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      Increase in Tuberculosis Diagnostic Delay during First Wave of the COVID-19 Pandemic: Data from an Italian Infectious Disease Referral Hospital

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          Abstract

          Background: The WHO advised that the impact of COVID-19 pandemic on TB services was estimated to be dramatic due to the disruption of TB services. Methods: A retrospective data collection and evaluation was conducted to include all the patients hospitalized for TB at INMI from 9 March to 31 August 2020 (lockdown period and three months thereafter). For the purpose of the study, data from patients hospitalized in the same period of 2019 were also collected. Results: In the period of March–August 2019, 201 patients were hospitalized with a diagnosis of TB, while in the same period of 2020, only 115 patients, with a case reduction of 43%. Patients with weight loss, acute respiratory failure, concurrent extrapulmonary TB, and higher Timika radiographic scores were significantly more frequently hospitalized during 2020 vs. 2019. The median patient delay was 75 days (IQR: 40–100) in 2020 compared to 30 days (IQR: 10–60) in 2019 ( p < 0.01). Diagnostic delays in 2020 remain significant in the multiple logistic model (AOR = 6.93, 95%CI: 3.9–12.3). Conclusions: Our experience suggests that COVID-19 pandemic had an impact on TB patient care in terms of higher diagnostic delay, reduction in hospitalization, and a greater severity of clinical presentations.

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          The impact of the COVID-19 pandemic on cancer deaths due to delays in diagnosis in England, UK: a national, population-based, modelling study

          Summary Background Since a national lockdown was introduced across the UK in March, 2020, in response to the COVID-19 pandemic, cancer screening has been suspended, routine diagnostic work deferred, and only urgent symptomatic cases prioritised for diagnostic intervention. In this study, we estimated the impact of delays in diagnosis on cancer survival outcomes in four major tumour types. Methods In this national population-based modelling study, we used linked English National Health Service (NHS) cancer registration and hospital administrative datasets for patients aged 15–84 years, diagnosed with breast, colorectal, and oesophageal cancer between Jan 1, 2010, and Dec 31, 2010, with follow-up data until Dec 31, 2014, and diagnosed with lung cancer between Jan 1, 2012, and Dec 31, 2012, with follow-up data until Dec 31, 2015. We use a routes-to-diagnosis framework to estimate the impact of diagnostic delays over a 12-month period from the commencement of physical distancing measures, on March 16, 2020, up to 1, 3, and 5 years after diagnosis. To model the subsequent impact of diagnostic delays on survival, we reallocated patients who were on screening and routine referral pathways to urgent and emergency pathways that are associated with more advanced stage of disease at diagnosis. We considered three reallocation scenarios representing the best to worst case scenarios and reflect actual changes in the diagnostic pathway being seen in the NHS, as of March 16, 2020, and estimated the impact on net survival at 1, 3, and 5 years after diagnosis to calculate the additional deaths that can be attributed to cancer, and the total years of life lost (YLLs) compared with pre-pandemic data. Findings We collected data for 32 583 patients with breast cancer, 24 975 with colorectal cancer, 6744 with oesophageal cancer, and 29 305 with lung cancer. Across the three different scenarios, compared with pre-pandemic figures, we estimate a 7·9–9·6% increase in the number of deaths due to breast cancer up to year 5 after diagnosis, corresponding to between 281 (95% CI 266–295) and 344 (329–358) additional deaths. For colorectal cancer, we estimate 1445 (1392–1591) to 1563 (1534–1592) additional deaths, a 15·3–16·6% increase; for lung cancer, 1235 (1220–1254) to 1372 (1343–1401) additional deaths, a 4·8–5·3% increase; and for oesophageal cancer, 330 (324–335) to 342 (336–348) additional deaths, 5·8–6·0% increase up to 5 years after diagnosis. For these four tumour types, these data correspond with 3291–3621 additional deaths across the scenarios within 5 years. The total additional YLLs across these cancers is estimated to be 59 204–63 229 years. Interpretation Substantial increases in the number of avoidable cancer deaths in England are to be expected as a result of diagnostic delays due to the COVID-19 pandemic in the UK. Urgent policy interventions are necessary, particularly the need to manage the backlog within routine diagnostic services to mitigate the expected impact of the COVID-19 pandemic on patients with cancer. Funding UK Research and Innovation Economic and Social Research Council.
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            Reduction of hospitalizations for myocardial infarction in Italy in the COVID-19 era

            Abstract Aims To evaluate the impact of the COVID-19 pandemic on patient admissions to Italian cardiac care units (CCUs). Methods and Results We conducted a multicentre, observational, nationwide survey to collect data on admissions for acute myocardial infarction (AMI) at Italian CCUs throughout a 1 week period during the COVID-19 outbreak, compared with the equivalent week in 2019. We observed a 48.4% reduction in admissions for AMI compared with the equivalent week in 2019 (P < 0.001). The reduction was significant for both ST-segment elevation myocardial infarction [STEMI; 26.5%, 95% confidence interval (CI) 21.7–32.3; P = 0.009] and non-STEMI (NSTEMI; 65.1%, 95% CI 60.3–70.3; P < 0.001). Among STEMIs, the reduction was higher for women (41.2%; P = 0.011) than men (17.8%; P = 0.191). A similar reduction in AMI admissions was registered in North Italy (52.1%), Central Italy (59.3%), and South Italy (52.1%). The STEMI case fatality rate during the pandemic was substantially increased compared with 2019 [risk ratio (RR) = 3.3, 95% CI 1.7–6.6; P < 0.001]. A parallel increase in complications was also registered (RR = 1.8, 95% CI 1.1–2.8; P = 0.009). Conclusion Admissions for AMI were significantly reduced during the COVID-19 pandemic across Italy, with a parallel increase in fatality and complication rates. This constitutes a serious social issue, demanding attention by the scientific and healthcare communities and public regulatory agencies.
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              Mass gathering events and reducing further global spread of COVID-19: a political and public health dilemma

              The coronavirus disease 2019 (COVID-19) pandemic 1 presents countries with major political, scientific, and public health challenges. Pandemic preparedness and reducing risk of global spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are key concerns. Mass gathering (MG) events 2 pose considerable public health challenges to health authorities and governments. Historically, sporting, religious, music, and other MGs have been the source of infectious diseases that have spread globally. 3 However, the scale of the problem has declined over the years as better public health measures have been implemented at MGs in response to the World Health Assembly's endorsement on Dec 22, 2011, of the 130th Executive Board Decision “Global mass gatherings: implications and opportunities for global health security” that encompassed joint planning, enhancement of health infrastructures, and taking proper pre-emptive and preventive measures to control infectious diseases on an international scale. 4 Since then, many MGs have been held safely and successfully without any major communicable disease issues arising,3, 5, 6, 7 even for MG events held during three WHO declared Public Health Emergencies of International Concern: the Vancouver 2010 Winter Olympics and the 2010 FIFA World Cup in South Africa during the H1N1 influenza pandemic; the 2015 Africa Cup of Nations Football tournament in Equatorial Guinea during the outbreak of Ebola virus disease; and the Rio 2016 Olympics during the Zika virus outbreak.8, 9 The emergence of SARS-CoV-2 in China in 2019–20 as a pathogen transmitted by the respiratory route leading to the COVID-19 pandemic 1 has refocused global attention on national, regional, and pandemic spread through MGs events. Since early March, 2020, there has been a step increase in cancellation of international and national religious, sporting, musical, and other MGs as countries worldwide take measures to contain the spread of SARS-CoV-2. Many prominent MGs have been cancelled or postponed, including sports fixtures such as the Union of European Football Associations Euro 2020 football championship, the Formula 1 Grand Prix in China, the Six Nations rugby championship in Italy and Ireland, Olympic boxing qualifying events, the Mobile World Congress in Barcelona, and the Umrah in Saudi Arabia. 10 Although appropriate public health surveillance and interventions for reducing the risk of disease transmission at MGs are informed by previous experiences, the evidence base for infectious disease transmission during MGs is still evolving and needs to be more comprehensive.3, 11 For COVID-19, in addition to the major public health risks at MGs, the management of enhanced media interest and public and political perceptions and expectations are major challenges. 12 Fear, uncertainty, and a desire not to be seen to get things wrong can influence decisions about the risks of MGs, rather than an understanding of the risks and of the interventions available to reduce that risk. WHO, working with global partners in MG health, many of whom were involved in the Riyadh conferences and The Lancet's 2014 Mass Gatherings Medicine Series,4, 5, 6, 7, 13 has developed comprehensive recommendations for managing the public health aspects of MGs that have been updated with interim key recommendations for COVID-19. 14 These recommendations have to be used in consultation with updated technical guidance on COVID-19. 15 Risk assessments for COVID-19 (panel ) need to consider the capacity of host countries to diagnose and treat severe respiratory illness. Panel Risk assessment for MGs during COVID-19 pandemic14,15 (1) General considerations at the beginning of the planning phase: • Risk assessment must be coordinated and integrated with the host country's national risk assessment • Comprehensive risk assessment (with input from public health authorities) reviewed and updated regularly (2) COVID-19 specific considerations: • Consult WHO's updated technical guidance on COVID-19 14 • Specific features of the event that should be considered include • Crowd density • The nature of contact between participants • The profession of the participants and their possible previous exposure • The number of participants coming from countries or areas affected by COVID-19 • The age of participants • The type or purpose of event • The duration • The mode of travel of participants. (3) Specific action plan for COVID-19: • Action plans should be developed to mitigate all risks identified in the assessment. Action plans should include: • Integration with national emergency planning and response plans for infectious diseases • Command and control arrangements • Any appropriate screening requirements for event participants • Disease surveillance and detection • Treatment • Decision trigger points (4) If the decision is made to proceed with a MG, the planning should consider measures to: • Detect and monitor event-related COVID-19 • Reduce the spread of the virus • Manage and treat all ill persons • Disseminate public health messages specific to COVID-19 (5) Risk communication and community engagement: • Event organisers should agree with the public health authority on how participants and the local population will be kept informed about the health situation, key developments, and any relevant advice and recommended actions (6) Risk mitigation strategies: • Reducing the number of participants or changing the venue to prevent crowding, or having a participant-only event without spectators • Staggering arrivals and departures • Providing packaged refreshments instead of a buffet • Increasing the number of, and access to, handwashing stations • Promoting personal protective practices (hand hygiene, respiratory etiquette, staying home if ill) • Offering virtual or live-streamed activities • Changing the event programme to reduce high-risk activities such as those that require physical contact between participants Since MG events, their settings, and participants or attendees are generally unique, the advice will vary regarding which specific measures should be implemented. MG=mass gathering. COVID-19=coronavirus disease 2019. WHO's risk assessment tool enables organisers to methodically review key considerations and risk management steps for hosting an event, assess risks with a weighted-system approach, and factor in risk reduction through various mitigation measures. The COVID-19 Risk Assessment for MGs 14 builds on existing guidance for MGs. The standard risk questions for a MG involve assessment of how well prepared and equipped the host country health system is to detect an usual health event, such as a disease outbreak, and to respond quickly and effectively to the event if it happens. The new risk assessment tool adds an element to assess the additional risk from the MG in relation to COVID-19 (panel). This risk assessment includes questions on the range of countries participants will come from, the prevalence and transmission pattern of COVID-19 in these countries and in the host country, the extent of social interactions that is likely to arise at the MG, and the demographic profile of participants. The COVID-19 Risk Assessment for MGs tool then involves consideration of the possible mitigation actions that could be put in place at the MG to reduce the risk against a list of questions about the host's understanding of, and preparedness for, COVID-19 response measures. At present there is scant evidence on the effectiveness of individual mitigation actions for COVID-19. As better epidemiology about COVID-19 and evidence on the effectiveness of different mitigation strategies become available, the COVID-19 Risk Assessment for MGs tool will be continuously refined to reflect changing knowledge. This rigorous process can inform risk assessment and decision making about MGs during the COVID-19 pandemic. Such MG risk assessments should be reviewed regularly during planning and updated immediately before the MG operational phase, especially in light of the evolving national and international epidemiological situations. There is no specific evidence base yet specific to planning and implementing a MG during the COVID-19 pandemic. Detection and monitoring of MG-event-related COVID-19 should be considered in the context of surveillance schemes that are already in place and if new or enhanced surveillance is deemed necessary. In collaboration with local health authorities, organisers should agree in advance the circumstances in which risk-mitigation measures would need to be enhanced or the event postponed or cancelled. Despite the development of the COVID-19 Risk Assessment for MGs tool, events continue to be cancelled without this risk assessment being done and without clear communication of justification in terms of the expected impact on the spread of COVID-19. These cancellations have social and economic impacts on public morale, on national economies, and on individual livelihoods. The effect of MG cancellations on reducing the spread of COVID-19 needs to be determined. The global public health community needs to consider the effects of MG cancellations on the future wellbeing of communities through economic recession or job losses, as well as through the spread, or otherwise, of COVID-19. A precautionary approach is often used to explain MG cancellations, but when does an abundance of caution become counterproductive? The overarching advice 14 during the ongoing COVID-19 pandemic is that events should be cancelled or postponed on the basis of a context-specific risk assessment. If a decision is made to proceed with MG events, risk mitigation measures should be put in place, consistent with WHO guidance on social distancing for COVID-19, 16 and the rationale for the decision should be clearly explained and communicated to the public.
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                Author and article information

                Contributors
                On behalf of : on behalf of the TB-INMI Working Group
                Role: Academic Editor
                Journal
                Antibiotics (Basel)
                Antibiotics (Basel)
                antibiotics
                Antibiotics
                MDPI
                2079-6382
                08 March 2021
                March 2021
                : 10
                : 3
                Affiliations
                Author notes
                [* ]Correspondence: francesco.digennaro@ 123456inmi.it ; Tel.: +39-392-480-4707
                [†]

                TB-INMI Working Group: Fabrizio Palmieri, Gina Gualano, Andrea Antinori, Nazario Bevilacqua, Maria Capobianchi, Carmine Ciaralli, Gilda Cuzzi, Alessia De Angelis, Antonino Di Caro, Franca Del Nonno, Gianpiero D’Offizi, Emanuela Ercoli, Delia Goletti, Fabio Iacomi, Stefania Ianniello, Giuseppe Ippolito, Luisa Marchioni, Annelisa Mastrobattista, Maria Musso, Paola Mencarini, Annalisa Mondi, Silvia Mosti, Silvia Murachelli, Emanuele Nicastri, Carla Nisii, Carlo Pareo, Antonella Petrecchia, Nicola Petrosillo, Vincenza Puro, Silvia Rosati, Vincenzo Schininà, Paola Scognamiglio, Tommaso Speranza, Simone Topino, Francesco Vaia.

                Article
                antibiotics-10-00272
                10.3390/antibiotics10030272
                7998965
                © 2021 by the authors.

                Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license ( http://creativecommons.org/licenses/by/4.0/).

                Categories
                Article

                tuberculosis, diagnostic delay, covid 19, sars cov2, pandemic

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