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BackgroundCoronavirus disease 2019 (COVID-19), caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is estimated to have caused more than 18 million deaths worldwide as of end-May 2022. MethodsCOVIDENCE UK is a longitudinal population-based study that investigates risk factors for, and impacts of, COVID-19 in UK residents aged [≥]16 years. A unique feature is the capacity to support trial-within-cohort studies to evaluate interventions for prevention of COVID-19 and other acute respiratory illnesses. Participants complete a detailed online baseline questionnaire capturing self-reported information relating to their socio-demographic characteristics, occupation, lifestyle, quality of life, weight, height, longstanding medical conditions, medication use, vaccination status, diet and supplemental micronutrient intake. Follow-up on-line questionnaires capturing incident symptoms of COVID-19 and other acute respiratory infections, incident swab test-confirmed COVID-19, doses of SARS-CoV-2 vaccine received, and quality of life are completed at monthly intervals. ResultsThe study was launched on 1st May 2020 and closed to recruitment on 6th October 2021. A total of 19,981 participants enrolled and consented to 5-year follow-up with medical record linkage. Their mean age was 59.1 years (range 16.0 to 94.4 years), 70.2% were female, and 93.7% identified their ethnic origin as White. Analyses conducted to date have provided key insights into risk factors for SARS-CoV-2 infection and COVID-19 disease, determinants of SARS-CoV-2 vaccine immunogenicity and efficacy, and impacts of COVID-19 on health economic outcomes. The cohort has also supported conduct of a Phase 3 randomised trial-within-cohort study (CORONAVIT) evaluating implementation of a test-and-treat approach to correcting sub-optimal vitamin D status on incidence and severity of acute respiratory infections, including COVID-19. ConclusionsThe COVIDENCE UK dataset represents a valuable resource containing granular information on factors influencing susceptibility to, and impacts of, COVID-19 in UK adults. Researchers wishing to access anonymised participant-level data should contacting the corresponding author for further information.
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BackgroundLittle is known about the relative influence of demographic, behavioural, and vaccine-related factors on risk of post-vaccination SARS-CoV-2 infection. We aimed to identify risk factors for SARS-CoV-2 infection after primary and booster vaccinations. MethodsWe undertook a prospective population-based study in UK adults ([≥]16 years) vaccinated against SARS-CoV-2, including data from Jan 12, 2021, to Feb 21, 2022. We modelled risk of post-vaccination SARS-CoV-2 infection separately for participants who had completed a primary course of vaccination (two-dose or, in the immunosuppressed, three-dose course of either ChAdOx1 nCoV-19 [ChAdOx1] or BNT1262b2) and for those who had additionally received a booster dose (BNT1262b2 or mRNA-1273). Cox regression models were used to explore associations between sociodemographic, behavioural, clinical, pharmacological, and nutritional factors and breakthrough infection, defined as a self-reported positive result on a lateral flow or reverse transcription PCR (RT-PCR) test for SARS-CoV-2. Models were further adjusted for weekly SARS-CoV-2 incidence at the local (lower tier local authority) level. Findings14,713 participants were included in the post-primary analysis and 10,665 in the post-booster analysis, with a median follow-up of 203 days (IQR 195-216) in the post-primary cohort and 85 days (66-103) in the post-booster cohort. 1051 (7.1%) participants in the post-primary cohort and 1009 (9.4%) participants in the post-booster cohort reported a breakthrough SARS-CoV-2 infection. A primary course of ChAdOx1 (vs BNT182b2) was associated with higher risk of infection, both in the post-primary cohort (adjusted hazard ratio 1.63, 95% CI 1.41-1.88) and in the post-booster cohort after boosting with mRNA-1273 (1.29 [1.03-1.61] vs BNT162b2 primary plus BNT162b2 booster). A lower risk of breakthrough infection was associated with older age (post-primary: 0.96 [0.96-0.97] per year; post-booster: 0.97 [0.96-0.98]), whereas a higher risk of breakthrough infection was associated with lower levels of education (post-primary: 1.66 [1.35-2.06] for primary or secondary vs postgraduate; post-booster: 1.36 [1.08-1.71]) and at least three weekly visits to indoor public places (post-primary: 1.38 [1.15-1.66] vs none; post-booster: 1.33 [1.10-1.60]). ConclusionsVaccine type, socioeconomic status, age, and behaviours affect risk of breakthrough SARS-CoV-2 infection following a primary schedule and a booster dose. Research in contextO_ST_ABSEvidence before this studyC_ST_ABSWe searched PubMed, medRxiv, and Google Scholar for papers published up to Feb 18, 2022, using the search terms (breakthrough OR post-vaccin*) AND (SARS-CoV-2 OR COVID) AND (disease OR infection) AND (determinant OR "risk factor" OR associat*), with no language restrictions. Existing studies on risk factors for breakthrough SARS-CoV-2 infection among vaccinated individuals have found associations with age, comorbidities, vaccine type, and previous infection; however, findings have been inconsistent across studies. Most studies have been limited to specific subgroups or have focused on severe outcomes, and very few have considered breakthrough infections after a booster dose or have adjusted for behaviours affecting exposure to other people. Added value of this studyThis study is among the first to provide a detailed analysis of a wide range of risk factors for breakthrough SARS-CoV-2 infection, both after the primary course of vaccination and after a booster dose. Our large study size and detailed data have allowed us to investigate associations with various sociodemographic, clinical, pharmacological, and nutritional factors. Monthly follow-up data have additionally given us the opportunity to consider the effects of behaviours that may have changed across the pandemic, while adjusting for local SARS-CoV-2 incidence. Implications of all the available evidenceOur findings add to growing evidence that risk factors for SARS-CoV-2 infection after primary or booster vaccinations can differ to those in unvaccinated populations, with effects attenuated for previously observed risk factors such as body-mass index and Asian ethnicity. The clear difference we observed between the efficacies of ChAdOx1 and BNT162b2 as the primary course of vaccination appears to have been reduced by the use of BNT162b2 boosters, but not by mNRA-1273 boosters. As more countries introduce booster vaccinations, future population-based studies with longer follow-up will be needed to investigate our findings further.
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BackgroundProspective population-based studies investigating multiple determinants of pre-vaccination antibody responses to SARS-CoV-2 are lacking. MethodsWe did a prospective population-based study in SARS-CoV-2 vaccine-naive UK adults recruited between May 1 and November 2, 2020, without a positive swab test result for SARS-CoV-2 prior to enrolment. Information on 88 potential sociodemographic, behavioural, nutritional, clinical and pharmacological risk factors was obtained through online questionnaires, and combined IgG/IgA/IgM responses to SARS-CoV-2 spike glycoprotein were determined in dried blood spots obtained between November 6, 2020 and April 18, 2021. We used logistic and linear regression to estimate adjusted odds ratios (aORs) and adjusted geometric mean ratios (aGMRs) for potential determinants of SARS-CoV-2 seropositivity (all participants) and antibody titres (seropositive participants only), respectively. Results1696 (15.2%) of 11,130 participants were seropositive. Factors independently associated with increased risk of SARS-CoV-2 seropositivity included frontline health/care occupation (aOR 1.86, 95% CI 1.48-2.33), international travel (1.20, 1.07-1.35), number of visits to shops and other indoor public places ([≥]5 vs. 0/week: 1.29, 1.06-1.57, P-trend=0.01), body mass index (BMI) [≥]25 vs <25 kg/m2 (1.24, 1.11-1.39), Asian/Asian British vs White ethnicity (1.65, 1.10-2.49), and alcohol consumption [≥]15 vs 0 units/week (1.23, 1.04-1.46). Light physical exercise associated with decreased risk (0.80, 0.70-0.93, for [≥]10 vs 0-4 h/week). Among seropositive participants, higher titres of anti-Spike antibodies associated with factors including BMI [≥]30 vs <25 kg/m2 (aGMR 1.10, 1.02-1.19), Asian/Asian British vs White ethnicity (1.22, 1.04-1.44), frontline health/care occupation (1.24, 95% CI 1.11-1.39), international travel (1.11, 1.05-1.16), and number of visits to shops and other indoor public places ([≥]5 vs. 0/week: 1.12, 1.02-1.23, P-trend=0.01); these associations were not substantially attenuated by adjustment for COVID-19 disease severity. ConclusionsHigher alcohol consumption and reduced light physical exercise represent new modifiable risk factors for SARS-CoV-2 infection. Recognised associations between Asian/Asian British ethnic origin and obesity and increased risk of SARS-CoV-2 seropositivity were independent of other sociodemographic, behavioural, nutritional, clinical and pharmacological factors investigated. Among seropositive participants, higher titres of anti-Spike antibodies in people of Asian ancestry and in obese people were not explained by greater COVID-19 disease severity in these groups. FundingBarts Charity, Health Data Research UK.
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ObjectivesDetermine individual level risk factors for care home residents testing positive for SARS-CoV-2. Study DesignLongitudinal observational cohort study using individual-level linked data. SettingCare home residents in Wales (United Kingdom) between 1st September 2020 and 1st May 2021. Participants14,786 older care home residents (aged 65+). Our dataset consisted of 2,613,341 individual-level daily observations within 697 care homes. MethodsWe estimated odds ratios (ORs [95% confidence interval]) using multilevel logistic regression models. Our outcome of interest was a positive SARS-CoV-2 polymerase chain reaction (PCR) test. We included time dependent covariates for the estimated community positive test rate of COVID-19, hospital admissions, and vaccination status. Additional covariates were included for age, positive PCR tests prior to the study, sex, frailty (using the hospital frailty risk score), and specialist care home services. ResultsThe multivariable logistic regression model indicated an increase in age (OR 1.01 [1.00,1.01] per year of age), community positive test rate (OR 1.13 [1.12,1.13] per percent increase in positive test rate), hospital inpatients (OR 7.40 [6.54,8.36]), and residents in care homes with non-specialist dementia care (OR 1.42 [1.01,1.99]) had an increased odds of a positive test. Having a positive test prior to the observation period (OR 0.58 [0.49,0.68]) and either one or two doses of a vaccine (0.21 [0.17,0.25] and 0.05 [0.02,0.09] respectively) were associated with a decreased odds of a positive test. ConclusionsOur findings suggest care providers need to stay vigilant despite the vaccination rollout, and extra precautions should be taken when caring for the most vulnerable. Furthermore, minimising potential COVID-19 infection for care home residents admitted to hospital should be prioritised. SUMMARY BOXESO_ST_ABSSection 1: What is already known on this topicC_ST_ABSO_LICare home residents are at a high risk of COVID-19 infection, but existing literature has mainly focussed on excess mortality rather than infection risk. C_LIO_LIIn our study we were able to investigate associations between COVID-19 infections and the community positive test rate of COVID-19, the vaccination status of care home residents, hospital admissions, and frailty. C_LI Section 2: What this study addsO_LIOur study suggests an increased community positive test rate and hospital inpatients had an increased likelihood of a positive SARS-CoV-2 polymerase chain reaction test, whilst one or two doses of vaccination indicated a decreased chance of a positive test. C_LIO_LIOur findings suggest care providers need to stay vigilant despite the vaccination rollout, and extra precautions should be taken when caring for the most vulnerable, especially in a hospital setting. C_LI
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BackgroundMulti-setting population-based studies on healthcare service presentations with self-harm covering the first 12 months of the COVID-19 pandemic are yet to be published. AimsAscertain changes across settings in healthcare service presentations with self-harm during Waves 1 and 2 of the COVID-19 pandemic. MethodE-cohort study using individual-level linked routine healthcare data from Wales, UK, 2016-March 2021. We measured weekly proportion of self-harm contacts and people who self-harmed in contact with general practice (GP), emergency department (ED) and hospital admissions. We modelled weekly trends using linear regression and generalised estimated equations, quantifying time differences using difference-in-difference (DiD). ResultsWe included 3,552,210 Welsh residents aged [≥]10 years. Counts of self-harm presentations across settings was at a minimum at the start of stay-at-home restrictions during both waves and recovered compared to previous years in 3-5 months. Those who self-harmed in April 2020 were more likely to be seen in GP compared to other settings and previous years - mean rate of OR=1.2, although actual numbers fell. The proportion of self-harm ED contacts admitted to hospital dropped from June 2020 (1.9 [1.5-2.3] pp/month). Self-harm and COVID-19 infection had a bidirectional effect - self-harm history had OR=1.4 [1.2-1.6] and incidence had DiD=1.1 [0.8-1.4]. ConclusionsThose that self-harmed and sought help during the COVID-19 pandemic potentially encountered stringent criteria for hospitalisation, particularly in Wave 2, while in Wave 1 they preferentially presented to GP. Reductions in contacts likely resulted in unmet healthcare needs which may later emerge placing further burden on individuals and healthcare services. Relevance statementThis study provides novel findings on how the COVID-19 pandemic and the measures taken to curb its spread affected self-harm healthcare service presentations. To our knowledge no other population-based studies in the UK have linked routinely collected general practice (GP), emergency department (ED) and hospital admission data covering Waves 1 and 2 of the pandemic. Reductions in presentations with self-harm during the pandemic may be the result of those not requiring ED care or hospitalisation avoiding seeking help during the pandemic as often as before. Those that did seek help potentially encountered more stringent criteria for hospitalisation, particularly during Wave 2. This likely resulted in unmet healthcare needs which may later emerge placing further burden on individuals and healthcare services. Measures should be put in place to ensure that those who self-harm receive appropriate assessment and intervention.
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BackgroundRisk factors for severe COVID-19 include older age, male sex, obesity, Black or Asian ethnicity and underlying medical conditions. Whether these factors also influence susceptibility to developing COVID-19 is uncertain. MethodsWe undertook a prospective, population-based cohort study (COVIDENCE UK) from 1st May 2020 to 5th February 2021. Baseline information on potential risk factors was captured by online questionnaire. Monthly follow-up questionnaires captured incident COVID-19. We used logistic regression models to estimate multivariable-adjusted odds ratios (aORs) for associations between potential risk factors and risk of COVID-19. FindingsWe recorded 446 incident cases of COVID-19 in 15,227 participants (2.9%). Increased risk of developing COVID-19 was independently associated with Asian/Asian British vs. White ethnicity (aOR 2.31, 95% CI 1.35-3.95), household overcrowding (aOR per additional 0.5 people/bedroom 1.26, 1.11-1.43), any vs. no visits to/from other households in previous week (aOR 1.33, 1.07-1.64), number of visits to indoor public places (aOR per extra visit per week 1.05, 1.01-1.09), frontline occupation excluding health/social care vs. no frontline occupation (aOR 1.49, 1.12-1.98), and raised body mass index (BMI) (aOR 1.51 [1.20-1.90] for BMI 25.0-30.0 kg/m2 and 1.38 [1.05-1.82] for BMI >30.0 kg/m2 vs. BMI <25.0 kg/m2). Atopic disease was independently associated with decreased risk (aOR 0.76, 0.59-0.98). No independent associations were seen for age, sex, other medical conditions, diet, or micronutrient supplement use. InterpretationAfter rigorous adjustment for factors influencing exposure to SARS-CoV-2, Asian/Asian British ethnicity and raised BMI were associated with increased risk of developing COVID-19, while atopic disease was associated with decreased risk. FundingBarts Charity, Health Data Research UK
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BackgroundVaccinations for COVID-19 have been prioritised for older people living in care homes. However, vaccination trials included limited numbers of older people. AimWe aimed to study infection rates of SARS-CoV-2 for older care home residents following vaccination and identify factors associated with increased risk of infection. Study Design and SettingWe conducted an observational data-linkage study including 14,104 vaccinated older care home residents in Wales (UK) using anonymised electronic health records and administrative data. MethodsWe used Cox proportional hazards models to estimate hazard ratios (HRs) for the risk of testing positive for SARS-CoV-2 infection following vaccination, after landmark times of either 7 or 21-days post-vaccination. We adjusted hazard ratios for age, sex, frailty, prior SARS-CoV-2 infections and vaccination type. ResultsWe observed a small proportion of care home residents with positive PCR tests following vaccination 1.05% (N=148), with 90% of infections occurring within 28-days. For the 7-day landmark analysis we found a reduced risk of SARS-CoV-2 infection for vaccinated individuals who had a previous infection; HR (95% confidence interval) 0.54 (0.30,0.95), and an increased HR for those receiving the Pfizer-BioNTECH vaccine compared to the Oxford-AstraZeneca; 3.83 (2.45,5.98). For the 21-day landmark analysis we observed high HRs for individuals with low and intermediate frailty compared to those without; 4.59 (1.23,17.12) and 4.85 (1.68,14.04) respectively. ConclusionsIncreased risk of infection after 21-days was associated with frailty. We found most infections occurred within 28-days of vaccination, suggesting extra precautions to reduce transmission risk should be taken in this time frame.
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BackgroundA defining feature of the COVID-19 pandemic in many countries was the tragic extent to which care home residents were affected, and the difficulty preventing introduction and subsequent spread of infection. Management of risk in care homes requires good evidence on the most important transmission pathways. One hypothesised route at the start of the pandemic, prior to widespread testing, was transfer of patients from hospitals, which were experiencing high levels of nosocomial events. MethodsWe tested the hypothesis that hospital discharge events increased the intensity of care home cases using a national individually linked health record cohort in Wales, UK. We monitored 186,772 hospital discharge events over the period March to July 2020, tracking individuals to 923 care homes and recording the daily case rate in the homes populated by 15,772 residents. We estimated the risk of an increase in cases rates following exposure to a hospital discharge using multi-level hierarchical logistic regression, and a novel stochastic Hawkes process outbreak model. FindingsIn regression analysis, after adjusting for care home size, we found no significant association between hospital discharge and subsequent increases in care home case numbers (odds ratio: 0.99, 95% CI 0.82, 1.90). Risk factors for increased cases included care home size, care home resident density, and provision of nursing care. Using our outbreak model, we found a significant effect of hospital discharge on the subsequent intensity of cases. However, the effect was small, and considerably less than the effect of care home size, suggesting the highest risk of introduction came from interaction with the community. We estimated approximately 1.8% of hospital discharged patients may have been infected. InterpretationThere is growing evidence in the UK that the risk of transfer of COVID-19 from the high-risk hospital setting to the high-risk care home setting during the early stages of the pandemic was relatively small. Although access to testing was limited to initial symptomatic cases in each care home at this time, our results suggest that reduced numbers of discharges, selection of patients, and action taken within care homes following transfer all may have contributed to mitigation. The precise key transmission routes from the community remain to be quantified.
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ObjectivesTo report the volume of surgical activity and the number of cancelled surgical procedures during the COVID-19 pandemic. Design and settingAnalysis of electronic health record data from the National Health Service (NHS) in England and Wales. MethodsWe used hospital episode statistics for all adult patients undergoing surgery between 1st January 2020 and 31st December 2020. We identified surgical procedures using a previously published list of procedure codes. Procedures were stratified by urgency of surgery as defined by NHS England. We calculated the deficit of surgical activity by comparing the expected number of procedures from the years 2016-2019 with the actual number of procedures in 2020. We estimated the cumulative number of cancelled procedures by 31st December 2021 according patterns of activity in 2020. ResultsThe total number of surgical procedures carried out in England and Wales in 2020 was 3,102,674 compared to the predicted number of 4,671,338. This represents a 33.6% reduction in the national volume of surgical activity. There were 763,730 emergency surgical procedures (13.4% reduction), compared to 2,338,944 elective surgical procedures (38.6% reduction). The cumulative number of cancelled or postponed procedures was 1,568,664. We estimate that this will increase to 2,358,420 by 31st December 2021. ConclusionsThe volume of surgical activity in England and Wales was reduced by 33.6% in 2020, resulting in over 1,568,664 cancelled operations. This deficit will continue to grow in 2021. Summary boxesO_ST_ABSWhat is already known on this topicC_ST_ABSO_LIThe COVID-19 pandemic necessitated a rapid change in the provision of care, including the suspension of a large proportion of surgical activity C_LIO_LISurgical activity has yet to return to normal and has been further impacted by subsequent waves of the pandemic C_LIO_LIThis will lead to a large backlog of cases C_LI What this study addsO_LI3,102,674 surgical procedures were performed in England and Wales during 2020, a 33.6% reduction on the expected yearly surgical activity C_LIO_LIOver 1.5 million procedures were not performed, with this deficit likely to continue to grow to 2.3 million by the end of 2021 C_LIO_LIThis deficit is the equivalent of more than 6 months of pre-pandemic surgical activity, requiring a monumental financial and logistic challenge to manage C_LI
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BackgroundMedication prescribing and dispensing often regarded as one of the most effective ways to manage and improve population health. Prescribed and dispensed medications can be monitored through data linkage for each patient. We hypothesised that changes in patient care resulting from COVID-19, changed the way patients access their prescribed medication. ObjectiveTo develop an efficient approach for evaluation of the impact of COVID-19 on drug dispensing patterns. MethodsRetrospective observational study using national patient-level dispensing records in Wales-UK. Total dispensed drug items between 01-Jan-2016 and 31-Dec-2019 (counterfactual pre-COVID-19) were compared to 2020 (COVID-19 year). We compared trends of dispensed items in three main British National Formulary (BNF) sections(Cardiovascular system, Central Nervous System, Immunological & Vaccine) using European Age-Standardized rates. We developed an online tool to enable monitoring of changes in dispensing as the pandemic evolves. ResultAmongst all BNF chapters, 52,357,639 items were dispensed in 2020 compared to 49,747,141 items in 2019 demonstrating a relative increase of 5.25% in 2020(95%CI[5.21,5.29]). Comparison of monthly patterns of 2020 and 2019 dispensed items showed a notable difference between the total number of dispensed drug items each month, with an average difference (D) of +290,055 and average Relative Change (RC) of +5.52%. The greatest RC was observed in a substantial March-2020 increase (D=+1,501,242 and RC=+28%), followed by second peak in June (D=+565,004, RC=+10.97%). May was characterised by lower dispensing (D=-399,244, RC=-5.9%). Cardiovascular categories were characterised, across all age groups, by dramatic March-2020 increases, at the epidemic peak, followed by months of lower than expected dispensing, and gradual recovery by September. The Central Nervous System category was similar, but with only a short decline in May, and quicker recovery. A stand-out grouping was Immunological and Vaccine, which dropped to very low levels across all age groups, and all months (including the March dispensing peak). ConclusionsAberration in clinical service delivery during COVID-19 led to substantial changes in community pharmacy drug dispensing. This change may contribute to a long-term burden of COVID-19, raising the importance of a comprehensive and timely monitoring of changes for evaluation of the potential impact on clinical care and outcomes
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BackgroundBetter understanding of the role that children and school staff play in the transmission of SARS-CoV-2 is essential to guide policy development on controlling infection whilst minimising disruption to childrens education and wellbeing. MethodsOur national e-cohort (n=500,779) study used anonymised linked data for pupils, staff and associated households linked via educational settings. We estimated the risk of testing positive for SARS-CoV-2 infection for staff and pupils over the period August - December 2020, dependent on measures of recent exposure to known cases linked to their educational settings. ResultsThe total number of cases in a school was not associated with a subsequent increase in the risk of testing positive (Staff OR per case 0.92, 95%CI 0.85, 1.00; Pupils OR per case 0.98, 95%CI 0.93, 1.02). Amongst pupils, the number of recent cases within the same year group was significantly associated with subsequent increased risk of testing positive (OR per case 1.12, 95%CI 1.08 - 1.15). These effects were adjusted for a range of demographic covariates, and in particular any known cases within the same household, which had the strongest association with testing positive (Staff OR 39.86, 95%CI 35.01, 45.38, pupil OR 9.39, 95%CI 8.94 - 9.88). ConclusionsIn a national school cohort, the odds of staff testing positive for SARS-CoV-2 infection were not significantly increased in the 14-day period after case detection in the school. However, pupils were found to be at increased risk, following cases appearing within their own year group, where most of their contacts occur. Strong mitigation measures over the whole of the study period may have reduced wider spread within the school environment. O_TEXTBOXWhat is knownO_LIEvidence of the role schools play in the transmission of SARS-CoV-2 is limited C_LIO_LIHigher positivity rates are observed in school staff compared to pupils C_LIO_LILack of evidence on transmission pathways transmission into and within schools C_LI What this study addsO_LIFirst UK national level study of transmission between pupils and staff in a school environment during the SARS-CoV-2 pandemic. C_LIO_LISchools opening September-December 2020 was not associated with an increased subsequent risk of testing positive in staff C_LIO_LIPupils were found to be at increased risk of testing positive, following cases appearing within their own year group C_LI C_TEXTBOX
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The COVID-19 pandemic has highlighted the need for robust data linkage systems and methods for identifying outbreaks of disease in near real-time. Using self-reported app data and the Secure Anonymised Information Linkage (SAIL) Databank, we demonstrate the use of sophisticated spatial modelling for near-real-time prediction of COVID-19 prevalence at small-area resolution to inform strategic government policy areas. A pre-requisite to an effective control strategy is that predictions need to be accompanied by estimates of their precision, to guard against over-reaction to potentially spurious features of best guess predictions. In the UK, important emerging risk-factors such as social deprivation or ethnicity vary over small distances, hence risk needs to be modelled at fine spatial resolution to avoid aggregation bias. We demonstrate that existing geospatial statistical methods originally developed for global health applications are well-suited to this task and can be used in an anonymised databank environment, thus preserving the privacy of the individuals who contribute their data.
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BackgroundMortality in care homes has had a prominent focus during the COVID-19 outbreak. Multiple and interconnected challenges face the care home sector in the prevention and management of outbreaks of COVID-19, including adequate supply of personal protective equipment, staff shortages, and insufficient or lack of timely COVID-19 testing. Care homes are particularly vulnerable to infectious diseases. AimTo analyse the mortality of older care home residents in Wales during COVID-19 lockdown and compare this across the population of Wales and the previous 4-years. Study Design and SettingWe used anonymised Electronic Health Records (EHRs) and administrative data from the Secure Anonymised Information Linkage (SAIL) Databank to create a cross-sectional cohort study. We anonymously linked data for Welsh residents to mortality data up to the 14th June 2020. MethodsWe calculated survival curves and adjusted Cox proportional hazards models to estimate hazard ratios (HRs) for the risk of mortality. We adjusted hazard ratios for age, gender, social economic status and prior health conditions. ResultsSurvival curves show an increased proportion of deaths between 23rd March and 14th June 2020 in care homes for older people, with an adjusted HR of 1{middle dot}72 (1{middle dot}55, 1{middle dot}90) compared to 2016. Compared to the general population in 2016-2019, adjusted care home mortality HRs for older adults rose from 2{middle dot}15 (2{middle dot}11,2{middle dot}20) in 2016-2019 to 2{middle dot}94 (2{middle dot}81,3{middle dot}08) in 2020. ConclusionsThe survival curves and increased HRs show a significantly increased risk of death in the 2020 study periods.
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IntroductionNovel coronavirus 2019 (COVID-19) has propagated a global pandemic with significant health, economic and social costs. Emerging emergence has suggested that several factors may be associated with increased risk from severe outcomes or death from COVID-19. Clinical risk prediction tools have significant potential to generate individualised assessment of risk and may be useful for population stratification and other use cases. Methods and analysisWe will use a prospective open cohort study of routinely collected data from 1205 general practices in England in the QResearch database. The primary outcome is COVID-19 mortality (in or out-of-hospital) defined as confirmed or suspected COVID-19 mentioned on the death certificate, or death occurring in a person with SARS-CoV-2 infection between 24th January and 30th April 2020. Our primary outcome in adults is COVID-19 mortality (including out of hospital and in hospital deaths). We will also examine COVID-19 hospitalisation in children. Time-to-event models will be developed in the training data to derive separate risk equations in adults (19-100 years) for males and females for evaluation of risk of each outcome within the 3-month follow-up period (24th January to 30th April 2020), accounting for competing risks. Predictors considered will include age, sex, ethnicity, deprivation, smoking status, alcohol intake, body mass index, pre-existing medical co-morbidities, and concurrent medication. Measures of performance (prediction errors, calibration and discrimination) will be determined in the test data for men and women separately and by ten-year age group. For children, descriptive statistics will be undertaken if there are currently too few serious events to allow development of a risk model. The final model will be externally evaluated in (a) geographically separate practices and (b) other relevant datasets as they become available. Ethics and disseminationThe project has ethical approval and the results will be submitted for publication in a peer-reviewed journal. Strengths and limitations of the studyO_LIThe individual-level linkage of general practice, Public Health England testing, Hospital Episode Statistics and Office of National Statistics death register datasets enable a robust and accurate ascertainment of outcomes C_LIO_LIThe models will be trained and evaluated in population-representative datasets of millions of individuals C_LIO_LIShielding for clinically extremely vulnerable was advised and in place during the study period, therefore risk predictions influenced by the presence of some shielding conditions may require careful consideration C_LI
