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Objectives: Mass COVID-19 immunization campaigns altered the pandemic's progress by protecting the vaccine recipient and reducing transmission. However, evidence for indirect vaccine effectiveness (IVE) is limited due to the difficulties of ascertaining this type of protection. Methods: Using linked national Brazilian databases, we adapted the test-negative design to evaluate the IVE against symptomatic infection. We analyzed data from January 1 to December 1, 2021 (pre-omicron) and January 1 to April 30, 2022 (omicron BA.1 and BA.2). We compared the probability of testing positive across various levels of second ancestral-strain monovalent COVID-19 vaccine dose coverage, including only unvaccinated individuals in the main analysis and both vaccinated and unvaccinated individuals in additional analyses. Sensitivity analysis focused on children younger than 12 years who did not have access to COVID-19 vaccines during the pre-omicron period. Results: We included 11,039,315 unvaccinated individuals tested during the pre-omicron study period. IVE was minimal until 30% vaccination coverage (

Abstract An outbreak of SARS-CoV-2 (1 March to 10 May 2021) with an attack rate of 26.5% among approximately 1150 workers at a storage and distribution centre in England prompted a multidisciplinary outbreak investigation (5 May to 6 August 2021), with the aim of better understanding worker- and workplace-related risk factors for viral transmission in the warehousing sector. Overall, environmental factors (e.g., ventilation, humidity and temperature) were assessed to be appropriate at the facility. Nevertheless, 39 (51.3%) surface samples from across the site tested positive for low/ very low levels of SARS-CoV-2 RNA (Ct value ≥ 32.0 for all). Among the study participants, of whom 35.6% were confirmed or suspected cases, 95.5% reported having received COVID-19 prevention training, 100.0% reported handwashing, and 80.0% reported use of face coverings at work. Notably, 43.9% and 19.0% reported working with a symptomatic and a positive contact respectively. Furthermore, 80.5% and 46.3% had concerns regarding reduction in their income and future unemployment, respectively, due to self-isolation. The findings of this study suggest that, in addition to targeted workplace infection control measures and tailored work area specific risk assessments, an enhanced and equitable sick leave policy may help limit presenteeism and viral transmission in large workplaces.

Abstract EFSA requested its Scientific Committee to prepare a guidance document on appraising and integrating evidence from epidemiological studies for use in EFSA's scientific assessments. The guidance document provides an introduction to epidemiological studies and illustrates the typical biases, which may be present in different epidemiological study designs. It then describes key epidemiological concepts relevant for evidence appraisal. This includes brief explanations for measures of association, exposure assessment, statistical inference, systematic error and effect modification. The guidance then describes the concept of external validity and the principles of appraising epidemiological studies. The customisation of the study appraisal process is explained including tailoring of tools for assessing the risk of bias (RoB). Several examples of appraising experimental and observational studies using a RoB tool are annexed to the document to illustrate the application of the approach. The latter part of this guidance focuses on different steps of evidence integration, first within and then across different streams of evidence. With respect to risk characterisation, the guidance considers how evidence from human epidemiological studies can be used in dose–response modelling with several different options being presented. Finally, the guidance addresses the application of uncertainty factors in risk characterisation when using evidence from human epidemiological studies.

Background: The International Study of Asthma and Allergies in Childhood (ISAAC) and the Global Asthma Network (GAN) conducted a series of global asthma prevalence surveys, between 1990 and 2020, in adolescents aged 13–14 and children aged 6–7 years. We used them to assess whether potential asthma risk factors explain global asthma symptom prevalence trends over this period. Method: We fitted mixed-effects linear regression models to estimate associations between centre-level risk factor prevalence and both the mid-point asthma symptom prevalence and the change per decade. We also estimated the 2019 asthma symptom prevalence across all included centres. Results: For adolescents, across 50 centres in 26 countries there was weak evidence that decreasing asthma prevalence over time was associated with regular fast-food consumption and frequent television viewing. However, frequent television viewing, along with heavy truck traffic, were associated with higher prevalence of asthma symptoms at the study mid-point. For children, across 41 centres in 21 countries, no risk factors were associated with time trends in asthma symptom prevalence, but truck traffic and paracetamol in the first year of life were associated with higher mid-point prevalence.We estimated the 2019 asthma symptom prevalence, across a total of 124 centres, to be 12.8% (11.4%, 14.2%) with little evidence of a difference by age. Low-income countries had lower prevalence (children 5.2% [2.5%, 7.8%], adolescents 5.3% [2.8%, 7.8%]), than lower-middle-, upper-middle- and high-income countries (all approximately 14–15%). Including risk factors in the models did not change the estimates. Conclusion: Potential asthma risk factors do not seem to explain the global prevalence patterns or time trends. Country income accounts for some of the differences, but the unexplained variation is very high.

Background: Asthma is a complex disease and a severe global public health problem resulting from interactions between genetic background and environmental exposures. It has been suggested that gut microbiota may be related to asthma development; however, such relationships needs further investigation. Objective: This study aimed to characterize the gut microbiota as well as the nasal lavage cytokine profile of asthmatic and nonasthmatic individuals. Methods: Stool and nasal lavage samples were collected from 29 children and adolescents with type 2 asthma and 28 children without asthma in Brazil. Amplicon sequencing of the stool bacterial V4 region of the 16S rRNA gene was performed using Illumina MiSeq. Microbiota analysis was performed by QIIME 2 and PICRUSt2. Type 2 asthma phenotype was characterized by high sputum eosinophil counts and positive skin prick tests for house dust mite, cockroach, and/or cat or dog dander. The nasal immune marker profile was assessed using a customized multiplex panel. Results: Stool microbiota differed significantly between asthmatic and nonasthmatic participants (P = .001). Bacteroides was more abundant in participants with asthma (P < .05), while Prevotella was more abundant in nonasthmatic individuals (P < .05). In people with asthma, the relative abundance of Bacteroides correlated with IL-4 concentration in nasal lavage samples. Inference of microbiota functional capacity identified differential fatty acid biosynthesis in asthmatic compared to nonasthmatic subjects. Conclusion: The stool microbiota differed between asthmatic and nonasthmatic young people in Brazil. Asthma was associated with higher Bacteroides levels, which correlated with nasal IL-4 concentration.

Abstract Background A SARS-CoV-2 outbreak with an attack rate of 14.3% was reported at a plastics manufacturing plant in England. Methods Between 23rd March and 13th May 2021, the COVID-OUT team undertook a comprehensive outbreak investigation, including environmental assessment, surface sampling, molecular and serological testing, and detailed questionnaires, to identify potential SARS-CoV-2 transmission routes, and workplace- and worker-related risk factors. Results While ventilation, indicated using real-time CO2 proxy measures, was generally adequate on-site, the technical office with the highest localized attack rate (21.4%) frequently reached peaks in CO2 of 2100ppm. SARS-CoV-2 RNA was found in low levels (Ct ≥35) in surface samples collected across the site. High noise levels (79dB) were recorded in the main production area, and study participants reported having close work contacts (73.1%) and sharing tools (75.5%). Only 20.0% of participants reported using a surgical mask and/or FFP2/FFP3 respirator at least half the time and 71.0% expressed concerns regarding potential pay decreases and/or unemployment due to self-isolation or workplace closure. Conclusions The findings reinforce the importance of enhanced infection control measures in manufacturing sectors, including improved ventilation with possible consideration of CO2 monitoring, utilising air cleaning interventions in enclosed environments, and provision of good-quality face masks (i.e., surgical masks or FFP2/FFP3 respirators) especially when social distancing cannot be maintained. Further research on the impacts of job security-related concerns is warranted.

Objectives This study aims to assess risk factors for SARS-CoV-2 infection by combined design; first comparing positive cases to negative controls as determined by PCR testing and then comparing these two groups to an additional prepandemic population control group.Design and setting Test-negative design (TND), multicentre case–control study with additional population controls in South-Eastern Norway.Participants Adults who underwent SARS-CoV-2 PCR testing between February and December 2020. PCR-positive cases, PCR-negative controls and additional age-matched population controls.Primary outcome measures The associations between various risk factors based on self- reported questionnaire and SARS-CoV-2 infection comparing PCR-positive cases and PCR-negative controls. Using subgroup analysis, the risk factors for both PCR-positive and PCR-negative participants were compared with a population control group.Results In total, 400 PCR-positive cases, 719 PCR-negative controls and 14 509 population controls were included. Male sex was associated with the risk of SARS-CoV-2 infection only in the TND study (OR 1.9, 95% CI 1.4 to 2.6), but not when PCR-positive cases were compared with population controls (OR 1.2, 95% CI 0.9. to 1.5). Some factors were positively (asthma, wood heating) or negatively (hypertension) associated with SARS-CoV-2 infection when PCR-positive cases were compared with population controls, but lacked convincing association in the TND study. Smoking was negatively associated with the risk of SARS-CoV-2 infection in both analyses (OR 0.5, 95% CI 0.3 to 0.8 and OR 0.6, 95% CI 0.4 to 0.8).Conclusions Male sex was a possible risk factor for SARS-CoV-2 infection only in the TND study, whereas smoking was negatively associated with SARS-CoV-2 infection in both the TND study and when using population controls. Several factors were associated with SARS-CoV-2 infection when PCR-positive cases were compared with population controls, but not in the TND study, highlighting the strength of combining case–control study designs during the pandemic.

OBJECTIVE: This study aimed to investigate the effects of occupational exposures on the risk of a positive COVID-19 test, and whether this differed across pandemic waves.METHODS: Data from 207 034 workers from The Netherlands with test data on COVID-19 from June 2020 until August 2021 were available. Occupational exposure was estimated by using the eight dimensions of a COVID-19 job exposure matrix (JEM). Personal characteristics, household composition and residence area were derived from Statistics Netherlands. A test-negative design was applied in which the risk of a positive test was analyzed in a conditional logit model.RESULTS: All eight dimensions of occupational exposure included in the JEM increased the odds of a positive test for the entire study period and three pandemic waves [OR ranging from 1.09, (95% confidence interval (CI) 1.02–1.17) to 1.77 (95% CI 1.61–1.96)]. Adjusting for a previous positive test and other covariates strongly reduced the odds to be infected, but most dimensions remained at elevated risk. Fully adjusted models showed that contaminated work spaces and face covering were mostly relevant in the first two pandemic waves, whereas income insecurity showed higher odds in the third wave. Several occupations have a higher predicted value for a positive COVID-19 test, with variation over time.Discussion Occupational exposures are associated with a higher risk of a positive test, but variations over time exist in occupations with the highest risks. These findings provide insights for interventions among workers for future pandemic waves of COVID-19 or other respiratory epidemics.

OBJECTIVE: This study aimed to assess whether workplace exposures as estimated via a COVID-19 job exposure matrix (JEM) are associated with SARS-CoV-2 in the UK.METHODS: Data on 244 470 participants were available from the Office for National Statistics Coronavirus Infection Survey (CIS) and 16 801 participants from the Virus Watch Cohort, restricted to workers aged 20–64 years. Analysis used logistic regression models with SARS-CoV-2 as the dependent variable for eight individual JEM domains (number of workers, nature of contacts, contact via surfaces, indoor or outdoor location, ability to social distance, use of face covering, job insecurity, and migrant workers) with adjustment for age, sex, ethnicity, index of multiple deprivation (IMD), region, household size, urban versus rural area, and health conditions. Analyses were repeated for three time periods (i) February 2020 (Virus Watch)/April 2020 (CIS) to May 2021), (ii) June 2021 to November 2021, and (iii) December 2021 to January 2022.RESULTS: Overall, higher risk classifications for the first six domains tended to be associated with an increased risk of infection, with little evidence of a relationship for domains relating to proportion of workers with job insecurity or migrant workers. By time there was a clear exposure-response relationship for these domains in the first period only. Results were largely consistent across the two UK cohorts.CONCLUSIONS: An exposure-response relationship exists in the early phase of the COVID-19 pandemic for number of contacts, nature of contacts, contacts via surfaces, indoor or outdoor location, ability to social distance and use of face coverings. These associations appear to have diminished over time.

Objective Arterial stiffness and exposure to psychosocial work-related factors increase the risk of developing cardiovascular disease. However, little is known about the relationship between psychosocial work-related factors and arterial stiffness. We aimed to examine this relationship.Design Prospective cohort study.Setting Public organisations in Quebec City, Canada.Participants The study included 1736 white-collar workers (women 52%) from 19 public organisations.Primary and secondary outcome measures Association between psychosocial work-related factors from the job strain and effort–reward imbalance (ERI) models assessed at study baseline (1999–2001) with validated instruments and arterial stiffness assessed using carotid–femoral pulse wave velocity at follow-up, on average 16 years later (2015–2018). Generalised estimating equations were used to estimate differences in arterial stiffness between exposed and unexposed participants. Subgroup analyses according to sex, age, blood pressure (BP), cardiovascular risk score and employment status were conducted.Results Among participants with high diastolic BP (≥90 mm Hg) at baseline, aged 47 on average, those exposed to high job strain had higher arterial stiffness (1.38 m/s (95% CI: 0.57 to 2.19)) at follow-up, 16 years later, following adjustment for a large set of potential confounders. The trend was similar in participants with high systolic BP (≥140 mm Hg) exposed to high job strain (0.84 m/s (95% CI: −0.35 to 2.03)). No association was observed for ERI in the total sample and counterintuitive associations were observed in subgroup analyses.Conclusions Job strain may have a long-term deleterious effect on arterial stiffness in people with high BP. Interventions at midlife to reduce job strain may mitigate arterial stiffness progression.

Abstract Objective To investigate whether herpes simplex virus type 1 (HSV‐1) infection was associated with rates of cognitive decline or whole brain atrophy among individuals from the Dominantly Inherited Alzheimer Network (DIAN). Methods Among two subsets of the DIAN cohort (age range 19.6–66.6 years; median follow‐up 3.0 years) we examined (i) rate of cognitive decline (N = 164) using change in mini‐mental state examination (MMSE) score, (ii) rate of whole brain atrophy (N = 149), derived from serial MR imaging, calculated using the boundary shift integral (BSI) method. HSV‐1 antibodies were assayed in baseline sera collected from 2009–2015. Linear mixed‐effects models were used to compare outcomes by HSV‐1 seropositivity and high HSV‐1 IgG titres/IgM status. Results There was no association between baseline HSV‐1 seropositivity and rates of cognitive decline or whole brain atrophy. Having high HSV‐1 IgG titres/IgM was associated with a slightly greater decline in MMSE points per year (difference in slope − 0.365, 95% CI: −0.958 to −0.072), but not with rate of whole brain atrophy. Symptomatic mutation carriers declined fastest on both MMSE and BSI measures, however, this was not influenced by HSV‐1. Among asymptomatic mutation carriers, rates of decline on MMSE and BSI were slightly greater among those who were HSV‐1 seronegative. Among mutation‐negative individuals, no differences were seen by HSV‐1. Stratifying by APOE4 status yielded inconsistent results. Interpretation We found no evidence for a major role of HSV‐1, measured by serum antibodies, in cognitive decline or whole brain atrophy among individuals at high risk of early‐onset AD.

OBJECTIVE: This study aimed to understand whether the proportionate mortality of COVID-19 for various occupational groups has varied over the pandemic. METHODS: We used the Office for National Statistics (ONS) mortality data for England and Wales. The deaths (20–64 years) were classified as either COVID-19-related using ICD-10 codes (U07.1, U07.2), or from other causes. Occupational data recorded at the time of death was coded using the SOC10 coding system into 13 groups. Three time periods (TP) were used: (i) January 2020 to September 2020; (ii) October 2020–May 2021; and (iii) June 2021–October 2021. We analyzed the data with logistic regression and compared odds of death by COVID-19 to other causes, adjusting for age, sex, deprivation, region, urban/rural and population density. RESULTS: Healthcare professionals and associates had a higher proportionate odds of COVID-19 death in TP1 compared to non-essential workers but were not observed to have increased odds thereafter. Medical support staff had increased odds of death from COVID-19 during both TP1 and TP2, but this had reduced by TP3. This latter pattern was also seen for social care, food retail and distribution, and bus and coach drivers. Taxi and cab drivers were the only group that had higher odds of death from COVID-19 compared to other causes throughout the whole period under study [TP1: odds ratio (OR) 2.42, 95% confidence interval (CI) 1.99–2.93; TP2: OR 3.15, 95% CI 2.63–3.78; TP3: OR 1.7, 95% CI 1.26–2.29]. CONCLUSION: Differences in the odds of death from COVID-19 between occupational groups has declined over the course of the pandemic, although some occupations have remained relatively high throughout.

There is limited evidence of the effectiveness of the CoronaVac vaccine for children against the Omicron SARS-CoV-2 variant. Here, the authors use data from Brazil for children aged 6–11 years and estimate effectiveness of 40% against infection and 59% against severe disease at least two weeks after the second dose.

Primary CoronaVac vaccination followed by a BNT162b2 booster dose confers protection against some SARS-CoV-2 variants but its effectiveness against Omicron is unknown. Here, the authors show that this combination confers a high level of protection against severe outcomes for up to 120 days, with evidence of waning for those aged 80 or older.

Abstract Background More doses of CoronaVac have been administered worldwide than any other COVID-19 vaccine. However, the effectiveness of COVID-19 inactivated vaccines in pregnant women is still unknown. We estimated the vaccine effectiveness (VE) of CoronaVac against symptomatic and severe COVID-19 in pregnant women in Brazil. Methods We conducted a test-negative design study in all pregnant women aged 18–49 years with COVID-19-related symptoms in Brazil from March 15, 2021, to October 03, 2021, linking records of negative and positive SARS-CoV-2 reverse transcription polymerase chain reaction (RT-PCR) tests to national vaccination records. We also linked records of test-positive cases with notifications of severe, hospitalised or fatal COVID-19. Using logistic regression, we estimated the adjusted odds ratio and VE against symptomatic COVID-19 and against severe COVID-19 by comparing vaccine status in test-negative subjects to test-positive symptomatic cases and severe cases. Results Of the 19,838 tested pregnant women, 7424 (37.4%) tested positive for COVID-19 and 588 (7.9%) had severe disease. Only 83% of pregnant women who received the first dose of CoronaVac completed the vaccination scheme. A single dose of the CoronaVac vaccine was not effective at preventing symptomatic COVID-19. The effectiveness of two doses of CoronaVac was 41% (95% CI 27.1–52.2) against symptomatic COVID-19 and 85% (95% CI 59.5–94.8) against severe COVID-19. Conclusions A complete regimen of CoronaVac in pregnant women was effective in preventing symptomatic COVID-19 and highly effective against severe illness in a setting that combined high disease burden and marked COVID-19-related maternal deaths.

Abstract Objective To investigate whether herpes zoster (HZ) was associated with subsequent increased risk of dementia diagnosis. Methods We conducted a historical cohort study using primary care electronic health records from the Clinical Practice Research Datalink in the United Kingdom. Individuals with incident HZ aged ≥40 years from 2000 to 2017 were matched with up to four individuals without HZ by age, sex, primary care practise and calendar time. The primary outcome was a new diagnosis of all‐cause dementia. We used the Cox proportional hazards regression adjusting for demographic, lifestyle and clinical confounders to assess any association between HZ and dementia. We investigated interactions with sex, frailty index and antiviral treatment and conducted various sensitivity analyses. Results The cohort comprised 177,144 individuals with HZ and 706,901 matched unexposed individuals (median age 65 years (IQR 55.1–75.0), 40% male) followed for a median duration of 4.6 years (IQR 2.0–8.1). In total, 26,585 (3%) patients had an incident dementia diagnosis recorded and 113,056 patients died (12.8%). HZ was associated with a small reduction in dementia diagnosis (adjusted HR 0.92 (95% CI 0.89–0.95)), occurring predominantly in frail individuals and females. For patients who were fit (578,115, 65%), no association was seen (adjusted HR 0.97, 95% CI 0.92–1.02). There was no association between HZ and a composite outcome of dementia or death (adjusted HR 1.00, 95% CI 0.99–1.02). Dementia risk did not vary by prescription of antiviral agents. Sensitivity analyses showed consistent results. Interpretation HZ was not associated with increased dementia diagnosis in a UK primary care‐based cohort.

BackgroundBrazil and Scotland have used mRNA boosters in their respective populations since September 2021, with Omicron's emergence accelerating their booster program. Despite this, both countries have reported substantial recent increases in Coronavirus Disease 2019 (COVID-19) cases. The duration of the protection conferred by the booster dose against symptomatic Omicron cases and severe outcomes is unclear.Methods and findingsUsing a test-negative design, we analyzed national databases to estimate the vaccine effectiveness (VE) of a primary series (with ChAdOx1 or BNT162b2) plus an mRNA vaccine booster (with BNT162b2 or mRNA-1273) against symptomatic Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection and severe COVID-19 outcomes (hospitalization or death) during the period of Omicron dominance in Brazil and Scotland compared to unvaccinated individuals. Additional analyses included stratification by age group (18 to 49, 50 to 64, ≥65). All individuals aged 18 years or older who reported acute respiratory illness symptoms and tested for SARS-CoV-2 infection between January 1, 2022, and April 23, 2022, in Brazil and Scotland were eligible for the study. At 14 to 29 days after the mRNA booster, the VE against symptomatic SARS-CoV-2 infection of ChAdOx1 plus BNT162b2 booster was 51.6%, (95% confidence interval (CI): [51.0, 52.2], p < 0.001) in Brazil and 67.1% (95% CI [65.5, 68.5], p < 0.001) in Scotland. At ≥4 months, protection against symptomatic infection waned to 4.2% (95% CI [0.7, 7.6], p = 0.02) in Brazil and 37.4% (95% CI [33.8, 40.9], p < 0.001) in Scotland. VE against severe outcomes in Brazil was 93.5% (95% CI [93.0, 94.0], p < 0.001) at 14 to 29 days post-booster, decreasing to 82.3% (95% CI [79.7, 84.7], p < 0.001) and 98.3% (95% CI [87.3, 99.8], p < 0.001) to 77.8% (95% CI [51.4, 89.9], p < 0.001) in Scotland for the same periods. Similar results were obtained with the primary series of BNT162b2 plus homologous booster. Potential limitations of this study were that we assumed that all cases included in the analysis were due to the Omicron variant based on the period of dominance and the limited follow-up time since the booster dose.ConclusionsWe observed that mRNA boosters after a primary vaccination course with either mRNA or viral-vector vaccines provided modest, short-lived protection against symptomatic infection with Omicron but substantial and more sustained protection against severe COVID-19 outcomes for at least 3 months.

There are important differences in the risk of SARS-CoV-2 infection and death depending on occupation. Infections in healthcare workers have received the most attention, and there are clearly increased risks for intensive care unit workers who are caring for COVID-19 patients. However, a number of other occupations may also be at an increased risk, particularly those which involve social care or contact with the public. A large number of data sets are available with the potential to assess occupational risks of COVID-19 incidence, severity, or mortality. We are reviewing these data sets as part of the Partnership for Research in Occupational, Transport, Environmental COVID Transmission (PROTECT) initiative, which is part of the National COVID-19 Core Studies. In this report, we review the data sets available (including the key variables on occupation and potential confounders) for examining occupational differences in SARS-CoV-2 infection and COVID-19 incidence, severity and mortality. We also discuss the possible types of analyses of these data sets and the definitions of (occupational) exposure and outcomes. We conclude that none of these data sets are ideal, and all have various strengths and weaknesses. For example, mortality data suffer from problems of coding of COVID-19 deaths, and the deaths (in England and Wales) that have been referred to the coroner are unavailable. On the other hand, testing data is heavily biased in some periods (particularly the first wave) because some occupations (e.g. healthcare workers) were tested more often than the general population. Random population surveys are, in principle, ideal for estimating population prevalence and incidence, but are also affected by non-response. Thus, any analysis of the risks in a particular occupation or sector (e.g. transport), will require a careful analysis and triangulation of findings across the various available data sets.

A 58-year-old female had undergone previous mechanical mitral replacement with a Starr-Edwards ball and cage valve (Edwards Lifesciences, Irvine, CA) at 11 years of age for rheumatic disease. The valve functioned well until pannus resulted in prosthetic valve stenosis with class IV dyspnea and pulmonary hypertension. She underwent reoperative mitral replacement with an On-X mechanical mitral prosthesis (Cryolife, Kennesaw, GA) 48 years after initial implantation. To our knowledge, this case represents the longest known implant period of a ball and cage mitral valve in the literature. This presentation highlights the durability of this historic prosthesis, along with the role of reoperative surgery decades after initial implantation. Résumé: Une femme de 58 ans avait subi un remplacement mécanique d’une valve mitrale par une valve à bille Starr-Edwards alors (Edwards Lifesciences, Irvine, CA) qu’elle avait 11 ans par suite d’une maladie rhumatismale. La valve avait bien fonctionné jusqu’à ce que la formation de pannus entraîne une sténose de celle-ci s’accompagnant de dyspnée de classe IV et d’hypertension pulmonaire. La femme a subi une intervention chirurgicale visant à remplacer la valve sténosée par une valve mécanique On-X (Cryolife, Kennesaw, GA) 48 ans après l’implantation initiale. À notre connaissance, il s’agit de la plus longue période d’implantation connue d’une valve mécanique mitrale à bille Starr-Edwards rapportée dans la littérature. Le présent article met en évidence la durabilité de cette prothèse historique, ainsi que le rôle de la chirurgie réopératoire des décennies après l’implantation initiale.

Advanced minimally invasive surgery (MIS) is not universally available in the Anglophone Caribbean, partly due to a shortage of trained laparoscopic surgeons. However, we have witnessed new opportunities for MIS advancement as we enter a period of rapid change in healthcare education. In this paper, we discuss the concept of distance mentoring and the opportunities to promote advanced MIS in the Caribbean. We believe that, if carefully and effectively administered, distance mentoring has the potential for widespread utility, but it requires a change in institutional and medical culture from direct personal training to one that also actively supports distance mentoring.

Abstract Background This study estimated the prevalence and risk factors for decreased estimated glomerular filtration rate (eGFR) in those without known hypertension, type 2 diabetes mellitus, or heavy proteinuria as a surrogate marker for chronic kidney disease of unknown cause (CKDu) among adults in the North of Peru. Methods A cross-sectional study was conducted following the Disadvantaged Populations eGFR Epidemiology (DEGREE) Study protocol. Low eGFR was defined based on a single eGFR ≤60 mL/min/1.7m2 estimated using the CKD-EPI equation. Environmental conditions related to CKDu (i.e., work in agriculture or sugarcane, water source, heat intolerance, and pesticide exposure) were evaluated, in addition to traditional risk factors for CKD (i.e., smoking, heavy drinking, physical activity, hypertension, type 2 diabetes mellitus, urolithiasis, among others). Results A total of 1514 subjects were included in the study, mean age 45.1 (SD: 16.4), and 55.2% were females. Overall, only 26 cases (1.7%; 95%CI: 1.1–2.5%) had an eGFR

We read with great interest the paper by Reuter et al (1) on the differences in risk of SARS-CoV2 infection by occupation during the first pandemic wave in Germany. Occupation has been linked with differential risks of infection (2, 3) as well as severe disease and death (4, 5). Hence, this is a potentially very important paper, advancing the evidence in relation to occupational risk factors for infection. This study makes use of an existing cohort (the German National Cohort – NAKO), with data from over 100 000 workers who were employed or self-employed and completed a COVID-19 questionnaire. SARS-CoV2 infection was assessed through a self-reported positive PCR test carried out in a doctor’s practice, test centre or in a hospital. The main analyses used a Poisson regression model to obtain incidence rates of infection by occupation, both crude and analyses adjusted for potential confounding factors (sociodemographic and employment related factors) were carried out. Based on the results of the analyses, the authors conclude that (i) there were relatively high infection rates in healthcare and personal services but also in business management and business services, (ii) there were relatively low infection rates in manufacturing and production related occupations, and (iii) there was an inverse social gradient between occupational position and risk of infection, with higher risk in occupations with advanced tertiary degrees/managers. Like other studies, these analyses found relatively high infection rates in essential occupations. However, important differences with other studies included the inverse social gradient and the relatively high infection rates in occupations with management responsibility and requiring higher degrees. The authors postulated a possible explanation for this finding, stating that managers in Germany may be at higher risk due to recreational ski trips. Although this may well be a partial explanation, we argue that there is a more likely explanation for the high rates in higher educated people and those working in the healthcare sector. These groups are more likely to have been tested, particularly during the early stage of the pandemic, compared to other occupations such as those working in manufacturing and production-related occupations. This could be due to differential access to testing due to employer requirements or financial restraints (especially at times when tests were not free for all in Germany, https://www.reuters.com/business/healthcare-pharmaceuticals/germany-offer-free-covid-19-tests-saturday-2021-11-12/) or different motivations for testing (due to lack of sick pay or self-employment). The authors estimate the infection rates using these positive tests as the numerator and the total cohort population (many of whom have never been tested) as the denominator. Therefore, if there is a differential likelihood of testing between different occupations, this would lead to bias in the results. It is relatively simple to address this problem by using a test-negative design (6, 7), which is a type of case–control approach where those with a positive test are compared to those who have tested negative (ie, excluding those who have never been tested). This has been widely used as the gold standard method for studying vaccine effectiveness (8) and is increasingly being used to study risk factors for COVID-19 infection. We would encourage the authors to carry out such analyses and present the results in their response to this letter. If, as we expect, the high relative risks in those with higher education and/or managers are reduced in these analyses, this would strongly indicate that the reported findings are primarily due to selection bias. References 1. Reuter M, Rigó M, Formazin M, Liebers F, Latza U, Castell S et al. Occupation and SARS-CoV-2 infection risk in 108 960 workers during the first pandemic wave in Germany. Scand J Work Environ Health – online first. https://doi.org/10.5271/sjweh.4037 2. Rhodes S, Wilkinson J, Pearce N, Mueller W, Cherrie M, Stocking K, et al. Occupational differences in SARS-CoV-2 infection: Analysis of the UK ONS Coronavirus (COVID-19) Infection Survey. medRxiv. 2022 https://doi.org/10.1101/2022.04.28.22273177 3. Beale S, Patel P, Rodger A, Braithwaite I, Byrne T, Fong WLE, et al. Occupation, work-related contact and SARS-CoV-2 anti-nucleocapsid serological status: findings from the Virus Watch prospective cohort study. Occup Environ Med. 2022. https://doi.org/10.1136/oemed-2021-107920 4. Nafilyan V, Pawelek P, Ayoubkhani D, Rhodes S, Pembrey L, Matz M, et al. Occupation and COVID-19 mortality in England: a national linked data study of 14.3 million adults. Occup Environ Med. 2022;79(7):433-41. https://doi.org/10.1136/oemed-2021-107818 5. Mutambudzi M, Niedzwiedz C, Macdonald EB, Leyland A, Mair F, Anderson J, et al. Occupation and risk of severe COVID-19: prospective cohort study of 120 075 UK Biobank participants. Occup Environ Med. 2021;78(5):307-14. https://doi.org/10.1136/oemed-2020-106731 6. Vandenbroucke JP, Brickley EB, Pearce N, Vandenbroucke-Grauls CMJE. The Evolving Usefulness of the Test-negative Design in Studying Risk Factors for COVID-19. Epidemiology. 2022;33(2):e7-e8. https://doi.org/10.1097/EDE.0000000000001438 7. Vandenbroucke JP, Brickley EB, Vandenbroucke-Grauls CMJE, Pearce N. A Test-Negative Design with Additional Population Controls Can Be Used to Rapidly Study Causes of the SARS-CoV-2 Epidemic. Epidemiology. 2020;31(6):836-43. https://doi.org/10.1097/EDE.0000000000001251 8. Cerqueira-Silva T, Katikireddi SV, de Araujo Oliveira V, Flores-Ortiz R, Júnior JB, Paixão ES, et al. Vaccine effectiveness of heterologous CoronaVac plus BNT162b2 in Brazil. Nature Med. 2022;28(4):838-43. https://doi.org/10.1038/s41591-022-01701-w

This study aimed to assess pesticide exposure and its determinants in children aged 5–14 years. Urine samples (n = 953) were collected from 501 participating children living in urban areas (participant n = 300), rural areas but not on a farm (n = 76), and living on a farm (n = 125). The majority provided two samples, one in the high and one in the low spraying season. Information on diet, lifestyle, and demographic factors was collected by questionnaire. Urine was analysed for 20 pesticide biomarkers by GC–MS/MS and LC-MS/MS. Nine analytes were detected in > 80% of samples, including six organophosphate insecticide metabolites (DMP, DMTP, DEP, DETP, TCPy, PNP), two pyrethroid insecticide metabolites (3-PBA, trans-DCCA), and one herbicide (2,4-D). The highest concentration was measured for TCPy (median 13 μg/g creatinine), a metabolite of chlorpyrifos and triclopyr, followed by DMP (11 μg/g) and DMTP (3.7 μg/g). Urine metabolite levels were generally similar or low compared to those reported for other countries, while relatively high for TCPy and pyrethroid metabolites. Living on a farm was associated with higher TCPy levels during the high spray season. Living in rural areas, dog ownership and in-home pest control were associated with higher levels of pyrethroid metabolites. Urinary concentrations of several pesticide metabolites were higher during the low spraying season, possibly due to consumption of imported fruits and vegetables. Organic fruit consumption was not associated with lower urine concentrations, but consumption of organic food other than fruit or vegetables was associated with lower concentrations of TCPy in the high spray season. In conclusion, compared to other countries such as the U.S., New Zealand children had relatively high exposures to chlorpyrifos/triclopyr and pyrethroids. Factors associated with exposure included age, season, area of residence, diet, in-home pest control, and pets.

Abstract Background An epidemic of chronic kidney disease of unknown cause (CKDu) is occurring in rural communities in tropical regions of low-and middle-income countries in South America and India. Little information is available from Southern African countries which have similar climatic and occupational characteristics to CKDu-endemic countries. We investigated whether CKDu is prevalent in Malawi and identified its potential risk factors in this setting. Methods We conducted a cross-sectional study from January–August 2018 collecting bio samples and anthropometric data in two Malawian populations. The sample comprised adults > 18 years (n = 821) without diabetes, hypertension, and proteinuria. Estimates of glomerular filtration rate (eGFR) were calculated using the CKD-EPI equation. Linear and logistic regression models were applied with potential risk factors, to estimate risk of reduced eGFR. Results The mean eGFR was 117.1 ± 16.0 ml/min per 1.73m2 and the mean participant age was 33.5 ± 12.7 years. The prevalence of eGFR

Abstract Background Three-dimensional (3D) models have the unique ability to replicate individualized cardiac anatomy and may therefore provide clinical benefit. Transcatheter aortic valve implantation (TAVI) currently relies on preoperative imaging for accurate valve sizing, type of valve used, and avoidance of complications. Three-dimensional (3D) modelling may provide benefit for optimal preoperative TAVI planning. The goal of this study is to assess the utility of 3D modelling in the prediction of paravalvular leak (PVL) post TAVI. Methods Retrospective analysis of five patients who underwent TAVI at our center. Pre-operative cardiac gated CT images were utilized to create a 3D printed model with true size aortic root dimensions, including the coronary artery ostium location and left ventricular outflow tract. Deployment of the corresponding model and size TAVI valve into the created 3D model at a similar depth of implantation via fluoroscopy was performed for each patient. Degree of PVL was assessed using a closed system with water infusion under pressure over a duration of 5 s. Correlation was made between the volume obtained in the closed loop model during the pressurized period and the degree of PVL reported on the patients post TAVI placement on transthoracic echocardiogram. Results One female, and four males (age in years ranged from 68 to 87) underwent successful TAVI (0% 30-day mortality). PVL on post procedure TTE ranged from none to trivial. Successful deployment of TAVI valves inside the 3D model occurred in all cases. The average volume of water collected on three trials over 5 s ranged between 19.1–24.1 ml A multivariate linear regression showed significant association between the degree of PVL reported on post-operative transthoracic echocardiogram and the amount of volume detected in the 3D model (difference: -3.9657, 95% CI: (− 4.6761,-3.2554), p

Background. Typically, the celiac trunk and superior mesenteric artery branch off separately from the anterior aspect of the abdominal aorta. The celiacomesenteric trunk (CMT) is a rare variant in which those arteries share a common origin. We sought to compare the prevalence of CMT in the Caribbean with the global prevalence as calculated by a systematic review. Methods. In this study, we evaluated all consecutive patients who had multiphase contrast-enhanced CT scans at two major referral centres in the Caribbean from August 30, 2017, to September 1, 2019. In patients with a CMT, we recorded demographic and anatomic details. We then conducted a systematic literature search and retrieved raw data to calculate the global prevalence (number of individuals with a CMT divided by the sum total of study samples). We compared CMT prevalence in our sample with the global prevalence using Pearson’s chi-square and Fisher’s exact tests. Statistical significance was considered to be present when the P value was

ObjectivesTo assess total antibody levels against Severe Acute Respiratory Syndrome CoronaVirus 2 (SARS CoV-2) spike protein up to 12 months after Coronavirus Disease (COVID-19) infection in non-vaccinated individuals and the possible predictors of antibody persistence.MethodsThis is the first part of a prospective multi-centre cohort study.ParticipantsThe study included SARS-CoV-2 real-time polymerase chain reaction (RT-PCR) positive and negative participants in South-Eastern Norway from February to December 2020. Possible predictors of SARS-CoV-2 total antibody persistence was assessed. The SARS-CoV-2 total antibody levels against spike protein were measured three to five months after PCR in 391 PCR-positive and 703 PCR-negative participants; 212 PCR-positive participants were included in follow-up measurements at 10 to 12 months. The participants completed a questionnaire including information about symptoms, comorbidities, allergies, body mass index (BMI), and hospitalisation.Primary outcomeThe SARS-CoV-2 total antibody levels against spike protein three to five and 10 to 12 months after PCR positive tests.ResultsSARS-CoV-2 total antibodies against spike protein were present in 366 (94%) non-vaccinated PCR-positive participants after three to five months, compared with nine (1%) PCR-negative participants. After 10 to 12 months, antibodies were present in 204 (96%) non-vaccinated PCR-positive participants. Of the PCR-positive participants, 369 (94%) were not hospitalised. The mean age of the PCR-positive participants was 48 years (SD 15, range 20-85) and 50% of them were male. BMI ≥ 25 kg/m2 was positively associated with decreased antibody levels (OR 2.34, 95% CI 1.06 to 5.42). Participants with higher age and self-reported initial fever with chills or sweating were less likely to have decreased antibody levels (age: OR 0.97, 95% CI 0.94 to 0.99; fever: OR 0.33, 95% CI 0.13 to 0.75).ConclusionOur results indicate that the level of SARS-CoV-2 total antibodies against spike protein persists for the vast majority of non-vaccinated PCR-positive persons at least 10 to 12 months after mild COVID-19.

OBJECTIVES The BRAIN-Q is a tool aimed at maximising the accuracy and minimising measurement error for retrospectively assessing concussions. This paper reports the agreement of the BRAIN-Q tool when compared to extant questionnaire questions, and its reproducibility when compared with its telephonic version (tBRAIN-Q). METHODS The BRAIN-Q entails a 3-stage process: defining a concussion, creating a visual timeline with life events, and establishing detailed characteristics for each reported concussion. It was designed to be administered in-person by trained personnel, and was used in the BRAIN study. Its performance was compared with the MSK study, which previously collected a few questions in a broader self-administered questionnaire, and with the tBRAIN-Q Recall, its telephonic version. RESULTS In total, 101 participants were included, of whom 9 were re-assessed with the tBRAIN-Q. The agreement of the BRAIN-Q with the muscle skeletal-questionnaire for rugby-related concussion was 86.7% (κ=0.6). Rugby-related concussion with loss of consciousness showed lower agreement (82.0%; κ=0.6). The comparison between the BRAIN-Q and the tBRAIN-Q showed good reproducibility. CONCLUSIONS The BRAIN-Q is a relatively easy tool to administer in face-to-face assessments, and it showed optimal reproducibility. It includes a well-established definition of concussion, and is used to collect detailed information on each concussion, allowing for a number of subgroup analyses (e.g., by severity, age, or context). The BRAIN-Q is easily adaptable to other sporting settings.

Summary: Background: Uncertainty remains concerning the association of blood cholesterol with the risk of subsequent dementia. Using data from people with lipid measurements in the UK Clinical Practice Research Datalink (CPRD), we examined the association between blood lipid levels and dementia (both vascular and non-vascular, including Alzheimer's disease) by age at first measurement of blood lipids and duration of follow-up. Methods: We studied a cohort from the UK CPRD of people aged 40 years or older with a first total cholesterol recording between Jan 1, 1992, and Dec 31, 2009. Follow-up was until the first record of dementia, the last data collection date, patient death or transfer out of the practice, or Jan 5, 2015, whichever was earliest. We excluded individuals with a record of dementia before the total cholesterol measurement. We used Poisson regression to examine the association between baseline total cholesterol, LDL cholesterol and HDL cholesterol, and triglycerides and incident dementia diagnosis. Analyses were stratified by age at first measurement (

Abstract Background Over the last 20 years there have been reports of a form of chronic kidney disease of unknown cause (CKDu) affecting rural communities in the North Central Province of Sri Lanka. Valid prevalence estimates, using a standardised methodology, are needed to assess the burden of disease, assess secular trends, and perform international comparisons. Methods We conducted a cross-sectional representative population survey in five study areas with different expected prevalences of CKDu. We used a proxy definition of CKDu involving a single measure of impaired kidney function (eGFR

Abstract Background After two-years of follow-up of 263 apparently healthy 18- to 30-year-old men in communities affected by Mesoamerican nephropathy (MeN), we identified three distinct case groups: a subgroup with (i) established renal dysfunction (case-group 1); individuals with (ii) a rapid decline in kidney function (case-group 2); and individuals with (iii) stable kidney function (non-cases). This paper investigates whether local tests are potentially useful for the timely identification of these case groups. Methods Creatinine levels were measured in local laboratories every six months for two years. Aliquots were sent to a centralized laboratory for measurements of cystatin C and creatinine levels. We investigated agreement between the locally and centrally measured creatinine-based Chronic Kidney disease Epidemiology Collaboration (CKD-EPI) equation for estimating the Glomerular Filtration Rate (eGFR). A logistic regression analysis was used to assess predictive factors for case groups 1 and 2 compared to non-cases. Predictive variables were locally measured eGFR, and urinary neutrophil gelatinase-associated lipocalin (uNGAL) levels. The discrimination performance of the model was assessed using the area under the receiver operating characteristic curve (AUC). Results Considerable variation in local eGFR measurements was observed. The prediction model for case-group 1 included baseline kidney function and with or without uNGAL (AUC = 0.98, 95% confidence interval (CI), 0.91–1.00). The prediction model for case-group 2 also required eGFRScr at six and twelve months after baseline, with or without uNGAL levels (AUC = 0.88; 95% CI 0.80–0.99). Conclusions Established renal dysfunction was detected at a single time point using local measurements and uNGAL. For the detection of a rapid decline in kidney function over time, at least 2 more measurements at six and twelve months are needed.

There are important differences in the risk of SARS-CoV-2 infection and death depending on occupation. Infections in healthcare workers have received the most attention, and there are clearly increased risks for intensive care unit workers who are caring for COVID-19 patients. However, a number of other occupations may also be at an increased risk, particularly those which involve social care or contact with the public. A large number of data sets are available with the potential to assess occupational risks of COVID-19 incidence, severity, or mortality. We are reviewing these data sets as part of the Partnership for Research in Occupational, Transport, Environmental COVID Transmission (PROTECT) initiative, which is part of the National COVID-19 Core Studies. In this report, we review the data sets available (including the key variables on occupation and potential confounders) for examining occupational differences in SARS-CoV-2 infection and COVID-19 incidence, severity and mortality. We also discuss the possible types of analyses of these data sets and the definitions of (occupational) exposure and outcomes. We conclude that none of these data sets are ideal, and all have various strengths and weaknesses. For example, mortality data suffer from problems of coding of COVID-19 deaths, and the deaths (in England and Wales) that have been referred to the coroner are unavailable. On the other hand, testing data is heavily biased in some periods (particularly the first wave) because some occupations (e.g. healthcare workers) were tested more often than the general population. Random population surveys are, in principle, ideal for estimating population prevalence and incidence, but are also affected by non-response. Thus, any analysis of the risks in a particular occupation or sector (e.g. transport), will require a careful analysis and triangulation of findings across the various available data sets.

The reasons for the positive association between anxiety disorders and asthma are unknown. We investigated the possible role of shared exposures in early life. We conducted a case–control study among adolescents (age 12–17 years) with and without asthma in urban Uganda, as part of a larger asthma case–control study. Anxiety disorders were diagnosed by psychiatric clinical officers. We focused on generalised anxiety disorder (GAD), panic disorder and social anxiety disorder. Asthma was doctor-diagnosed by study clinicians. We used questionnaires to collect data on early-life exposures. The data were analysed using multiple logistic regression. We enrolled 162 adolescents; 73 of them had asthma. Adolescents with asthma were more likely to have any of the three anxiety disorders studied (46.6%) than adolescents without asthma (21.4%) (adjusted OR (aOR) 2.68, 95% CI 1.30–5.53). The association was strong for GAD (aOR 4.49, 95% CI 1.48–13.56) and panic disorder (aOR 5.43, 95% CI 2.11–14.02), but not for social anxiety disorder. The early-life risk factors associated with anxiety disorders among adolescents were similar to asthma risk factors previously published, including urban residence at birth (aOR 3.42, 95% CI 1.29–9.09) and during most of the first 5 years of life (aOR 2.87, 95% CI 1.07–7.66), father's tertiary education (aOR 2.09, 95% CI 1.00–4.37), and adolescent's history of other allergy-related diseases (aOR 4.64, 95% CI 1.66–13.00). We confirm a positive association between anxiety disorders and asthma among adolescents in urban Uganda. The early-life risk factors associated with anxiety disorders among adolescents were similar to those for asthma in the same age group, suggesting shared underlying environmental exposures.

The outbreak of COVID-19 raised numerous questions on the interactions between the occurrence of new infections, the environment, climate and health. The European Union requested the H2020 HERA project which aims at setting priorities in research on environment, climate and health, to identify relevant research needs regarding Covid-19. The emergence and spread of SARS-CoV-2 appears to be related to urbanization, habitat destruction, live animal trade, intensive livestock farming and global travel. The contribution of climate and air pollution requires additional studies. Importantly, the severity of COVID-19 depends on the interactions between the viral infection, ageing and chronic diseases such as metabolic, respiratory and cardiovascular diseases and obesity which are themselves influenced by environmental stressors. The mechanisms of these interactions deserve additional scrutiny. Both the pandemic and the social response to the disease have elicited an array of behavioural and societal changes that may remain long after the pandemic and that may have long term health effects including on mental health. Recovery plans are currently being discussed or implemented and the environmental and health impacts of those plans are not clearly foreseen. Clearly, COVID-19 will have a long-lasting impact on the environmental health field and will open new research perspectives and policy needs.

Purpose. There are many known variations in the arterial supply to the liver. We sought to document the incidence and details of anomalies of the extrahepatic arteries in an unselected population in the West Indies. Methods. This study spanned 24 months. All 205 CT scans were evaluated at a hepatobiliary referral center in Trinidad and Tobago. We described the anomalies of the arterial supply to the liver using the conventional classification proposed by Michels. Results. 205 CT scans were evaluated, and 112 persons (54.6%) had conventional Type 1 anatomy. However, compared to the incidence in the existing medical literature, we encountered a greater incidence of replaced right hepatic arteries (18.1% vs 11%; P 0.04) and a lower incidence of accessory right hepatic arteries (2.4% vs 7%; P 0.030). Conclusion. Although 54.6% of persons in this West Indian population have conventional hepatic arterial supply, the distribution of anatomic variants of the right hepatic artery is quite different to that seen in North American and European centers. We found a higher incidence of replaced right hepatic arteries and a lower incidence of accessory right hepatic arteries.

Abstract EFSA requested its Scientific Committee to prepare a guidance document on appraising and integrating evidence from epidemiological studies for use in EFSA's scientific assessments. The guidance document provides an introduction to epidemiological studies and illustrates the typical biases of the different epidemiological study designs. It describes key epidemiological concepts relevant for evidence appraisal. Regarding study reliability, measures of association, exposure assessment, statistical inferences, systematic error and effect modification are explained. Regarding study relevance, the guidance describes the concept of external validity. The principles of appraising epidemiological studies are illustrated, and an overview of Risk of Bias (RoB) tools is given. A decision tree is developed to assist in the selection of the appropriate Risk of Bias tool, depending on study question, population and design. The customisation of the study appraisal process is explained, detailing the use of RoB tools and assessing the risk of bias in the body of evidence. Several examples of appraising experimental and observational studies using a Risk of Bias tool are annexed to the document to illustrate the application of the approach. This document constitutes a draft that will be applied in EFSA's assessments during a 1‐year pilot phase and be revised and complemented as necessary. Before finalisation of the document, a public consultation will be launched.

Background: Symptoms of asthma, allergic rhinoconjunctivitis, and atopic eczema in children cluster at both the individual and population levels. Objectives: To assess individual-level and school-level risk factors for symptoms of rhinoconjunctivitis and compare them to corresponding associations with symptoms of asthma and eczema in Phase Three of the International Study of Asthma and Allergies in Childhood. Methods: We studied 116,863 children aged 6–7 years from 2163 schools in 59 centres and 22 countries and 224,436 adolescents aged 13–14 years from 2037 schools in 97 centres in 41 countries. Multilevel logistic regression models were fitted with random intercepts for school, centre, and country, adjusting for sex and maternal education at the child level. Associations between symptoms and a range of lifestyle and environmental risk factors were assessed for both the child's exposure and mean exposure at the school. Models were fitted for rhinoconjunctivitis, asthma, and eczema singly (unimorbidity) and for combinations of these conditions (multimorbidity). Results: Generally, associations between symptoms and exposures at the school level were similar in direction and magnitude to those at the child level. Associations with multimorbidity were stronger than for unimorbidity, particularly in individuals with symptoms of all three diseases, but risk factor associations found in conventional single disease analyses persisted among children with only one condition, after excluding multimorbid groups.Comparisons of individuals with only one disease showed that many risk factor associations were consistent across the three conditions. More strongly associated with asthma were low birthweight, cat exposure in infancy, and current maternal smoking. Current paracetamol use was more strongly associated with asthma and rhinoconjunctivitis than eczema. Breastfeeding was more strongly associated with eczema than asthma or rhinoconjunctivitis.The direction and magnitude of most risk factor associations were similar in affluent and non-affluent countries, although notable exceptions include farm animal contact in infancy and larger sibships, which were associated with increased risk of rhinoconjunctivitis in non-affluent countries but reduced risk in affluent countries. In both age groups, current paracetamol use increased risk of each disease to a greater extent in affluent countries than in non-affluent countries. Effects of paracetamol and antibiotics in infancy were more consistent between richer and poorer settings. Conclusions: Most of the environmental and lifestyle correlates of rhinoconjunctivitis, asthma and eczema in childhood display similarity across the three conditions, even in less affluent settings where allergic sensitisation is less likely to explain the concordant epidemiological patterns. Trial registration: Not applicable.

The COVID-19 epidemic can probably be ended and normal life restored, perhaps quite quickly, by weekly SARS-CoV-2 RNA testing together with household quarantine and systematic contact tracing. Isolated outbreaks could then be contained by contact tracing, supplemented if necessary by temporary local reintroduction of population testing or lockdown. Leading public health experts have recommended that this should be tried in a demonstration project in which a medium-sized city introduces weekly testing and lifts lockdown completely. The idea was not considered by the groups whose predictions have guided UK policy, so we have examined the statistical case for such a study. The combination of regular testing with strict household quarantine, which was not analysed in their models, has remarkable power to reduce transmission to the community from other household members as well as providing earlier diagnosis and facilitating rapid contact tracing.

Abstract Background Ghana faces an increasing burden of non-communicable disease with rates of hypertension estimated as high as 36% in adults. Despite these high rates, hypertension control remains very poor in Ghana (4%). The current project aims to implement and evaluate a community-based programme to raise awareness, and to improve treatment and control of hypertension in the Eastern Region of Ghana. In this paper, we present the findings of the baseline cross-sectional survey focusing on hypertension prevalence, awareness, treatment, and control. Methods To evaluate the ComHIP project, a quasi-experimental design consisted of a before and after evaluations are being implemented in the intervention and comparison districts. A cohort study component is being implemented in the intervention district to assess hypertension control. Background anthropometric and clinical data collected as part of the baseline survey were analyzed in STATA Version 11. We examined the characteristics of individuals, associated with the baseline study outcomes using logistic regression models. Results We interviewed 2400 respondents (1200 each from the comparison and intervention districts), although final sample sizes after data cleaning were 1170 participants in the comparison district and 1167 in the intervention district. With the exception of ethnicity, the control and intervention districts compare favorably. Overall 32.4% of the study respondents were hypertensive (31.4% in the control site; and 33.4% in the intervention site); 46.2% of hypertensive individuals were aware of a previous diagnosis of hypertension (44.7% in the control site, and 47.7% in the intervention site), and only around 9% of these were being treated in either arm. Hypertension control was 1.3% overall (0.5% in the comparison site, and 2.1% in the intervention site). Age was a predictor of having hypertension, and so was increasing body mass index (BMI), waist, and hip circumferences. After adjusting for age, the risk factors with the greatest association with hypertension were being overweight (aOR = 2.30; 95% CI 1.53–3.46) or obese (aOR = 3.61; 95% CI 2.37–5.51). Older individuals were more likely to be aware of their hypertension status than younger people. After adjusting for age people with a family history of hypertension or CVD, or having an unhealthy waist hip ratio, were more likely to be aware of their hypertension status. Conclusions The high burden of hypertension among the studied population, coupled with high awareness, yet very low level of hypertension treatment and control requires in-depth investigation of the bottlenecks to treatment and control. The low hypertension treatment and control rates despite current and previous general educational programs particularly in the intervention district, may suggest that such programs are not necessarily impactful on the health of the population.

Abstract Background Mental health problems (MHP) are the leading cause of disability worldwide. The inverse association between socioeconomic position (SEP) and MHP has been well documented. There is prospective evidence that factors from the work environment, including adverse psychosocial work factors, could contribute to the development of MHP including psychological distress. However, the contribution of psychosocial work factors to social inequalities in MHP remains unclear. This study evaluates the contribution of psychosocial work factors from two highly supported models, the Demand-Control-Support (DCS) and the Effort-Reward Imbalance (ERI) models to SEP inequalities of psychological distress in men and women from a population-based sample of Quebec workers. Methods Data were collected during a survey on working conditions, health and safety at work. SEP was evaluated using education, occupation and household income. Psychosocial work factors and psychological distress were assessed using validated instruments. Mean differences (MD) in the score of psychological distress were estimated separately for men and women. Results Low education level and low household income were associated with psychological distress among men (MD, 0.56 (95% CI 0.06; 1.05) and 1.26 (95% CI 0.79; 1.73) respectively). In men, the contribution of psychosocial work factors from the DCS and the ERI models to the association between household income and psychological distress ranged from 9% to 24%. No clear inequalities were observed among women. Conclusions These results suggest that psychosocial work factors from the DCS and the ERI models contribute to explain a part of social inequalities in psychological distress among men. Psychosocial factors at work are frequent and modifiable. The present study supports the relevance of targeting these factors for the primary prevention of MHP and for health policies aiming to reduce social inequalities in mental health.