Heterogeneity in the effectiveness of non-pharmaceutical interventions during the first SARS-CoV2 wave in the United States

Background: Attempts to quantify effect sizes of non-pharmaceutical interventions (NPI) to control COVID-19 in the US have not accounted for heterogeneity in social or environmental factors that may influence NPI effectiveness. This study quantifies national and sub-national effect sizes of NPIs during the early months of the pandemic in the US. Methods: Daily county-level COVID-19 cases and deaths during the first wave (January 2020 through phased removal of interventions) were obtained. County-level cases, doubling times, and death rates were compared to four increasingly restrictive NPI levels. Socio-demographic, climate and mobility factors were analyzed to explain and evaluate NPI heterogeneity, with mobility used to approximate NPI compliance. Analyses were conducted separately for the US and for each Census regions (Pacific, Mountain, east/West North Central, East/West South Central, South Atlantic, Middle Atlantic and New England). A stepped-wedge cluster-randomized trial analysis was used, leveraging the phased implementation of policies. Results: Aggressive (level 4) NPIs were associated with slower COVID-19 propagation, particularly in high compliance counties. Longer duration of level 4 NPIs was associated with lower case rates (log beta -0.028, 95% CI -0.04 to -0.02) and longer doubling times (log beta 0.02, 95% CI 0.01–0.03). Effects varied by Census region, for example, level 4 effects on doubling time in Pacific states were opposite to those in Middle Atlantic and New England states. NPI heterogeneity can be explained by differential timing of policy initiation and by variable socio-demographic county characteristics that predict compliance, particularly poverty and racial/ethnic population. Climate exhibits relatively consistent relationships across Census regions, for example, higher minimum temperature and specific humidity were associated with lower doubling times and higher death rates for this period of analysis in South Central, South Atlantic, Middle Atlantic, and New England states. Conclusion and Relevance: Heterogeneity exists in both the effectiveness of NPIs across US Census regions and policy compliance. This county-level variability indicates that control strategies are best designed at community-levelswhere policies can be tuned based on knowledge of local disparities and compliance with public health ordinances.Peer ReviewedPostprint (published version

Government interventions and control policies to contain the first COVID-19 outbreak: An analysis of evidence

Background: The overarching aim of this study was to evaluate the effectiveness over time of government interventions and policy restrictions and the impact of determinants on spread and mortality during the first-wave of the COVID-19 pandemic, globally, regionally and by country-income level, up to 18 May 2020. Methods: We created a global database merging World Health Organization daily case reports (from 218 countries/territories) with other socio-demographic and population health measures from 21 January to 18 May 2020. A four-level government policy interventions score (low to very high) was created based on the Oxford Stringency Index. Results: Our results support the use of very high government interventions to suppress both COVID-19 spread and mortality effectively during wave one globally compared to other policy levels of control. Similar trends in virus propagation and mortality were observed in all country-income levels and specific regions. Conclusions: Rapid implementation of government interventions was needed to contain the first wave of the COVID-19 outbreak and to reduce COVID-19-related mortality.Peer ReviewedPostprint (author's final draft

Pain rates in general population for the period 1991-2015 and 10-years prediction: Results from a multi-continent age-period-cohort analysis

Background: Pain is a common symptom, often associated with neurological and musculoskeletal conditions, and experienced especially by females and by older people. The aims of this study are to evaluate the temporal variations of pain rates among general populations for the period 1991-2015 and to project 10-year pain rates. Methods: We used the harmonized dataset of ATHLOS project, which included 660,028 valid observations in the period 1990-2015 and we applied Bayesian age-period-cohort modeling to perform projections up to 2025. The harmonized Pain variable covers the content "self-reported pain experienced at the time of the interview", with a dichotomous (yes or no) modality. Results: Pain rates were higher among females, older subjects, in recent periods, and among observations referred to cohorts of subjects born between the 20s and the 60s. The 10-year projections indicate a noteworthy increase in pain rates in both genders and particularly among subjects aged 66 or over, for whom a 10-20% increase in pain rate is foreseen; among females only, a 10-15% increase in pain rates is foreseen for those aged 36-50. Conclusions: Projected increase in pain rates will require specific interventions by health and welfare systems, as pain is responsible for limited quality of subjective well-being, reduced employment rates and hampered work performance. Worksite and lifestyle interventions will therefore be needed to limit the impact of projected higher pain rates.The ATHLOS project (Ageing Trajectories of Health: Longitudinal Opportunities and Synergies) has received funding from the European Union’s Horizon 2020 research and innovation programme under grant agreement No 635316

Predictors of pain in general ageing populations: Results from a multi-country analysis based on ATHLOS harmonized database

Background: Pain is a common symptom, often associated with neurological and musculoskeletal conditions, and experienced especially by females and by older people, and with increasing trends in general populations. Different risk factors for pain have been identified, but generally from studies with limited samples and a limited number of candidate predictors. The aim of this study is to evaluate the predictors of pain from a large set of variables and respondents. Methods: We used part of the harmonized dataset of ATHLOS project, selecting studies and waves with a longitudinal course, and in which pain was absent at baseline and with no missing at follow-up. Predictors were selected based on missing distribution and univariable association with pain, and were selected from the following domains: Socio-demographic and economic characteristics, Lifestyle and health behaviours, Health status and functional limitations, Diseases, Physical measures, Cognition, personality and other psychological measures, and Social environment. Hierarchical logistic regression models were then applied to identify significant predictors. Results: A total of 13,545 subjects were included of whom 5348 (39.5%) developed pain between baseline and the average 5.2 years' follow-up. Baseline risk factors for pain were female gender (OR 1.34), engaging in vigorous exercise (OR 2.51), being obese (OR 1.36) and suffering from the loss of a close person (OR 1.88) whereas follow-up risk factors were low energy levels/fatigue (1.93), difficulties with walking (1.69), self-rated health referred as poor (OR 2.20) or average to moderate (OR 1.57) and presence of sleep problems (1.80). Conclusions: Our results showed that 39.5% of respondents developed pain over a five-year follow-up period, that there are proximal and distal risk factors for pain, and that part of them are directly modifiable. Actions aimed at improving sleep, reducing weight among obese people and treating fatigue would positively impact on pain onset, and avoiding vigorous exercise should be advised to people aged 60 or over, in particular if female or obese.The ATHLOS project (Ageing Trajectories of Health: Longitudinal Opportunities and Synergies) has received funding from the European Union’s Horizon 2020 research and innovation programme under grant agreement No 63531

Effectiveness of a mental health stepped-care programme for healthcare workers with psychological distress in crisis settings: a multicentre randomised controlled trial

Background Evidence-based mental health interventions to support healthcare workers (HCWs) in crisis settings are scarce. Objective To evaluate the capacity of a mental health intervention in reducing anxiety and depression symptoms in HCWs, relative to enhanced care as usual (eCAU), amidst the COVID-19 pandemic. Methods We conducted an analyst-blind, parallel, multicentre, randomised controlled trial. We recruited HCWs with psychological distress from Madrid and Catalonia (Spain). The intervention arm received a stepped-care programme consisting of two WHO-developed interventions adapted for HCWs: Doing What Matters in Times of Stress (DWM) and Problem Management Plus (PM+). Each intervention lasted 5 weeks and was delivered remotely by non-specialist mental health providers. HCWs reporting psychological distress after DWM completion were invited to continue to PM+. The primary endpoint was self-reported anxiety/depression symptoms (Patient Health Questionnaire-Anxiety and Depression Scale) at week 21. Findings Between 3 November 2021 and 31 March 2022, 115 participants were randomised to stepped care and 117 to eCAU (86% women, mean age 37.5). The intervention showed a greater decrease in anxiety/depression symptoms compared with eCAU at the primary endpoint (baseline-adjusted difference 4.4, 95% CI 2.1 to 6.7; standardised effect size 0.8, 95% CI 0.4 to 1.2). No serious adverse events occurred. Conclusions Brief stepped-care psychological interventions reduce anxiety and depression during a period of stress among HCWs. Clinical implications Our results can inform policies and actions to protect the mental health of HCWs during major health crises and are potentially rapidly replicable in other settings where workers are affected by global emergencies

A GBD 2019 study of health and Sustainable Development Goal gains and forecasts to 2030 in Spain

This study aimed to report mortality, risk factors, and burden of diseases in Spain. The Global Burden of Disease, Injuries, and Risk Factors 2019 estimates the burden due to 369 diseases, injuries, and impairments and 87 risk factors and risk factor combinations. Here, we detail the updated Spain 1990-2019 burden of disease estimates and project certain metrics up to 2030. In 2019, leading causes of death were ischaemic heart disease, stroke, chronic obstructive pulmonary disease, Alzheimer's disease, and lung cancer. Main causes of disability adjusted life years (DALYs) were ischaemic heart disease, diabetes, lung cancer, low back pain, and stroke. Leading DALYs risk factors included smoking, high body mass index, and high fasting plasma glucose. Spain scored 74/100 among all health-related Sustainable Development Goals (SDGs) indicators, ranking 20 of 195 countries and territories. We forecasted that by 2030, Spain would outpace Japan, the United States, and the European Union. Behavioural risk factors, such as smoking and poor diet, and environmental factors added a significant burden to the Spanish population's health in 2019. Monitoring these trends, particularly in light of COVID-19, is essential to prioritise interventions that will reduce the future burden of disease to meet population health and SDG commitments

Albanese varieties of non-Archimedean uniformized varieties

En esta tesis doctoral ofrecemos una construcción conjetural de la variedad de Albanese de una variedad uniformizada no arquimediana fijándonos en una estructura métrica contenida en la última y llamada su esqueleto (que es, esencialmente, una curva tropical). Para ello realizamos una construcción paralela (real, tropical) sobre el esqueleto, que deviene el esqueleto de nuestra propuesta para variedad de Albanese, la subimos a una construcción analítica sobre la variedad dada y usamos que su esqueleto es el cociente de un cierto subedificio localmente finito de un edificio de Bruhat-Tits, que también aparece como el esqueleto de la variedad uniformizante. Entonces, relacionamos unas ciertas cocadenas armónicas en los edificios con las medidas armónicas en sus finales como paso clave en la demostración de que la construcción hecha es la variedad de Albanese. Esta tesis tiene dos partes principales. Una está dedicada a describir con completa generalidad esta construcción en dimensión 1, mientras en la segunda estudiamos la estructura del edificio de Bruhat-Tits y realizamos una construcción que preveemos que es la variedad de Albanese buscada, bajo la hipótesis de que el cuerpo base tiene una valoración discreta. Empezamos estudiando la Jacobiana de un grafo, en el capítulo 1 sin más estructura, en el capítulo 2 un grafo métrico. Nuestro trabajo, junto con otros, muestra que nuestra descripción de la Jacobiana de un grafo métrico en términos de integración sobre los finales del árbol métrico que es su recubrimiento universal extiende, de alguna manera, la Jacobiana (discreta) de un grafo sin estructura métrica. Aquí introducimos las cocadenas armónicas en los árboles y las medidas armónicas en los finales, y demostramos que hay un isomorfismo entre ellas como paso importante para lograr el resultado principal. En el capítulo 3 desarrollamos la teoría de curvas de Mumford y sus Jacobianas en el marco de la geometría de Berkovich, las relacionamos con sus esqueletos por medio de la aplicación de retracción e introducimos las integrales multiplicativas. Entonces extendemos a nuestras hipótesis generales varios resultados conocidos en casos particulares (por ejemplo, sobre un cuerpo base local) gracias a esas herramientas recientes, y usamos los resutados sobre la Jacobiana de un grafo métrico aplicados al esqueleto correspondiente para obtener que la construcción realizada mediante integrales multiplicativas y medidas armónicas es una variedad abeliana. Después probamos que es la Jacobiana mediante la teoría de funciones theta, desarrollada desde la perspectiva novedosa de la geometría de Berkovich usando funciones tropicales. En el capítulo 4 adaptamos esta construcción a dimensión superior, dando un candidato natural a ser la variedad de Albanese de una variedad uniformizada no arquimediana tal como construyó Mustafin como una generalización de las curvas de Mumford. Para ello extendemos la noción de grupo de Schottky a cualquier dimensión siguiendo el trabajo de Mustafin y estudiamos con detalle la estructura de los edificios de Bruhat-Tits sobre un cuerpo completo con una valoración discreta. Entonces nos retringimos a dimensión 2 para definir las cocadenas armónicas sobre ciertos subcomplejos de cámaras, y probamos que son isomorfas a las medidas armónicas sobre un cierto compacto de los puntos racionales del correspondiente espacio proyectivo cuando el subcomplejo asociado es un edificio. Finalmente, usamos esto para hacer una reducción de la demostración de que la construcción realizada es un toro analítico.In this PhD thesis, we give a conjectural construction of the Albanese variety of a non-Archimedean uniformized variety by means of looking at a metrical structure contained in the last one and called its skeleton (which is, essentially, a tropical curve). In order to do that we make a parallel (real, tropical) construction on the skeleton, which becomes the skeleton of the conjectural Albanese we were seeking for, we rise this to an analytic construction over the given variety and we use that its skeleton is the quotient of a certain locally finite subbuilding of a Bruhat-Tits building, which appears also as the skeleton of the uniformizing variety. Later, we relate the harmonic cochains on the buildings with the harmonic measures on the ends as a key step in the proof that one gets the Albanese variety. The thesis has two main parts. One is devoted to describe with complete generality this construction in dimension 1, while in the second we study the structure of the Bruhat-Tits building and we make a construction that we expect it is the Albanese variety, under the assumption that the ground field has a discrete valuation. We start by study the Jacobian of a graph, in the chapter 1 without more structure, in the chapter 2 a metric graph. Our work, together with others, shows that our description of the Jacobian of a metric graph in terms of integration on the ends of the universal covering metric tree extends in some way the (discrete) Jacobian of a graph without metric structure. Here we introduce harmonic cochains on the trees and harmonic measures on the ends, and we prove that they are isomorphic, as an important step to the main result. In the chapter 3 we develope the theory of Mumford curves and their Jacobians in the setting of Berkovich geometry, we relate them with their skeletons by means of the retraction map and we introduce the multiplicative integrals. Then, we extend to our general hypotheses several known results about them in particular cases (like for a local ground field) with those new tools, and we use the results on the Jacobian of a metric graph applied to the corresponding skeleton to get that the construction we do with multiplicative integrals and harmonic measures is an abelian variety. After that, we prove that it is the Jacobian by means of the theory of theta functions, developed from the new perspective of Berkovich geometry using tropical functions. In the chapter 4 we adapt this construction to higher dimension, giving a natural candidate to be the Albanese variety of a non-Archimedean uniformized variety as it was built by Mustafin as a generalization of Mumford curves. In order to do it, we extend the notion of Schottky group to any dimension following the work of Mustafin, and we study deeply the structure of the Bruhat-Tits buildings over a complete field with a discrete valuation. Then, we restrict to dimension 2 to define the harmonic cochains over certain chamber subcomplexes, and we prove that they are isomorphic to the harmonic measures over a certain compact set of the rational points of the corresponding projective space when the associated subcomplex is a building. Finally we use it to start to prove that the construction we do is an analytic torus

Albanese varieties of non-Archimedean uniformized varieties

En esta tesis doctoral ofrecemos una construcción conjetural de la variedad de Albanese de una variedad uniformizada no arquimediana fijándonos en una estructura métrica contenida en la última y llamada su esqueleto (que es, esencialmente, una curva tropical). Para ello realizamos una construcción paralela (real, tropical) sobre el esqueleto, que deviene el esqueleto de nuestra propuesta para variedad de Albanese, la subimos a una construcción analítica sobre la variedad dada y usamos que su esqueleto es el cociente de un cierto subedificio localmente finito de un edificio de Bruhat-Tits, que también aparece como el esqueleto de la variedad uniformizante. Entonces, relacionamos unas ciertas cocadenas armónicas en los edificios con las medidas armónicas en sus finales como paso clave en la demostración de que la construcción hecha es la variedad de Albanese. Esta tesis tiene dos partes principales. Una está dedicada a describir con completa generalidad esta construcción en dimensión 1, mientras en la segunda estudiamos la estructura del edificio de Bruhat-Tits y realizamos una construcción que preveemos que es la variedad de Albanese buscada, bajo la hipótesis de que el cuerpo base tiene una valoración discreta. Empezamos estudiando la Jacobiana de un grafo, en el capítulo 1 sin más estructura, en el capítulo 2 un grafo métrico. Nuestro trabajo, junto con otros, muestra que nuestra descripción de la Jacobiana de un grafo métrico en términos de integración sobre los finales del árbol métrico que es su recubrimiento universal extiende, de alguna manera, la Jacobiana (discreta) de un grafo sin estructura métrica. Aquí introducimos las cocadenas armónicas en los árboles y las medidas armónicas en los finales, y demostramos que hay un isomorfismo entre ellas como paso importante para lograr el resultado principal. En el capítulo 3 desarrollamos la teoría de curvas de Mumford y sus Jacobianas en el marco de la geometría de Berkovich, las relacionamos con sus esqueletos por medio de la aplicación de retracción e introducimos las integrales multiplicativas. Entonces extendemos a nuestras hipótesis generales varios resultados conocidos en casos particulares (por ejemplo, sobre un cuerpo base local) gracias a esas herramientas recientes, y usamos los resutados sobre la Jacobiana de un grafo métrico aplicados al esqueleto correspondiente para obtener que la construcción realizada mediante integrales multiplicativas y medidas armónicas es una variedad abeliana. Después probamos que es la Jacobiana mediante la teoría de funciones theta, desarrollada desde la perspectiva novedosa de la geometría de Berkovich usando funciones tropicales. En el capítulo 4 adaptamos esta construcción a dimensión superior, dando un candidato natural a ser la variedad de Albanese de una variedad uniformizada no arquimediana tal como construyó Mustafin como una generalización de las curvas de Mumford. Para ello extendemos la noción de grupo de Schottky a cualquier dimensión siguiendo el trabajo de Mustafin y estudiamos con detalle la estructura de los edificios de Bruhat-Tits sobre un cuerpo completo con una valoración discreta. Entonces nos retringimos a dimensión 2 para definir las cocadenas armónicas sobre ciertos subcomplejos de cámaras, y probamos que son isomorfas a las medidas armónicas sobre un cierto compacto de los puntos racionales del correspondiente espacio proyectivo cuando el subcomplejo asociado es un edificio. Finalmente, usamos esto para hacer una reducción de la demostración de que la construcción realizada es un toro analítico.In this PhD thesis, we give a conjectural construction of the Albanese variety of a non-Archimedean uniformized variety by means of looking at a metrical structure contained in the last one and called its skeleton (which is, essentially, a tropical curve). In order to do that we make a parallel (real, tropical) construction on the skeleton, which becomes the skeleton of the conjectural Albanese we were seeking for, we rise this to an analytic construction over the given variety and we use that its skeleton is the quotient of a certain locally finite subbuilding of a Bruhat-Tits building, which appears also as the skeleton of the uniformizing variety. Later, we relate the harmonic cochains on the buildings with the harmonic measures on the ends as a key step in the proof that one gets the Albanese variety. The thesis has two main parts. One is devoted to describe with complete generality this construction in dimension 1, while in the second we study the structure of the Bruhat-Tits building and we make a construction that we expect it is the Albanese variety, under the assumption that the ground field has a discrete valuation. We start by study the Jacobian of a graph, in the chapter 1 without more structure, in the chapter 2 a metric graph. Our work, together with others, shows that our description of the Jacobian of a metric graph in terms of integration on the ends of the universal covering metric tree extends in some way the (discrete) Jacobian of a graph without metric structure. Here we introduce harmonic cochains on the trees and harmonic measures on the ends, and we prove that they are isomorphic, as an important step to the main result. In the chapter 3 we develope the theory of Mumford curves and their Jacobians in the setting of Berkovich geometry, we relate them with their skeletons by means of the retraction map and we introduce the multiplicative integrals. Then, we extend to our general hypotheses several known results about them in particular cases (like for a local ground field) with those new tools, and we use the results on the Jacobian of a metric graph applied to the corresponding skeleton to get that the construction we do with multiplicative integrals and harmonic measures is an abelian variety. After that, we prove that it is the Jacobian by means of the theory of theta functions, developed from the new perspective of Berkovich geometry using tropical functions. In the chapter 4 we adapt this construction to higher dimension, giving a natural candidate to be the Albanese variety of a non-Archimedean uniformized variety as it was built by Mustafin as a generalization of Mumford curves. In order to do it, we extend the notion of Schottky group to any dimension following the work of Mustafin, and we study deeply the structure of the Bruhat-Tits buildings over a complete field with a discrete valuation. Then, we restrict to dimension 2 to define the harmonic cochains over certain chamber subcomplexes, and we prove that they are isomorphic to the harmonic measures over a certain compact set of the rational points of the corresponding projective space when the associated subcomplex is a building. Finally we use it to start to prove that the construction we do is an analytic torus

Estimating the COVID-19 spread through real-time population mobility patterns: surveillance in low- and middle-income countries

Background: On January 21, 2020, the World Health Organization reported the first case of severe acute respiratory syndrome coronavirus 2, which rapidly evolved to the COVID-19 pandemic. Since then, the virus has also rapidly spread among Latin American, Caribbean, and African countries. Objective: The first aim of this study is to identify new emerging COVID-19 clusters over time and space (from January 21 to mid-May 2020) in Latin American, Caribbean, and African regions, using a prospective space–time scan measurement approach. The second aim is to assess the impact of real-time population mobility patterns between January 21 and May 18, 2020, under the implemented government interventions, measurements, and policy restrictions on COVID-19 spread among those regions and worldwide. Methods: We created a global COVID-19 database, of 218 countries and territories, merging the World Health Organization daily case reports with other measures such as population density and country income levels for January 21 to May 18, 2020. A score of government policy interventions was created for low, intermediate, high, and very high interventions. The population’s mobility patterns at the country level were obtained from Google community mobility reports. The prospective space–time scan statistic method was applied in five time periods between January and May 2020, and a regression mixed model analysis was used. Results: We found that COVID-19 emerging clusters within these five periods of time increased from 7 emerging clusters to 28 by mid-May 2020. We also detected various increasing and decreasing relative risk estimates of COVID-19 spread among Latin American, Caribbean, and African countries within the period of analysis. Globally, population mobility to parks and similar leisure areas during at least a minimum of implemented intermediate-level control policies (when compared to low-level control policies) was related to accelerated COVID-19 spread. Results were almost consistent when regional stratified analysis was applied. In addition, worldwide population mobility due to working during high implemented control policies and very high implemented control policies, when compared to low-level control policies, was related to positive COVID-19 spread. Conclusions: The prospective space–time scan is an approach that low-income and middle-income countries could use to detect emerging clusters in a timely manner and implement specific control policies and interventions to slow down COVID-19 transmission. In addition, real-time population mobility obtained from crowdsourced digital data could be useful for current and future targeted public health and mitigation policies at a global and regional level.DF is a Serra Húnter Fellow and was supported by Marsden grant E2987-3648 administrated by the Royal Society of New Zealand, and by grant 2017 SGR 622 (GRBIO) administrated by the Departament d'Economia i Coneixement de la Generalitat de Catalunya (Spain)Peer ReviewedPostprint (published version

Mental Disorders, Musculoskeletal Disorders and Income-Driven Patterns: Evidence from the Global Burden of Disease Study 2017

Background: The aim of the present study was to use the extensive Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) database from 1990–2017 to evaluate the levels and temporal correlation trends between disability adjusted life years (DALYs) attributed to musculoskeletal (MSK) disorders, all mental disorders collectively and by mental disorder sub-category. Methods: We utilized results of the GBD 2017 to describe the correlation patterns between DALYs due to MSK disorders, mental disorders and other diseases among 195 countries. Mixed model analysis was also applied. Results: A consistent relation was reported between age-adjusted DALYs attributed to MSK and mental disorders (in total) among the 195 countries, in both sexes, for 1990 to 2017 (1990 Rho = 0.487; 2017 Rho = 0.439 p < 0.05). Distinct regional and gender correlation patterns between age-adjusted DALYs due to MSK and mental disorders were reported. No correlation was reported between DALYs due to MSK and all mental disorders collectively, among Low- or Middle-income countries. However, in High-income countries (HICs), the correlation was strong and consistent between 1990 and 2017 (1990 Rho = 0.735; 2017 Rho = 0.727, p < 0.05). Conclusions: The reported correlation patterns call for targeted preventive strategies and intervention policies for mental and MSK disorders internationally. Special attention is needed among HICs