When schools were open for in-person teaching during the COVID-19 pandemic - the nordic experience on control measures and transmission in schools during the delta wave.

BACKGROUND: Extensive measures to control spread of SARS-CoV-2 have led to limited access to education for millions of children and adolescents during the COVID-19 pandemic. Education and access to schools is vital for children and adolescents' learning, health, and wellbeing. Based on high vaccine uptake and low incidence levels, the Nordic countries (Denmark, Finland, Iceland, Norway and Sweden) decided to start the academic year 2021/22 with schools open for in-person teaching and moderate mitigation measures. We describe trends in SARS-CoV-2 infections and vaccination coverage among students during the first 12 weeks of the fall semester. METHODS: In this multinational, retrospective, observational study, we have used surveillance and registry data from each of the Nordic countries to describe vaccine uptake (≥12 years), infection incidence (whole population) and transmission of SARS-CoV-2 among students. The study period, week 30 to 41 (Jul 26th - Oct 17th), represents the autumn semester from immediately before school started until fall break. In addition, we collected information on mitigation measures applied by the respective countries. RESULTS: There were slight variations between the countries regarding existing infection prevention and control (IPC) measures, testing strategies and vaccination start-up among adolescents. All countries had high vaccine uptake in the adult population, while uptake varied more in the younger age groups. Incidence in the school-aged population differed between countries and seemed to be influenced by both vaccine uptake and test activity. Infection clusters among school-aged children were described for Denmark and Norway, and the number of clusters per week reflected the incidence trend of the country. Most events consisted of only 1-2 cases. Larger clusters appeared more frequently in the higher grades in Norway and in lower grades in Denmark. CONCLUSION: Data from the Nordic countries indicate that vaccination of adults and adolescents, in addition to mitigation measures, enabled full in-person learning. As SARS-CoV-2 infection does not represent a severe medical risk for most children as previously thought, measures targeting this group should be carefully adjusted and kept at a minimum. Our data add to the evidence on incidence and transmission of SARS-CoV-2 among students in schools open for in-person teaching, and may be valuable for decision makers worldwide.

Experience with open schools and preschools in periods of high community transmission of COVID-19 in Norway during the academic year of 2020/2021.

BACKGROUND: Schools and preschools have largely remained open in Norway throughout the pandemic, with flexible mitigation measures in place. This contrasts with many other high-income countries that closed schools for long periods of time. Here we describe cases and outbreaks of COVID-19 in schools and preschools during the academic year 2020/2021, to evaluate the strategy of keeping these open with infection prevention control measures in place. METHODS: In this descriptive study, the Norwegian Institute of Public Health initiated systematic surveillance for COVID-19 cases and outbreaks in schools and preschools in October 2020. Data was compiled from the national outbreak alert system VESUV, municipality websites, and media scanning combined with the national emergency preparedness register Beredt C-19. An outbreak was defined as ≥ 2 cases among pupils or staff within 14 days at the same educational setting. Settings were categorized as preschool (1-5-years), primary school (6-12-years), lower secondary school (13-15-years) and upper secondary school (16-18- years). We reported the incidence rate among preschool and school-aged pupils and gave a descriptive overview of outbreaks and included cases per educational setting. RESULTS: During the whole academic year, a total of 1203 outbreaks in preschools and school settings were identified, out of a total of 8311 preschools and schools nationwide. The incidence of COVID-19 in preschool- and school-aged children and the rates of outbreaks in these settings largely followed the community trend. Most of the outbreaks occurred in primary schools (40%) and preschools (25%). Outbreaks across all settings were mostly small (median 3 cases, range 2 to 72), however, 40 outbreaks (3% of total) included 20 or more cases. The larger outbreaks were predominantly seen in primary schools (43%). CONCLUSIONS: We observed few large outbreaks in open schools and preschools in Norway during the academic year of 2020/2021, also when the Alpha variant was predominant. This illustrates that it is possible to keep schools and preschools open even during periods of high community transmission of COVID-19. Adherence to targeted IPC measures adaptable to the local situation has been essential to keep educational settings open, and thus reduce the total burden on children and adolescents.

How do reminder systems in follow-up screening for women with previous gestational diabetes work? - a realist review.

BACKGROUND: Women with previous gestational diabetes have an increased risk of developing type 2 diabetes later in life. Recommendations therefore urge these women to participate in follow-up screening, 4-12 weeks postpartum and every 1-3 years thereafter. We sought to theorize how reminder interventions to support early detection of diabetes work, for whom, and in what circumstances. METHODS: We used a method informed by realist review and synthesis. A systematic, iterative search in six electronic databases (PubMed, MEDLINE Ovid, The Cochrane Library, CINAHL, EMBASE) had a primary focus on experimental intervention studies and included additional information in relation to identified intervention studies. Analysis inductively identified context-mechanism-outcome configurations present in the evidence. RESULTS: We located 16 articles eligible for inclusion. A cross-case comparison identified seven grouped context-mechanism-outcome configurations leading to intervention mechanisms relating to changes in women's reasoning and behavior. Configurations were thematically ordered in relation to Systems Resources, Women's Circumstances, and Continuity of Care. These were mapped onto a socio-ecological model and discussed according to identified middle-range theories. CONCLUSION: Our findings adds to the body of evidence, that reminders have the potential to be effective in increasing participation in the recommended follow-up screening. Our study may assist researchers and policy and decision makers to analyze and judge if reminders are feasible and/or likely to succeed in their specific context. Further research into the perspective of socially disadvantaged and overweight women is needed to avoid unintended consequences such as social inequality in service use and stigmatization in future programs.

Early-life childhood obesity risk prediction: A Danish register-based cohort study exploring the predictive value of infancy weight gain.

BACKGROUND: Information on postnatal weight gain is important for predicting later overweight and obesity, but it is unclear whether inclusion of this postnatal predictor improves the predictive performance of a comprehensive model based on prenatal and birth-related predictors. OBJECTIVES: To compare performance of prediction models based on predictors available at birth, with and without information on infancy weight gain during the first year when predicting childhood obesity risk. METHODS: A Danish register-based cohort study including 55.041 term children born between January 2004 and July 2011 with birthweight >2500 g registered in The Children's Database was used to compare model discrimination, reclassification, sensitivity and specificity of two models predicting risk of childhood obesity at school age. Each model consisted of eight predictors available at birth, one additionally including information on weight gain during the first 12 months of life. RESULTS: The area under the receiving operating characteristic curve increased from 0.785 (95% confidence interval (CI) [0.773-0.798]) to 0.812 (95% CI [0.801-0.824]) after adding weight gain information when predicting childhood obesity. Adding this information correctly classified 30% more children without obesity and 21% with obesity and improved sensitivity from 0.42 to 0.48. Specificity remained unchanged at 0.91. CONCLUSION: Adding infancy weight gain information improves discrimination, reclassification and sensitivity of a comprehensive prediction model based on predictors available at birth.

Co-production as an Emerging Methodology for Developing School-Based Health Interventions with Students Aged 11-16: Systematic Review of Intervention Types, Theories and Processes and Thematic Synthesis of Stakeholders' Experiences.

Co-production affords an intervention's target population the opportunity to participate in intervention theory decision-making during the development process. This addresses the over-reliance on developing interventions through academic theories which can be devoid of contextual understanding and result in challenges to implementing school-based health programmes. There is an emergent empirical literature on co-producing school-based health interventions, but an understanding of appropriate theoretical types and processes and stakeholders' experiences is lacking. Through the conduct of a systematic review, this study seeks to understand the types and underlying theories and processes for co-production in school-based health interventions with students aged 11-16. A thematic synthesis explored stakeholders' experiences of the different types of co-production. A systematic search of five electronic bibliographic databases, citation tracking of included studies, and consultation with an expert international panel were employed. Of 27,433 unique papers, 30 papers representing 22 studies were retained to describe types, and 23 papers of 18 studies used to synthesise stakeholders' experiences. Three types were identified: external, individual-level, and system-level capacity-building. Whilst this review showed variability in co-production types, stakeholders involved and processes, shared functions were identified. Students', school staff, facilitators' and researchers' experiences in terms of acceptability, feasibility and undertaking decision-making are discussed. Recommendations for conceptualising and reporting co-production and process evaluations of co-produced school-based health interventions are highlighted.

Evaluating implementation strategies for essential newborn care interventions in low- and low middle-income countries: a systematic review.

Neonatal mortality remains a significant health problem in low-income settings. Low-cost essential newborn care (ENC) interventions with proven efficacy and cost-effectiveness exist but have not reached high coverage (≥90%). Little is known about the strategies used to implement these interventions or how they relate to improved coverage. We conducted a systematic review of implementation strategies and implementation outcomes for ENC in low- and low middle-income countries capturing evidence from five medical and global health databases from 1990 to 2018. We included studies of implementation of delayed cord clamping, immediate drying, skin-to-skin contact (SSC) and/or early initiation of breastfeeding implemented in the first hour (facility-based studies) or the 1st day (community-based studies) of life. Implementation strategies and outcomes were categorized according to published frameworks: Expert Recommendations for Implementing Change and Outcomes for Implementation Research. The relationship between implementation strategies and outcomes was evaluated using standardized mean differences and correlation coefficients. Forty-three papers met inclusion criteria. Interventions included community-based care/health promotion and facility-based support and health care provider training. Included studies used 3-31 implementation strategies, though the consistency with which strategies were applied was variable. Conduct educational meetings was the most frequently used strategy. Included studies reported 1-4 implementation outcomes with coverage reported most frequently. Heterogeneity was high and no statistically significant association was found between the number of implementation strategies used and coverage of ENC. This review highlights several challenges in learning from implementation of ENC in low- and low middle-income countries, particularly poor description of interventions and implementation outcomes. We recommend use of UK Medical Research Council guidelines (2015) for process evaluations and checklists for reporting implementation studies. Improved reporting of implementation research in this setting is necessary to learn how to improve service delivery and outcomes and thereby reduce neonatal mortality.

Infancy weight gain, parental socioeconomic position, and childhood overweight and obesity: a Danish register-based cohort study.

BACKGROUND: Rapid infant weight gain (RIWG) is a very strong predictor of childhood overweight and obesity (COO). Socioeconomic position (SEP) is also related to the risk of COO and parents of different SEP may differ in their reaction to accelerated infant weight gain. Together this could lead to differences in how weight gain and COO risk relate across SEP. This study aimed to analyse possible interaction of SEP and RIWG on COO risk. METHODS: A register-based longitudinal cohort study followed 19,894 healthy, term infants, born in Denmark between December 2011 and May 2015. Logistic regression models were used to estimate odds ratios (OR) of COO risk at 2 years (22-26 months) of age with 95% confidence intervals (95% CI) for categories of infancy weight gain based on changes in weight-for-age z-scores between 0 and 8-10 months of age (slow (<- 0.67), mean (- 0.67-0.67), rapid (> 0.67-1.34) and very rapid (> 1.34)). Possible multiplicative and additive interaction of SEP (based on household income and maternal education) on the relationship between infancy weight gain and COO were analysed. RESULTS: In total, 19.1 and 15.1% experienced rapid or very rapid weight gain, respectively, and 1497 (7.5%) children were classified with COO at follow-up. These prevalences were higher in those with lower levels of SEP. Adjusted OR for COO were 3.09 (95% CI [2.66-3.59]) and 7.58 (95% CI [6.51-8.83]) for rapid and very rapid weight gain, respectively, when household income was included in the model. Results were similar in the model including maternal education. No signs of interactions were detected on a multiplicative scale. Weak signs of additive interaction were present, but these values did not reach significance. CONCLUSION: Both rapid and very rapid weight gain were associated with substantially higher risks of COO but these associations were not modified by SEP. This indicates that promotion of healthy weight gain should take place in all population groups irrespective of their SEP.

Leisure-Time Physical Activity and the Risk of Suspected Bacterial Infections.

INTRODUCTION: The risk of upper respiratory tract viral infections is reduced with increased physical activity, but little information is available regarding bacterial infections. We examined the relationship between leisure-time physical activity and suspected bacterial infections. METHODS: Information on leisure-time physical activity was obtained from the 2007 and 2010 North Denmark Region Health Surveys of 18,874 Danes and linked to data from nationwide administrative registries. Suspected bacterial infections were determined based on filled prescriptions for antibiotics. Adjusted estimates were calculated using logistic regression models. RESULTS: During a 1-yr follow-up, 5368 participants filled at least one antibiotic prescription. There was a statistically significant difference between physical activity level and filling any antibiotic prescriptions among women (P = 0.003) but not among men (P = 0.191). Logistic regression analysis showed that compared with sedentary behavior, all levels of leisure-time physical activities lowered the likelihood of filling an antibiotic prescription. However, after multivariable adjustments, only estimates of low physical activity were significant (odds ratio [OR] = 0.90, 95% confidence interval [CI] = 0.82; 0.99). Multivariable adjusted subgroup analyses of suspected cystitis showed a decreased likelihood of engaging in low (OR = 0.79, 95% CI = 0.65-0.95) and moderate (OR = 0.68, 95% CI = 0.54-0.87) physical activity. CONCLUSION: Low leisure-time physical activity is associated with a statistically significant 10% lower risk of suspected bacterial infections during a 1-yr follow-up compared with sedentary behavior. Further, low and moderate levels of physical activity were associated with the statistically significant reduction of suspected cystitis. No reduction in suspected respiratory tract infections was statistically significant and associated with physical activity compared with sedentary behavior.