COVID-19 surveillance in England: lessons for the next pandemic

Knowing the size of an epidemic and whether it is increasing or decreasing is core to any response to it, be it by individuals, organisations, or governments. Julii Brainard and colleagues1 have compared 12 COVID-19 surveillance systems that were used in England from the start of the second wave of the pandemic (Sept 1, 2020) to just before Omicron emerged (Nov 30, 2021). Compared with the most accurate measures from the Office for National Statistics (those most representative of the whole population), which are least timely (10–24-day lag), they found that “laboratory-confirmed case counts and emergency department attendances were the most timely and also independent indicators of concurrent epidemic status”.

What is associated with reported acute respiratory infection in children under 5 and PCV vaccination in children aged 1–36 months in Malawi? A secondary data analysis using the Malawi 2014 MICS survey

INTRODUCTION: Acute respiratory illness (ARI) is a leading cause of mortality in children under 5 (CU5) in Malawi and can be prevented with 3-dose pneumococcal conjugate vaccine (PCV). There has been no national study in Malawi that seeks to associate social economic factors leading to PCV vaccine uptake and reported acute respiratory infections (RARI). The objectives of our study were to do this. METHODS: We conducted a cross-sectional analysis of secondary data from the 2014 UNICEF Malawi Multiple Indicator Cluster Survey to construct mutlivariable logistic regression models for independent associations with PCV 1/2/3 immunisation and RARI. RESULTS: 56% of CU5 in Malawi RARI in the 2 week recall period of the survey. Independent associations with reduced odds of RARI were central region living (OR 0.82, 95%CI (0.71-0.93)) middle (OR 0.84, (0.73-0.97)) fourth (OR 0.79, (0.68-0.92)) and richest wealth quintiles (OR 0.73, (0.60-0.88)). Using straw/shrubs for fuel was associated with increased RARI (OR 3.13, (1.00-9.79)). Among 1-36 month olds, in 2014, 93.3% received PCV1, 86.8% PCV2 and 77.0% PCV3. Between 2011-2014, the average age in months for a child to receive PCV1/2/3 reduced by 26.6 for PCV1, 26.4 for PCV2, and 26.1 for PCV 3. Independent predicators for increased odds of all 3 PCV doses, relative to 0-5 age group, were age group 6-11 (OR 21.8, (18.2-26.1) 12-23 (OR 27.5, (23.5-32.2) 24-36 months (OR 9.09, (7.89-10.5), mothers having a secondary (OR 1.52, (1.25-1.84)) or higher education (OR 2.68, (1.43-5.04) when compared to no education, and children in the middle (OR 1.24, (1.07-1.43)) fourth (OR 1.27, (1.09-1.48)) richest (OR 1.54, (1.27-1.88)) wealth quintiles relative to the lowest. Children living with 4-6 other children was independently associated with reduced odds of receiving all 3 PCV doses (OR 0.56, (0.33-0.96). CONCLUSION: We report nationally representative social economic associations with RARI and PCV vaccine uptake and coverage estimates. We found reductions in the average age a child receives all 3 PCV vaccine doses between 2011-2014

Testing, tracing and isolation in compartmental models

Existing compartmental mathematical modelling methods for epidemics, such as SEIR models, cannot accurately represent effects of contact tracing. This makes them inappropriate for evaluating testing and contact tracing strategies to contain an outbreak. An alternative used in practice is the application of agent- or individual-based models (ABM). However ABMs are complex, less well-understood and much more computationally expensive. This paper presents a new method for accurately including the effects of Testing, contact-Tracing and Isolation (TTI) strategies in standard compartmental models. We derive our method using a careful probabilistic argument to show how contact tracing at the individual level is reflected in aggregate on the population level. We show that the resultant SEIR-TTI model accurately approximates the behaviour of a mechanistic agent-based model at far less computational cost. The computational efficiency is such that it can be easily and cheaply used for exploratory modelling to quantify the required levels of testing and tracing, alone and with other interventions, to assist adaptive planning for managing disease outbreaks

‘That is because we are alone’:A relational qualitative study of socio-spatial inequities in maternal and newborn health programme coverage in rural Uttar Pradesh, India

This qualitative study was conducted in Uttar Pradesh state, India to explore how interrelated socio-economic position and spatial characteristics of four diverse villages may have influenced equity in coverage of community-based maternal and newborn health (MNH) services. We conducted social mapping and three focus group discussions in each village, among women of lower and higher socio-economic position who recently gave birth, and with community health workers (n = 134). Data were analysed in NVivo 11.0 using thematic framework analysis. The extent of socio-economic hierarchies and spatial disparateness within the village, combined with distance to larger centers, together shaped villages’ level of socio-spatial remoteness. Disadvantaged socio-economic groups expressed being more often spatially isolated, with less access to infrastructure, resources or services, which was heightened if the village was physically distant from larger centers. In more socio-spatially remote villages, inequities in coverage of MNH services that disadvantaged lower socio-economic position groups were compounded as these groups more often experienced ASHA vacancies, as well as greater distance to and poorer perceived quality of health services nearest the village. The results inform a conceptual framework of ‘socio-spatial remoteness’ that can guide public health research and programmes to more comprehensively address health inequities within India and beyond.</p

‘That is because we are alone’:A relational qualitative study of socio-spatial inequities in maternal and newborn health programme coverage in rural Uttar Pradesh, India

This qualitative study was conducted in Uttar Pradesh state, India to explore how interrelated socio-economic position and spatial characteristics of four diverse villages may have influenced equity in coverage of community-based maternal and newborn health (MNH) services. We conducted social mapping and three focus group discussions in each village, among women of lower and higher socio-economic position who recently gave birth, and with community health workers (n = 134). Data were analysed in NVivo 11.0 using thematic framework analysis. The extent of socio-economic hierarchies and spatial disparateness within the village, combined with distance to larger centers, together shaped villages’ level of socio-spatial remoteness. Disadvantaged socio-economic groups expressed being more often spatially isolated, with less access to infrastructure, resources or services, which was heightened if the village was physically distant from larger centers. In more socio-spatially remote villages, inequities in coverage of MNH services that disadvantaged lower socio-economic position groups were compounded as these groups more often experienced ASHA vacancies, as well as greater distance to and poorer perceived quality of health services nearest the village. The results inform a conceptual framework of ‘socio-spatial remoteness’ that can guide public health research and programmes to more comprehensively address health inequities within India and beyond.</p

A Critical Analysis of the Drivers of Human Migration Patterns in the Presence of Climate Change: A New Conceptual Model.

Both climate change and migration present key concerns for global health progress. Despite this, a transparent method for identifying and understanding the relationship between climate change, migration and other contextual factors remains a knowledge gap. Existing conceptual models are useful in understanding the complexities of climate migration, but provide varying degrees of applicability to quantitative studies, resulting in non-homogenous transferability of knowledge in this important area. This paper attempts to provide a critical review of climate migration literature, as well as presenting a new conceptual model for the identification of the drivers of migration in the context of climate change. It focuses on the interactions and the dynamics of drivers over time, space and society. Through systematic, pan-disciplinary and homogenous application of theory to different geographical contexts, we aim to improve understanding of the impacts of climate change on migration. A brief case study of Malawi is provided to demonstrate how this global conceptual model can be applied into local contextual scenarios. In doing so, we hope to provide insights that help in the more homogenous applications of conceptual frameworks for this area and more generally

Bioelectrical impedance vector analysis as an indicator of malnutrition in children under five years with and without pneumonia in Mchinji District, Malawi: An exploratory mixed-methods analysis [version 1; peer review: awaiting peer review]

Background: Bioelectrical impedance vector analysis (BIVA) is a non-invasive assessment of body composition and cellular health, which may improve the assessment of nutritional status in sick children. We explored the reliability, clinical utility, and acceptability of BIVA, as an indicator of nutritional status for children under five years with and without pneumonia, in Malawi. Methods: We conducted a parallel convergent mixed-methods exploratory study in Mchinji District Hospital, Malawi, in 2017. We planned to recruit a convenience sample of children aged 0-59 months with clinical pneumonia, and without an acute illness. Children had duplicate anthropometric and BIVA measurements taken. BIVA measurements of phase angle (PA) were taken of the whole body, and trunk and arm segments. Reliability was assessed by comparing the variability in the two measures, and clinical utility by estimating the association between anthropometry and PA using linear regression. Focus group discussions with healthcare workers who had not previously used BIVA instrumentation were conducted to explore acceptability. Results: A total of 52 children (24 with pneumonia and 28 healthy) were analysed. The reliability of sequential PA measurements was lower than anthropometric measurements, but trunk and arm segments performed better. The largest associations with PA were a negative relationship with weight-for-age z-score (WAZ) and PA in children with pneumonia in the trunk segment, and a positive association with WAZ in the full body measurement in healthy children. Healthcare workers in focus group discussions expressed trust in BIVA technology and that it would enable more accurate diagnosis of malnutrition; however, they raised concerns about the sustainability and necessary resources to implement BIVA. Conclusions: While healthcare workers were positive towards BIVA as a novel technology, implementation challenges should be expected. The differential direction of association between anthropometry and PA for children with pneumonia warrants further investigation

Mortality and its risk factors in Malawian children admitted to hospital with clinical pneumonia, 2001–12: a retrospective observational study

Background Few studies have reported long-term data on mortality rates for children admitted to hospital with pneumonia in Africa. We examined trends in case fatality rates for all-cause clinical pneumonia and its risk factors in Malawian children between 2001 and 2012. Methods Individual patient data for children (<5 years) with clinical pneumonia who were admitted to hospitals participating in Malawi’s Child Lung Health Programme between 2001 and 2012 were recorded prospectively on a standardised medical form. We analysed trends in pneumonia mortality and children’s clinical characteristics, and we estimated the association of risk factors with case fatality for children younger than 2 months, 2–11 months of age, and 12–59 months of age using separate multivariable mixed eff ects logistic regression models. Findings Between November, 2012, and May, 2013, we retrospectively collected all available hard copies of yellow forms from 40 of 41 participating hospitals. We examined 113 154 pneumonia cases, 104 932 (92∧7%) of whom had mortality data and 6903 of whom died, and calculated an overall case fatality rate of 6·6% (95% CI 6·4–6·7). The case fatality rate signifi cantly decreased between 2001 (15·2% [13·4–17·1]) and 2012 (4·5% [4·1–4·9]; ptrend<0·0001). Univariable analyses indicated that the decrease in case fatality rate was consistent across most subgroups. In multivariable analyses, the risk factors signifi cantly associated with increased odds of mortality were female sex, young age, very severe pneumonia, clinically suspected Pneumocystis jirovecii infection, moderate or severe underweight, severe acute malnutrition, disease duration of more than 21 days, and referral from a health centre. Increasing year between 2001 and 2012 and increasing age (in months) were associated with reduced odds of mortality. Fast breathing was associated with reduced odds of mortality in children 2–11 months of age. However, case fatality rate in 2012 remained high for children with very severe pneumonia (11·8%), severe undernutrition (15·4%), severe acute malnutrition (34·8%), and symptom duration of more than 21 days (9·0%). Interpretation Pneumonia mortality and its risk factors have steadily improved in the past decade in Malawi; however, mortality remains high in specifi c subgroups. Improvements in hospital care may have reduced case fatality rates though a lack of suffi cient data on quality of care indicators and the potential of socioeconomic and other improvements outside the hospital precludes adequate assessment of why case-fatality rates fell. Results from this study emphasise the importance of eff ective national systems for data collection. Further work combining this with data on trends in the incidence of pneumonia in the community are needed to estimate trends in the overall risk of mortality from pneumonia in children in Malawi