COVID-19 Cases Among Congregate Care Facility Staff by Neighborhood of Residence and Social and Structural Determinants: Observational Study.

BACKGROUND: Disproportionate risks of COVID-19 in congregate care facilities including long-term care homes, retirement homes, and shelters both affect and are affected by SARS-CoV-2 infections among facility staff. In cities across Canada, there has been a consistent trend of geographic clustering of COVID-19 cases. However, there is limited information on how COVID-19 among facility staff reflects urban neighborhood disparities, particularly when stratified by the social and structural determinants of community-level transmission. OBJECTIVE: This study aimed to compare the concentration of cumulative cases by geography and social and structural determinants across 3 mutually exclusive subgroups in the Greater Toronto Area (population: 7.1 million): community, facility staff, and health care workers (HCWs) in other settings. METHODS: We conducted a retrospective, observational study using surveillance data on laboratory-confirmed COVID-19 cases (January 23 to December 13, 2020; prior to vaccination rollout). We derived neighborhood-level social and structural determinants from census data and generated Lorenz curves, Gini coefficients, and the Hoover index to visualize and quantify inequalities in cases. RESULTS: The hardest-hit neighborhoods (comprising 20% of the population) accounted for 53.87% (44,937/83,419) of community cases, 48.59% (2356/4849) of facility staff cases, and 42.34% (1669/3942) of other HCW cases. Compared with other HCWs, cases among facility staff reflected the distribution of community cases more closely. Cases among facility staff reflected greater social and structural inequalities (larger Gini coefficients) than those of other HCWs across all determinants. Facility staff cases were also more likely than community cases to be concentrated in lower-income neighborhoods (Gini 0.24, 95% CI 0.15-0.38 vs 0.14, 95% CI 0.08-0.21) with a higher household density (Gini 0.23, 95% CI 0.17-0.29 vs 0.17, 95% CI 0.12-0.22) and with a greater proportion working in other essential services (Gini 0.29, 95% CI 0.21-0.40 vs 0.22, 95% CI 0.17-0.28). CONCLUSIONS: COVID-19 cases among facility staff largely reflect neighborhood-level heterogeneity and disparities, even more so than cases among other HCWs. The findings signal the importance of interventions prioritized and tailored to the home geographies of facility staff in addition to workplace measures, including prioritization and reach of vaccination at home (neighborhood level) and at work.

Geographic concentration of SARS-CoV-2 cases by social determinants of health in metropolitan areas in Canada: a cross-sectional study.

BACKGROUND: Understanding inequalities in SARS-CoV-2 transmission associated with the social determinants of health could help the development of effective mitigation strategies that are responsive to local transmission dynamics. This study aims to quantify social determinants of geographic concentration of SARS-CoV-2 cases across 16 census metropolitan areas (hereafter, cities) in 4 Canadian provinces, British Columbia, Manitoba, Ontario and Quebec. METHODS: We used surveillance data on confirmed SARS-CoV-2 cases and census data for social determinants at the level of the dissemination area (DA). We calculated Gini coefficients to determine the overall geographic heterogeneity of confirmed cases of SARS-CoV-2 in each city, and calculated Gini covariance coefficients to determine each city's heterogeneity by each social determinant (income, education, housing density and proportions of visible minorities, recent immigrants and essential workers). We visualized heterogeneity using Lorenz (concentration) curves. RESULTS: We observed geographic concentration of SARS-CoV-2 cases in cities, as half of the cumulative cases were concentrated in DAs containing 21%-35% of their population, with the greatest geographic heterogeneity in Ontario cities (Gini coefficients 0.32-0.47), followed by British Columbia (0.23-0.36), Manitoba (0.32) and Quebec (0.28-0.37). Cases were disproportionately concentrated in areas with lower income and educational attainment, and in areas with a higher proportion of visible minorities, recent immigrants, high-density housing and essential workers. Although a consistent feature across cities was concentration by the proportion of visible minorities, the magnitude of concentration by social determinant varied across cities. INTERPRETATION: Geographic concentration of SARS-CoV-2 cases was observed in all of the included cities, but the pattern by social determinants varied. Geographically prioritized allocation of resources and services should be tailored to the local drivers of inequalities in transmission in response to the resurgence of SARS-CoV-2.

Increasing concentration of COVID-19 by socioeconomic determinants and geography in Toronto, Canada: an observational study.

BACKGROUND: Inequities in the burden of COVID-19 were observed early in Canada and around the world, suggesting economically marginalized communities faced disproportionate risks. However, there has been limited systematic assessment of how heterogeneity in risks has evolved in large urban centers over time. PURPOSE: To address this gap, we quantified the magnitude of risk heterogeneity in Toronto, Ontario from January to November 2020 using a retrospective, population-based observational study using surveillance data. METHODS: We generated epidemic curves by social determinants of health (SDOH) and crude Lorenz curves by neighbourhoods to visualize inequities in the distribution of COVID-19 and estimated Gini coefficients. We examined the correlation between SDOH using Pearson-correlation coefficients. RESULTS: Gini coefficient of cumulative cases by population size was 0.41 (95% confidence interval [CI]:0.36-0.47) and estimated for: household income (0.20, 95%CI: 0.14-0.28); visible minority (0.21, 95%CI:0.16-0.28); recent immigration (0.12, 95%CI:0.09-0.16); suitable housing (0.21, 95%CI:0.14-0.30); multigenerational households (0.19, 95%CI:0.15-0.23); and essential workers (0.28, 95%CI:0.23-0.34). CONCLUSIONS: There was rapid epidemiologic transition from higher- to lower-income neighborhoods with Lorenz curve transitioning from below to above the line of equality across SDOH. Moving forward necessitates integrating programs and policies addressing socioeconomic inequities and structural racism into COVID-19 prevention and vaccination programs.

Heterogeneity in testing, diagnosis and outcome in SARS-CoV-2 infection across outbreak settings in the Greater Toronto Area, Canada: an observational study.

BACKGROUND: Congregate settings have been disproportionately affected by coronavirus disease 2019 (COVID-19). Our objective was to compare testing for, diagnosis of and death after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection across 3 settings (residents of long-term care homes, people living in shelters and the rest of the population). METHODS: We conducted a population-based prospective cohort study involving individuals tested for SARS-CoV-2 in the Greater Toronto Area between Jan. 23, 2020, and May 20, 2020. We sourced person-level data from COVID-19 surveillance and reporting systems in Ontario. We calculated cumulatively diagnosed cases per capita, proportion tested, proportion tested positive and case-fatality proportion for each setting. We estimated the age- and sex-adjusted rate ratios associated with setting for test positivity and case fatality using quasi-Poisson regression. RESULTS: Over the study period, a total of 173 092 individuals were tested for and 16 490 individuals were diagnosed with SARS-CoV-2 infection. We observed a shift in the proportion of cumulative cases from all cases being related to travel to cases in residents of long-term care homes (20.4% [3368/16 490]), shelters (2.3% [372/16 490]), other congregate settings (20.9% [3446/16 490]) and community settings (35.4% [5834/16 490]), with cumulative travel-related cases at 4.1% (674/16490). Cumulatively, compared with the rest of the population, the diagnosed cases per capita was 64-fold and 19-fold higher among long-term care home and shelter residents, respectively. By May 20, 2020, 76.3% (21 617/28 316) of long-term care home residents and 2.2% (150 077/6 808 890) of the rest of the population had been tested. After adjusting for age and sex, residents of long-term care homes were 2.4 (95% confidence interval [CI] 2.2-2.7) times more likely to test positive, and those who received a diagnosis of COVID-19 were 1.4-fold (95% CI 1.1-1.8) more likely to die than the rest of the population. INTERPRETATION: Long-term care homes and shelters had disproportionate diagnosed cases per capita, and residents of long-term care homes diagnosed with COVID-19 had higher case fatality than the rest of the population. Heterogeneity across micro-epidemics among specific populations and settings may reflect underlying heterogeneity in transmission risks, necessitating setting-specific COVID-19 prevention and mitigation strategies.

Estimated surge in hospital and intensive care admission because of the coronavirus disease 2019 pandemic in the Greater Toronto Area, Canada: a mathematical modelling study.

BACKGROUND: In pandemics, local hospitals need to anticipate a surge in health care needs. We examined the modelled surge because of the coronavirus disease 2019 (COVID-19) pandemic that was used to inform the early hospital-level response against cases as they transpired. METHODS: To estimate hospital-level surge in March and April 2020, we simulated a range of scenarios of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spread in the Greater Toronto Area (GTA), Canada, using the best available data at the time. We applied outputs to hospital-specific data to estimate surge over 6 weeks at 2 hospitals (St. Michael's Hospital and St. Joseph's Health Centre). We examined multiple scenarios, wherein the default (R0 = 2.4) resembled the early trajectory (to Mar. 25, 2020), and compared the default model projections with observed COVID-19 admissions in each hospital from Mar. 25 to May 6, 2020. RESULTS: For the hospitals to remain below non-ICU bed capacity, the default pessimistic scenario required a reduction in non-COVID-19 inpatient care by 38% and 28%, respectively, with St. Michael's Hospital requiring 40 new ICU beds and St. Joseph's Health Centre reducing its ICU beds for non-COVID-19 care by 6%. The absolute difference between default-projected and observed census of inpatients with COVID-19 at each hospital was less than 20 from Mar. 25 to Apr. 11; projected and observed cases diverged widely thereafter. Uncertainty in local epidemiological features was more influential than uncertainty in clinical severity. INTERPRETATION: Scenario-based analyses were reliable in estimating short-term cases, but would require frequent re-analyses. Distribution of the city's surge was expected to vary across hospitals, and community-level strategies were key to mitigating each hospital's surge.

Comparing Approaches to Research in Global and International Health: An Exploratory Study.

Background: Global health is a term often used interchangeably with international health due to overlapping similarities and unclear distinctions. While some international health supporters argue that global health as a field is unnecessary as it is simply a duplicate of international health, global health supporters argue that global health is unique; for instance, it actively includes elements of empowerment and promotes cross-border collaboration. Objective: To investigate differences and similarities in research representing the fields of global and international health. Methods: We analyzed all the articles published in 2017 in two comparable academic journals representing the fields of global health (Annals of Global Health, AGH) and international health (International Health Journal, IHJ). Abstracted data included: research design and methods, income status of country of study, empowerment recommendations for practice, participation and research collaboration. Findings: Most studies in both AGH and IHJ used quantitative research methods but were significantly more common in IHJ (70%) compared to AGH (48%), whereas mores studies in AGH (17%) than IHJ (9%) used mixed methods. The majority of studies in both journals focused on low- or lower-middle income countries whereas more AGH studies (16%) focused on high-income countries compared to the IHJ studies (4%). It was more common in the AGH studies to make empowerment recommendations (90%) and to include stakeholders/users in the study (40%) compared to the IHJ studies (75% empowerment recommendations and 18% stakeholder/user participation). No difference was observed regarding cross-border research collaboration. Conclusions: This study does not show great differences between global health and international health research; however, there are still some differences indicating that global health emphasises different aspects of research compared to international health. More research is necessary to understand whether and how the distinctions between the definitions of global and international health are applied in real life, in research and beyond.

Remote Supervision in Short-Term Global Health Experiences.

The global health development community is increasingly examining the phenomenon of short-term experiences in global health (STEGH), with an aim to mitigate the negative impacts of such activities on host communities. Appropriate supervision is one strategy, but various barriers (e.g., institutional requirements) limit the availability of qualified supervisors. Remote supervision represents one potential model to provide supervision that may mitigate the negative impacts of STEGH. This paper reports observed outcomes from a description of a pilot remote supervision program employed in a global health program for Canadian undergraduate students. Benefits for learners included greater confidence and independence, greater perceived effectiveness in conducting their project abroad, and reassurance of remote support from their supervisor, supplemented with day-to-day guidance from the local partner. Host communities reported greater trust in the bidirectional nature of partnership with the visiting institution, empowerment through directing students' work, and improved alignment of projects with community needs. Finally, faculty noted that remote supervision provided greater flexibility and freedom when compared to traditional in-person supervision, allowing them to maintain professional duties at home. Collectively, this pilot suggests that remote supervision demonstrates a potential solution to mitigating the harms of STEGHs undertaken by learners by providing adequate and appropriate remote supervision.

Characterizing a community health partnership in Dominican Republic: Network mapping and analysis of stakeholder perceptions.

BACKGROUND: Medical trainees complete learning experiences abroad to fulfil global health curricular elements, but this participation has been steadily criticized as fulfilling learner objectives at the cost of host communities. This study uses network and qualitative analyses in characterizing a community coalition in order to better understand its various dimensions and to explore the perceived benefits it provided towards optimizing community outcomes. METHODS: Data from a semi-structured survey was used for network and qualitative analyses. Partner linkages were assessed using network analysis tool UCINET 6 (version 6.6). Thematic analysis was conducted on qualitative responses around the perceived coalition strengths and weaknesses. RESULTS: Network analysis confirmed that local member organizations were key network influencers based on reported formal agreements, general interactions, and information shared. While sharing of resources was rare, qualitative analysis suggested that information sharing contributed to engagement, enthusiasm, and communication that allowed visiting partners to expand their understanding of community needs and shift their focus beyond learner objectives. CONCLUSION: Global health programs for medical students should consider the use of community health coalitions to optimally align the work undertaken by learners on global health experiences abroad. Network mapping can help educators and coalition partners visualize interactions and identify value.

Integration of care for hypertension and diabetes: a scoping review assessing the evidence from systematic reviews and evaluating reporting.

BACKGROUND: With the rise in pre-mature mortality rate from non-communicable disease (NCD), there is a need for evidence-based interventions. We evaluated existing systematic reviews on effectiveness of integration of healthcare services, in particular with focus on delivery of care designed to improve health and process outcomes in people with multi-morbidity, where at least one of the conditions was diabetes or hypertension. METHODS: We searched MEDLINE, EMBASE, Cochrane Library, and Health Evidence to November 8, 2016 and consulted experts. One review author screened titles, abstracts and two review authors independently screened short listed full-texts and selected reviews for inclusion. We considered systematic reviews evaluating integration of care, compared to usual care, for people with multi-morbidity. One review author extracted data and another author verified it. Two review authors independently evaluated risk of bias using ROBIS and AMSTAR. Inter-rater reliability was analysed for ROBIS and AMSTAR using Cohen's kappa and percent agreement. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist was used to assess reporting. RESULTS: We identified five systematic reviews on integration of care. Four reviews focused on comorbid diabetes and depression and two covered hypertension and comorbidities of cardiovascular disease, depression, or diabetes. Interventions were poorly described. The health outcomes evaluated included risk of all-cause mortality, measures of depression, cholesterol levels, HbA1c levels, effect of depression on HbA1c levels, symptom improvement, systolic blood pressure, and hypertension control. Process outcomes included access and utilisation of healthcare services, costs, and quality of care. Overall, three reviews had a low and medium risk of bias according to ROBIS and AMSTAR respectively, while two reviews had high risk of bias as judged by both ROBIS and AMSTAR. Findings have demonstrated that collaborative care in general resulted in better health and process outcomes when compared to usual care for both depression and diabetes and hypertension and diabetes. CONCLUSIONS: Several knowledge gaps were identified on integration of care for comorbidities with diabetes and/or hypertension: limited research on this topic for hypertension, limited reviews that included primary studies based in low-middle income countries, and limited reviews on collaborative care for communicable and NCDs.