"And Then It Spreads": contagion and disease as metaphors of sociomoral contamination in Charles Burns' graphic novel Black Hole.

This article attempts to demonstrate how Charles Burns' graphic novel Black Hole (1995) construes the prevalence of contagion and pathological transformation(s) as metaphors of social contamination operating within a biopolitics of segregation. Through a study of plague, infection and strange mutations in Burns' novel, this article offers a critical evaluation of the monstrous body and investigates how Black Hole portrays the social reception of a sexually contagious virus through conditions of sickness and exclusion, which become biopolitical in quality. It examines, through close reading, how Burns' novel uses metaphors of contagion, abjection and desire, often fusing those in order to foreground the complex intercorporeal state of the segregated subject and in the process dramatises the urgent need to revaluate conventional strategies of isolation and otherisation through a reconsideration of the biopolitical notions around engagement, community and immunity.

Coherent atomic mirror formed by randomly distributed ions inside a crystal.

Spatial distribution of atoms plays an important role in the interaction of atomic ensembles and electromagnetic fields. In this Letter, we show that by spatio-spectral tailoring of atomic absorption, one can effectively carve out a periodic array from randomly distributed atomic ensembles hosted by a solid-state crystal. Furthermore, we observe collective atomic resonances and coherent backscattering of light from rare-earth-doped crystals. Coherent backscattering as high as 20% was observed for light at telecom wavelength from Er ions, forming an effective array with over 5000 centers.

Controlling light emission by engineering atomic geometries in silicon photonics.

By engineering atomic geometries composed of nearly 1000 atomic segments embedded in micro-resonators, we observe Bragg resonances induced by the atomic lattice at the telecommunication wavelength. The geometrical arrangement of erbium atoms into a lattice inside a silicon nitride (SiN) microring resonator reduces the scattering loss at a wavelength commensurate with the lattice. We confirm dependency of light emission to the atomic positions and lattice spacing and also observe Fano interference between resonant modes in the system.

Relationship between early-life nutrition and ages at menarche and first pregnancy, and childbirth rates of young adults: Evidence from APCAPS in India.

India's Integrated Child Development Services (ICDS) provides daily supplementary nutrition and other public health services to women and children. We estimated associations between exposure to early-childhood ICDS nutrition and adult reproductive outcomes. During 1987-1990, a balanced protein-calorie supplement called "upma"-made from locally available corn-soya ingredients-was rolled out by subdistricts near Hyderabad and offered to pregnant women and children under age 6 years. In a controlled trial, 15 villages received the supplement and 14 did not. We used data from a 2010-2012 resurvey of adults born during the trial (n = 715 in intervention and n = 645 in control arms). We used propensity score matching methods to estimate the associations between birth in an intervention village and menarcheal age, age at first pregnancy, and fertility of adults. We found that women born in the intervention group during the trial, as compared with the control group, had menarche 0.45 (95% confidence interval [CI: 0.22, 0.68]; p < .001) years later and first pregnancy 0.53 (95% CI [0.04, 1.02]; p < .05) years later. Married women from the intervention group had menarche 0.36 (95% CI [0.09, 0.64]; p < .01) years later, first cohabitation with partner 0.8 (95% CI [0.27, 1.33]; p < .01) years later, and first pregnancy 0.53 (95% CI [0.04, 1.02]; p < .05) years later than married women in the control group. There was no significant difference between intervention and control group women regarding whether they had at least one childbirth or the total number of children born. The findings were similar when we employed inverse propensity score weighted regression models.

Optomechanical frequency comb memory.

Typical nano-mechanical oscillator arrays exhibit a mechanical frequency distribution arising from the imprecision in the nanofabrication process, thus hindering their collective dynamics. We tailor the inhomogeneously broadened spectrum of a nano-oscillator ensemble to unravel the collective dynamics of mechanical oscillators in an optomechanical array. We show that by engineering tunable optomechanical interactions, the instantaneous phase matching between the oscillators reveals collective dynamics in the form of a photon-phonon echo excitation without the need for active frequency tuning. Using numerical simulations, we demonstrate that by controlling such collective dynamics, broadband and scalable coherent light storage can be realized. An optomechanical memory of this kind enables information storage over a wide band of wavelengths, including the telecommunications band and, importantly, can be integrated into the silicon photonic networks.

Early-Life Nutrition Is Associated Positively with Schooling and Labor Market Outcomes and Negatively with Marriage Rates at Age 20-25 Years: Evidence from the Andhra Pradesh Children and Parents Study (APCAPS) in India.

Background: India's Integrated Child Development Services (ICDS) is among the world's largest public nutritional programs, providing daily nutritional supplements and other public health and educational services to pregnant and nursing women, children aged <6 y, and adolescent girls. Objective: We estimated the long-term association between early-childhood ICDS nutrition and adult outcomes. Methods: We used follow-up data from a controlled nutritional trial conducted during 1987-1990 in 29 villages near the city of Hyderabad. In 15 intervention villages, a balanced protein-calorie supplement-made from locally available corn-soya ingredients and called upma-was offered to pregnant women and to children <6 y old. No supplement was offered in the 14 control villages. During 2010-2012, adults born during the trial were re-surveyed (n = 715 in the intervention arm and n = 645 in the control arm). We used probit regression and propensity score-matching methods to estimate the association between birth in an intervention village and rates of secondary and graduate education completion, marriage, and employment or enrollment in higher education of these adults. Results: Adults born in the intervention group during the trial, compared with the control group, were 9% (95% CI: 0.04, 0.14; P < 0.01) more likely to complete secondary school and 11% (95% CI: 0.06, 0.15; P < 0.01) more likely to complete graduate education, were 6% (95% CI: -0.11, -0.01; P < 0.05) less likely to be ever-married at age 20-25 y, and were 5% (95% CI: 0, 0.11; P < 0.05) more likely to be employed or enrolled in higher education. The estimated associations for graduate education completion and employment-study rates were greater for men, whereas the associations for secondary education and ever-married rates were greater for women. Conclusion: Exposure to nutritional supplement in utero or during the first 3 y of life was associated with improved adult educational and employment outcomes and lower marriage rates in India.

Health and economic benefits of public financing of epilepsy treatment in India: An agent-based simulation model.

OBJECTIVE: An estimated 6-10 million people in India live with active epilepsy, and less than half are treated. We analyze the health and economic benefits of three scenarios of publicly financed national epilepsy programs that provide: (1) first-line antiepilepsy drugs (AEDs), (2) first- and second-line AEDs, and (3) first- and second-line AEDs and surgery. METHODS: We model the prevalence and distribution of epilepsy in India using IndiaSim, an agent-based, simulation model of the Indian population. Agents in the model are disease-free or in one of three disease states: untreated with seizures, treated with seizures, and treated without seizures. Outcome measures include the proportion of the population that has epilepsy and is untreated, disability-adjusted life years (DALYs) averted, and cost per DALY averted. Economic benefit measures estimated include out-of-pocket (OOP) expenditure averted and money-metric value of insurance. RESULTS: All three scenarios represent a cost-effective use of resources and would avert 800,000-1 million DALYs per year in India relative to the current scenario. However, especially in poor regions and populations, scenario 1 (which publicly finances only first-line therapy) does not decrease the OOP expenditure or provide financial risk protection if we include care-seeking costs. The OOP expenditure averted increases from scenarios 1 through 3, and the money-metric value of insurance follows a similar trend between scenarios and typically decreases with wealth. In the first 10 years of scenarios 2 and 3, households avert on average over US$80 million per year in medical expenditure. SIGNIFICANCE: Expanding and publicly financing epilepsy treatment in India averts substantial disease burden. A universal public finance policy that covers only first-line AEDs may not provide significant financial risk protection. Covering costs for both first- and second-line therapy and other medical costs alleviates the financial burden from epilepsy and is cost-effective across wealth quintiles and in all Indian states.

Early Childhood Nutrition Is Positively Associated with Adolescent Educational Outcomes: Evidence from the Andhra Pradesh Child and Parents Study (APCAPS).

BACKGROUND: India's Integrated Child Development Scheme, which provides supplementary nutrition and other public health services to >91 million women and children aged <6 y, is the largest program of its kind in the world. OBJECTIVE: We estimated the long-term associations of maternal and early childhood nutrition provided under the Integrated Child Development Scheme with educational outcomes when the children became adolescents. METHODS: We used longitudinal data from a controlled nutrition trial conducted near the city of Hyderabad, India. From 1987 to 1990, a balanced protein-energy supplement (corn-soya meal, called upma) was offered to pregnant women and children aged <6 y in 15 intervention villages, whereas no supplementation was offered in 14 control villages. Both groups had equal access to other public programs such as immunization and anemia control in pregnancy. Children born during the original trial period were resurveyed (654 intervention and 511 control group children) in 2003-2005. We used propensity score matching methods to correct for estimation bias in our regression models to assess the associations of supplementary nutrition with school enrollment, schooling grades completed, and academic test performance of these adolescents. RESULTS: Children born in intervention villages were 7.8% (95% CI: 0.1%, 15.4%; P < 0.05) more likely to be enrolled in school and completed 0.84 (95% CI: 0.28, 1.39; P < 0.005) more schooling grades than children born in control villages. We found no association between supplementary nutrition and academic performance, as measured by school test scores. CONCLUSION: Offering a nutritional supplement to pregnant women and children <6 y of age during the Hyderabad Nutrition Trial was associated with improved school enrollment and completion of more schooling grades when the children became adolescents.

Estimates of the economic contributions of the bidi manufacturing industry in India.

BACKGROUND: Bidis, the most common smoking tobacco product in India, remain largely untaxed and are subject to very few regulations to discourage their use. A major argument against tax increases is the large potential loss of economic activity and employment in the bidi industry from reduced consumption. METHODS: We used a nationally representative survey of unorganised bidi manufacturing firms (n=2841) in India to estimate the economic contribution of the industry. RESULTS: We find that of the 35 states and union territories of India, the bidi industry operated across 17 states, with over 95% of its production concentrated in 10 states. Bidi manufacturing firms contributed 0.50% of total sales and 0.6% of the gross value added by the manufacturing economy in 2005-2006. The industry employed approximately 3.4 million full-time workers, which comprise about 0.7% of employment in all sectors. A further 0.7 million were part-time workers. Bidi workers were also among the lowest paid employees in India. The industry offered only 0.09% of all compensation provided in the manufacturing sector (organised and unorganised). CONCLUSIONS: Considering the relatively small economic footprint of the bidi industry in India, higher excise taxes and regulations on bidis are unlikely to disrupt economic growth at an aggregate level, or lead to mass unemployment and economic hardship among small bidi workers. On average, the economic annual output per bidi worker is about US$143, which is an order of magnitude smaller than the large economic losses from the several hundred thousand deaths due to bidi smoking per year.

The need for better evidence to evaluate the health & economic benefits of India's Rashtriya Swasthya Bima Yojana.

In this review the existing evidence on the impact of Rashtriya Swasthya Bima Yojana (RSBY) is discussed in the context of international literature available on health insurance. We describe potential pathways through which health insurance can affect health and economic outcomes, discuss evidence from other developing countries, and identify potential biases and inconsistencies in existing studies on RSBY impact. Given the relatively recent introduction of RSBY, lack of quality, verifiable data on utilization patterns, and the absence of reliable evaluation studies, there is a need to exercise caution while assessing the merits of the programme. Considering the enormous potential and cost of the programme, we emphasize the need for a rigorous impact evaluation of RSBY. It will not only help capture the real impact of the scheme, but may also be able to estimate the extent of systemic inefficiencies at the level of the consumer.

"Undoubtedly a race, but they are not human": Immuno-politics and the Recognition of the Jew as Pathogenic Nonself in Art Spiegelman's Maus.

This article engages with the immuno-political juxtaposition of the healthy self and the pathogenic other to critically examine the representation of Nazis and Jews in Art Spiegelman's Pulitzer Prize-winning graphic novel Maus (1996). Written as a postmemory narrative, Maus recounts the horrors experienced by the author's father Vladek Spiegelman as a survivor of the Holocaust that claimed an approximate six million Jewish lives. Beginning with the years leading up to World War II, Spiegelman's novel reimagines the discrimination, dislocation, and dehumanization suffered by Vladek and his family at various prison camps in Nazi-occupied Poland before being transferred to Auschwitz. Deploying an immuno-political reading of Maus, this article investigates how the Third Reich undertook a systematic extermination of the Jewish race by construing them as immunological nonself or pathogenic others. It further argues that Nazism's fantasy of constructing a racially aseptic German identity by eradicating the Jews as vermin or parasites was reinforced by the late nineteenth-century eugenicist ideologies of racial hygiene. This article finally considers how policies of excessive immunization that was deployed by Nazi biopolitics against the Jewish community, as well as exercised by the Jews to survive the Holocaust, eventually assumed the form of an autoimmune pathology that culminated with the attempted destruction of the entire medico-juridical infrastructure of the German Reich on the one hand and the fostering of suicidal tendencies by the Jewish survivors on the other.

Analysis of anthropometric outcomes in Indian children during the COVID-19 pandemic using National Family Health Survey data.

BACKGROUND: Disruptions in food, health, and economic systems during the COVID-19 pandemic may have adversely affected child health. There is currently limited research on the potential effects of the COVID-19 pandemic on stunting, wasting, and underweight status of young children. METHODS: We examine the short-term associations between the pandemic and anthropometric outcomes of under-5 children (n = 232,920) in India, using data from the National Family Health Survey (2019-2021). Children surveyed after March 2020 are considered as the post-COVID group, while those surveyed earlier are considered as pre-COVID. Potential biases arising from differences in socioeconomic characteristics of the two groups are mitigated using propensity score matching methods. RESULTS: Post-COVID children surveyed in 2020 and 2021 have 1.2% higher underweight rates, 1.2% lower wasting rates, 0.1 lower height-for-age z-scores (HAZ), and 0.04 lower weight-for-height z-scores as compared with matched pre-COVID children. Post-COVID children surveyed in 2020 have 1.6%, 4.6%, and 2.4% higher stunting, underweight, and wasting rates, respectively, and 0.07 lower HAZ, as compared with matched pre-COVID children. Reductions in nutritional status are largest among children from households in the poorest wealth quintiles. CONCLUSIONS: These findings indicate a trend towards a recovery in child anthropometric outcomes in 2021 after the initial post-pandemic reductions. The resilience of health and food systems to shocks such as COVID-19 should be strengthened while immediate investments are required to decrease child malnutrition and improve broader child health outcomes.

This study examined how the COVID-19 pandemic affected the health of children under five years of age in India. We compared children surveyed before and after the pandemic. We find that children surveyed after the pandemic began in 2020 had decreased height and weight when compared to pre-pandemic measurements. In 2021, these outcomes improved but some outcomes, primarily weight, did not recover completely. These effects were most pronounced in the poorest households. Overall, our findings suggest that some of the effects of the pandemic may be short-term, but these require further study. Investments are required to reduce child malnutrition and improve the resilience of health and foods systems to shocks.

Effect of rotavirus vaccination on the burden of rotavirus disease and associated antibiotic use in India: A dynamic agent-based simulation analysis.

BACKGROUND: Rotavirus is a leading cause of diarrhea in infants and young children in many low- and middle-income countries. India launched a childhood immunization program for rotavirus in 2016, starting with four states and expanding it to cover all states by 2019. The objective of this study was to estimate the effects of the rotavirus vaccination program in India on disease burden and antibiotic misuse. METHODS: We built a dynamic agent-based model of rotavirus progression in children under five within each district in India. Simulations were run for various scenarios of vaccination coverage in the context of India's Universal Immunization Programme. Population data were obtained from the National Family Household Surveys and used to calibrate the models. Disease parameters were obtained from published studies. We estimated past and projected future reduction of disease burden and antibiotic misuse due to full vaccination nationwide, by state, and by wealth quintile. RESULTS: We estimate that rotavirus vaccination in India has reduced the prevalence of rotavirus cases by 33.7% (prediction interval: 30.7-36.0%), total antibiotic misuse due to rotavirus by 21.8% (18.6-25.1%), and total deaths due to rotavirus by 38.3% (31.3-44.4%) for children under five. We estimate total antibiotic misuse due to rotavirus infection to be 7.6% (7.5-7.9%) of total antibiotic consumption in this demographic versus 9.6% (9.4-9.9%) in the absence of vaccination. We project rotaviral prevalence to drop to below one case for every 100,000 individuals in those below five if vaccination coverage is increased by 50.3% (45.2-58.5%) to 68.1% (63.1-76.4) nationwide. CONCLUSION: Universal coverage of childhood rotavirus vaccination can substantially reduce inappropriate antibiotic use in India.

Estimates of hospitalisations and deaths in patients with COVID-19 associated with undiagnosed diabetes during the first phase of the pandemic in eight low-income and middle-income countries: a modelling study.

Background: Patients with COVID-19 that had diagnosed chronic diseases - including diabetes - may experience higher rates of hospitalisation and mortality relative to the general population. However, the burden of undiagnosed co-morbidities during the pandemic has not been adequately studied. Methods: We developed a model to estimate the hospitalisation and mortality burden of patients with COVID-19 that had undiagnosed type 1 and type 2 diabetes (UD). The retrospective analytical modelling framework was informed by country-level demographic, epidemiological and COVID-19 data and parameters. Eight low-and middle-income countries (LMICs) were studied: Brazil, China, India, Indonesia, Mexico, Nigeria, Pakistan, and South Africa. The modelling period consisted of the first phase of the pandemic - starting from the date when a country identified its first COVID case to the date when the country reached 1% coverage with one dose of a COVID-19 vaccine. The end date ranged from Jan 20, 2021 for China to June 2, 2021 for Nigeria. Additionally, we estimated the change in burden under a scenario in which all individuals with UD had been diagnosed prior to the pandemic. Findings: Based on our modelling estimates, across the eight countries, 6.7 (95% uncertainty interval: 3.4-11.3) million COVID-19 hospitalised patients had UD of which 1.9 (0.9-3.4) million died. These represented 21.1% (13.4%-30.1%) of all COVID-19 hospitalisations and 30.5% (14.3%-55.5%) of all COVID-19 deaths in these countries. Based on modelling estimates, if these populations had been diagnosed for diabetes prior to the COVID-19 pandemic, 1.7% (-3.0% to 5.9%) of COVID-19 hospitalisations and 5.0% (-0.9% to 14.1%) of COVID-19 deaths could have been prevented, and 1.8 (-0.3 to 5.0) million quality-adjusted life years gained. Interpretation: Our findings suggest that undiagnosed diabetes contributed substantially to COVID-19 hospitalisations and deaths in many LMICs. Funding: This work was supported, in part, by the Bill & Melinda Gates Foundation [INV-029062] and FIND.

Cost of care for Alzheimer's disease and related dementias in the United States: 2016 to 2060.

Medical and long-term care for Alzheimer's disease and related dementias (ADRDs) can impose a large economic burden on individuals and societies. We estimated the per capita cost of ADRDs care in the in the United States in 2016 and projected future aggregate care costs during 2020-2060. Based on a previously published methodology, we used U.S. Health and Retirement Survey (2010-2016) longitudinal data to estimate formal and informal care costs. In 2016, the estimated per patient cost of formal care was $28,078 (95% confidence interval [CI]: $25,893-$30,433), and informal care cost valued in terms of replacement cost and forgone wages was $36,667 ($34,025-$39,473) and $15,792 ($12,980-$18,713), respectively. Aggregate formal care cost and formal plus informal care cost using replacement cost and forgone wage methods were $196 billion (95% uncertainty range [UR]: $179-$213 billion), $450 billion ($424-$478 billion), and $305 billion ($278-$333 billion), respectively, in 2020. These were projected to increase to $1.4 trillion ($837 billion-$2.2 trillion), $3.3 trillion ($1.9-$5.1 trillion), and $2.2 trillion ($1.3-$3.5 trillion), respectively, in 2060.

The global macroeconomic burden of Alzheimer's disease and other dementias: estimates and projections for 152 countries or territories.

BACKGROUND: Alzheimer's disease and other dementias (ADODs) severely threaten the wellbeing of older people, their families, and communities, especially with projected exponential growth. Understanding the macroeconomic implications of ADODs for policy making is essential but under-researched. METHODS: We used a health-augmented macroeconomic model to calculate the macroeconomic burden of ADODs for 152 countries or territories, accounting for: the effect on labour supply of reduced working hours of informal caregivers; the effect on labour supply of ADODs-related mortality and morbidity; age-sex-specific differences in education, work experience, labour market participations, and informal caregivers; and treatment and formal care costs diverting from savings and investments. FINDINGS: ADODs will cost the world economy 14 513 billion international dollars (INT$, measured in the base year 2020; 95% uncertainty interval [UI] 12 106-17 778) from 2020 to 2050, equivalent to 0·421% (95% UI 0·351-0·515) of annual global GDP. Japan incurs the largest annual GDP loss at 1·463% (1·225-1·790). China (INT$2961 billion [2507-3564]), the USA (INT$2331 billion [1989-2829]), and Japan (INT$1758 billion [1471-2150]) face the largest absolute economic burdens. The economic burden of informal care ranges from 60·97% in high-income countries to 85·45% in lower-middle-income countries, and treatment and formal care costs range from 10·50% in lower-middle-income countries to 30·80% in high-income countries. INTERPRETATION: The macroeconomic burden of ADODs is substantial and unequally distributed across countries and regions. Global efforts to reduce the burden, especially with regard to informal care, are urgently needed. FUNDING: National Institute on Aging, National Institutes of Health; Chinese Academy of Engineering; Chinese Academy of Medical Sciences; Bill & Melinda Gates Foundation; Davos Alzheimer's Collaborative through Data for Decisions.

Vaccination for healthy aging.

As the world's population grows older, vaccination is becoming a key strategy for promoting healthy aging. Despite scientific progress in adult vaccine development, obstacles such as immunosenescence and vaccine hesitancy remain. To unlock the potential of adult vaccines fully, we must enhance immunization programs, dispel misinformation, and invest in research that deepens our understanding of aging and immunity.

The effect of the COVID-19 pandemic on routine childhood immunization coverage and timeliness in India: retrospective analysis of the National Family Health Survey of 2019-2021 data.

Background: The COVID-19 pandemic has disrupted health systems globally. We estimated the effect of the pandemic on the coverage and timeliness of routine childhood immunization in India through April 2021. Methods: We used data from India's National Family Health Survey 2019-2021 (NFHS-5), a cross-sectional survey which collected immunization information of under-five children from a nationally representative sample of households between June 2019 and April 2021. We used a mother fixed-effects regression model - accounting for secular trends and confounding factors - to compare COVID-affected children with their COVID-unaffected siblings (n = 59,144). Children who were eligible for a vaccine after January 30, 2020 (date of the first COVID case in India) were considered as the COVID-affected group and those eligible for a vaccine before this date were included in the COVID-unaffected group. Coverage of the following vaccine doses was considered-Bacillus Calmette-Guérin (BCG), hepatitis B birth dose (hepB0), DPT1 (diphtheria, pertussis, and tetanus, first dose), DPT2, DPT3, polio1, polio2, polio3, and measles first dose (MCV1). Indicators of vaccine coverage and vaccine timeliness (defined as receiving a dose within 45 days of minimum eligibility age) were separately examined. Findings: Immunization coverage was lower in COVID-affected children as compared with unaffected children, ranging from 2% lower for BCG and hepB0 to 9% for DPT3 and 10% for polio3. There was no significant difference in MCV1 coverage. Coverage reduction was greater for vaccines doses given in later age groups. The rate of timely receipt of polio and DPT vaccine doses was 3%-5% lower among COVID-affected children relative to unaffected children. Among population subgroups, COVID-affected male children and those from rural areas experienced the highest reduction in vaccine coverage. Interpretation: Children in India experienced lower routine immunization coverage and greater delays in immunization during the COVID-19 pandemic. Funding: The Bill & Melinda Gates Foundation.

Global antibiotic use during the COVID-19 pandemic: analysis of pharmaceutical sales data from 71 countries, 2020-2022.

Background: Despite bacterial coinfection rates of less than 10%, antibiotics are prescribed to an estimated 75% of patients with COVID-19, potentially exacerbating antimicrobial resistance. We estimated the associations of COVID-19 cases and vaccinations with global antibiotic sales during the first two years of the COVID-19 pandemic. Methods: We obtained monthly data on broad-spectrum antibiotic sales volumes (cephalosporins, penicillins, macrolides, and tetracyclines) in 71 countries during March 2020-May 2022 from the IQVIA MIDAS® database. These data were combined with country-month-level COVID-19 case and vaccination data from Our World in Data. We used least squares (pooled) and fixed-effects panel data regression models, accounting for country characteristics, to estimate the associations between antibiotic sales volumes and COVID-19 cases and vaccinations per 1000 people. Findings: Sales of all four antibiotics fell sharply during April and May 2020, followed by a gradual rise to near pre-pandemic levels through May 2022. In fixed-effects regression models, a 10% increase in monthly COVID-19 cases was associated with 0.2%-0.3% higher sales of cephalosporins, 0.2%-0.3% higher sales of penicillins, 0.4%-0.6% higher sales of macrolides, and 0.3% higher sales of all four antibiotics combined per 1000 people. Across continents, a 10% increase in monthly COVID-19 cases was associated with 0.8%, 1.3%, and 1.5% higher macrolides sales in Europe, North America, and Africa respectively. Sales of other antibiotics across continent were also positively associated with COVID-19 cases, although the estimated associations were smaller in magnitude. No consistent associations were observed between antibiotic sales and COVID-19 vaccinations. Results from pooled regression analysis were similar to those from the fixed-effects models. Interpretation: Antibiotic sales were positively associated with COVID-19 cases globally during 2020-2022. Our findings underline that antibiotic stewardship in the context of COVID-19 remains essential. Funding: Bill & Melinda Gates Foundation.

The gendered effects of the COVID-19 pandemic on adolescent literacy and schooling outcomes in India.

The COVID-19 pandemic disrupted education delivery around the world, with school closures affecting over 1.6 billion students worldwide. In India, schools were closed for over 18 months, affecting 248 million students. This study estimates the effect of the pandemic on adolescent literacy and schooling outcomes in India. We used data from the National Family Health Survey. (NFHS-5) which covered 636,699 households across all districts of India from June 2019 to April 2021. We considered 15-17 year old adolescents who were surveyed after March 2020 as the post-COVID group while those surveyed earlier were included in the pre-COVID group. We used propensity score matching and inverse propensity score weighted regression methods to account for differences in socioeconomic characteristics between the two groups. Rates of literacy (ability to read a complete sentence) were 1.5-1.6% lower among post-COVID girls as compared with similar pre-COVID girls. Among post-COVID girls in the lowest wealth quintile, rates of literacy were 3.1-3.8% lower than similar pre-COVID girls. There was no loss in literacy among post-COVID girls in the highest wealth quintile. COVID-induced loss in literacy among girls was twice in rural areas as compared to urban areas, and substantially higher among socioeconomically disadvantaged caste groups as compared with privileged caste groups. Post-COVID girls also had 0.08-0.1 lower years of schooling completed than similar pre-COVID girls but there was no difference in out-of-school rates. In a smaller subsample of 15-17 year old boys, the post-COVID group had 2% lower out-of-school rates and there was no difference in literacy or years of schooling completed as compared with matched pre-COVID boys. While markers of vulnerability such as residence, caste, and poverty further amplified the risk of learning. loss for girls, they did not have the same effect on boys.