WHO) websites consisting of weekly Influenza Serology A cases in Malaysia from the year 2006 until 2019 have been used for this study. The data were recategorized into monthly data. The findings of the study showed that the monthly influenza cases could be efficiently forecasted using three comparator models as all models outperformed the benchmark model (Naïve model). However, SVR with linear kernel produced the lowest values of RMSE and MAE for the test dataset suggesting the best performance out of the other comparators. This suggested that SVR has the potential to produce more consistent results in forecasting future values when compared with ARIMA and the ARIMA-SVR hybrid model.
Læs mere Tjek på PubMedNick Scott, Allan Saul, Tim Spelman, Mark Stoove, Alisa Pedrana, Alexander Saeri, Emily Grundy, Liam Smith, Michael Toole, Chandini Raina McIntyre, Brendan S. Crabb, Margaret Hellard
PLoS One Infectious Diseases, 21.07.2021
Tilføjet 22.07.2021
by Nick Scott, Allan Saul, Tim Spelman, Mark Stoove, Alisa Pedrana, Alexander Saeri, Emily Grundy, Liam Smith, Michael Toole, Chandini Raina McIntyre, Brendan S. Crabb, Margaret Hellard
Background Whilst evidence of use of face masks in reducing COVID-19 cases is increasing, the impact of mandatory use across a large population has been difficult to assess. Introduction of mandatory mask use on July 22, 2020 during a resurgence of COVID-19 in Melbourne, Australia created a situation that facilitated an assessment of the impact of the policy on the epidemic growth rate as its introduction occurred in the absence of other changes to restrictions.
Methods and findings Exponential epidemic growth or decay rates in daily COVID-19 diagnoses were estimated using a non-weighted linear regression of the natural logarithm of the daily cases against time, using a linear spline model with one knot (lspline package in R v 3.6.3). The model’s two linear segments pivot around the hinge day, on which the mask policy began to take effect, 8 days following the introduction of the policy. We used two forms of data to assess change in mask usage: images of people wearing masks in public places obtained from a major media outlet and population-based survey data. Potential confounding factors (including daily COVID-19 tests, number of COVID-19 cases among population subsets affected differentially by the mask policy–e.g., healthcare workers) were examined for their impact on the results. Daily cases fitted an exponential growth in the first log-linear segment (k = +0.042, s.e. = 0.007), and fitted an exponential decay in the second (k = -0.023, s.e. = 0.017) log-linear segment. Over a range of reported serial intervals for SARS-CoV-2 infection, these growth rates correspond to a 22–33% reduction in an effective reproduction ratio before and after mandatory mask use. Analysis of images of people in public spaces showed mask usage rose from approximately 43% to 97%. Analysis of survey data found that on the third day before policy introduction, 44% of participants reported “often” or “always” wearing a mask; on the fourth day after, 100% reported “always” doing so. No potentially confounding factors were associated with the observed change in growth rates.
Conclusions The mandatory mask use policy substantially increased public use of masks and was associated with a significant decline in new COVID-19 cases after introduction of the policy. This study strongly supports the use of masks for controlling epidemics in the broader community.
Læs mere Tjek på PubMedInfection, 21.07.2021
Tilføjet 21.07.2021