Christina Atchison

Objectives: The rapid spread of SARS-CoV-2 infection caused high levels of hospitalisation and deaths in late 2020 and early 2021 during the second wave in England. COVID-19 disease during this period was associated with marked health inequalities across ethnic and sociodemographic subgroups. In this paper, we aim to investigate and quantify inequalities in the risk of SARS-CoV-2 infection across ethnic and sociodemographic subgroups during a key period before widespread vaccination, thereby identifying the populations that bore a disproportionate burden of risk. Methods: We analysed risk factors for test-positivity for SARS-CoV-2, based on self-administered throat and nose swabs in the community during rounds 5–10 of the REal-time Assessment of Community Transmission-1 (REACT-1) study between 18 September 2020 and 30 March 2021. Results: Compared with the White ethnicity, people of Asian and the Black ethnicity had a higher risk of infection during rounds 5–10, with odds of 1.45 (1.27, 1.66) and 1.34 (1.11, 1.63), respectively, adjusted for demographic factors including age, sex, region, key work status, ethnicity and deprivation. Among ethnic subgroups, the highest and the second-highest odds were found in Bangladeshi and Pakistani participants at 3.28 (2.24, 4.80) and 2.12 (1.70, 2.64), respectively, when compared with the White British participants. People in larger (compared with smaller) households had higher odds of infection. Healthcare workers with direct patient contact and care home workers showed higher odds of infection compared with other essential/key workers. Additionally, the odds of infection among participants in public-facing activities or settings were greater than among those not working in those activities or settings. Conclusion: Our findings highlight the differences in the risk of SARS-CoV-2 infection in a global north population during a period when the risk of infection was high, and there were substantial levels of social mixing. Planning for future waves of severe respiratory pathogens should include policies to reduce inequality in the risk of infection by ethnicity, household size and occupational activity in order to reduce inequality in disease.

Objective: To determine how people in England changed their infection risk-related behaviours during the COVID-19 pandemic and in response to control measures, 19 June 2020 to 31 March 2022. Design: Over 18 (of 19) rounds, randomly selected participants across England completed a questionnaire about risk-related behaviours, sociodemographics and symptoms. Participants: Between 85 018 and 154 060 randomly selected participants per round, aged 5+ years, totalling 2 177 657 responses with relevant data. Main outcome measures: Primary outcomes were self-reported shielding and/or taking specific precautions, not leaving home in the prior week, not being in close proximity with anyone outside their household the day before and wearing face coverings outside the home. Secondary community-level measures of mobility and public health policy stringency were compared with the primary outcomes to provide population-level context to the observed findings. Results: Infection risk-related behaviours varied considerably over the nearly 2 years under study. Protective behaviours peaked in January 2021, during England’s winter wave, before widespread vaccination. At that time, the estimated proportion of self-reported shielding and/or taking specific precautions reached 21.6% (95% CI 21.4% to 21.8%), of self-reported not leaving home in the week prior to completing the questionnaire reached 7.99% (95% CI 7.85% to 8.13%) and of self-reported not having contact with anyone outside their household on the day before answering the questionnaire reached 89.2% (95% CI 89.1% to 89.4%). As self-reported vaccination rates increased and prevalence of infection decreased, protective behaviours decreased, although patterns varied by demographics. Protective behaviours were strongly correlated with community-level mobility data and the stringency of public health measures. Conclusions: Individual-based data showed sizeable proportions of people undertook protective behaviours during the pandemic, especially during the second lockdown in January 2021, although there was evidence of ‘pandemic fatigue’ in the study’s later stages. Self-reported behaviours were closely aligned with community mobility data and the stringency of government policies, indicating policy-driven behavioural changes.

Introduction People with Long Covid report a wide range of symptoms and inconsistent responses when seeking clinical diagnosis and support. Much of the qualitative research on Long Covid has been based on people attending specialist clinical services or who have accessed support groups. We describe the varied ways in which a diverse group of people in a community sample experience, recognise and manage persistent symptoms following COVID-19. Methods Qualitative interview study nested within the large, community-based REal-time Assessment of Community Transmission (REACT) study in England. Participants reporting persistent symptoms following COVID-19 were asked for consent to be contacted about a follow-up interview. We then purposively sampled by age, gender, ethnicity and symptom severity and conducted 60 interviews. Analysis was carried out using a reflexive thematic analysis approach. Results Participants were an ethnically diverse group aged between 18 and 80 years who reported symptoms following COVID-19 for between a few months and more than two years. Many had not accessed clinical care or specific Long Covid support, and some did not identify with the category of long covid, rendering their experiences largely invisible. Participants highlighted the ways in which they self-manage symptoms within this context, and the varied burden of coping with ongoing health problems. Conclusion This diverse sample of people with Long Covid report a range of challenges managing this emerging and contested condition, with uncertainty affecting their own understanding and the validation they receive from professionals, family and friends. These challenges intersect with others such as racism, and are compounded by a lack of specific resources for Long Covid as well as over-stretched health services in the UK. Nevertheless, people show resilience in their self-management, seeking information and support from a range of sources. Patient or Public Contribution Study design, analysis and outputs informed by Patient Advisory Group.

Objective: To determine how people in England changed their infection risk-related behaviours during the COVID-19 pandemic and in response to control measures, 19 June 2020 to 31 March 2022. Design: Over 18 (of 19) rounds, randomly selected participants across England completed a questionnaire about risk-related behaviours, socio-demographics, and symptoms. Participants: Between 85,018 and 154,060 randomly selected participants per round, aged 5+ years, totalling 2,177,657 responses with relevant data. Main outcome measures: Primary outcomes were self-reported shielding and/or taking specific precautions, not leaving home in the prior week, not being in close proximity with anyone outside their household the day before, and wearing face coverings outside the home. Secondary community-level measures of mobility and public health policy stringency were compared to the primary outcomes to provide population-level context to the observed findings. Results: Infection risk-related behaviours varied considerably over the nearly two years under study. Protective behaviours peaked in January 2021, during England’s winter wave, before widespread vaccination. At that time, the estimated proportion of self-reported shielding and/or taking specific precautions reached 21.6% (95% confidence interval 21.4% to 21.8%), of self-reported not leaving home in the week prior to completing the questionnaire reached 7.99% (7.85% to 8.13%) and of self-reported not having contact with anyone outside their household on the day before answering the questionnaire reached 89.2% (89.1% to 89.4%). As self-reported vaccination rates increased and prevalence of infection decreased, protective behaviours decreased, although patterns varied by demographics. Protective behaviours were strongly correlated with community-level mobility data and the stringency of public health measures. Conclusions: Individual-based data showed sizeable proportions of people undertook protective behaviours during the pandemic especially during the second lockdown in January 2021 although there was evidence of “pandemic fatigue” in the study’s later stages. Self-reported behaviours were closely aligned with community mobility data and the stringency of government policies, indicating policy-driven behaviour changes.

Background: High response rates are needed in population-based studies, as nonresponse reduces effective sample size and bias affects accuracy and decreases the generalizability of the study findings. Objective: We tested different strategies to improve response rate and reduce nonresponse bias in a national population–based COVID-19 surveillance program in England, United Kingdom. Methods: Over 19 rounds, a random sample of individuals aged 5 years and older from the general population in England were invited by mail to complete a web-based questionnaire and return a swab for SARS-CoV-2 testing. We carried out several nested randomized controlled experiments to measure the impact on response rates of different interventions, including (1) variations in invitation and reminder letters and SMS text messages and (2) the offer of a conditional monetary incentive to return a swab, reporting absolute changes in response and relative response rate (95% CIs). Results: Monetary incentives increased the response rate (completed swabs returned as a proportion of the number of individuals invited) across all age groups, sex at birth, and area deprivation with the biggest increase among the lowest responders, namely teenagers and young adults and those living in more deprived areas. With no monetary incentive, the response rate was 3.4% in participants aged 18‐22 years, increasing to 8.1% with a £10 (US $12.5) incentive, 11.9% with £20 (US $25.0), and 18.2% with £30 (US $37.5) (relative response rate 2.4 [95% CI 2.0-2.9], 3.5 [95% CI 3.0-4.2], and 5.4 [95% CI 4.4-6.7], respectively). Nonmonetary strategies had a modest, if any, impact on response rate. The largest effect was observed for sending an additional swab reminder (SMS text message or email). For example, those receiving an additional SMS text message were more likely to return a completed swab compared to those receiving the standard email-SMS approach, 73.3% versus 70.2%: percentage difference 3.1% (95% CI 2.2%-4.0%). Conclusions: Conditional monetary incentives improved response rates to a web-based survey, which required the return of a swab test, particularly for younger age groups. Used in a selective way, incentives may be an effective strategy for improving sample response and representativeness in population-based studies.

The COVID-19 pandemic is having a lasting impact on health and well-being. We compare current self-reported health, quality of life and symptom profiles for people with ongoing symptoms following COVID-19 to those who have never tested positive for SARS-CoV-2 infection and those who have recovered from COVID-19. Overall, 276,840/800,000 (34·6%) of invited participants took part. Mental health and health-related quality of life were worse among participants with ongoing persistent symptoms post-COVID compared with those who had never had COVID-19 or had recovered. In this study, median duration of COVID-related symptoms (N = 130,251) was 1·3 weeks (inter-quartile range 6 days to 2 weeks), with 7·5% and 5·2% reporting ongoing symptoms ≥12 weeks and ≥52 weeks respectively. Female sex, ≥1 comorbidity and being infected when Wild-type variant was dominant were associated with higher probability of symptoms lasting ≥12 weeks and longer recovery time in those with persistent symptoms. Although COVID-19 is usually of short duration, some adults experience persistent and burdensome illness.

The value of SARS-CoV-2 lateral flow immunoassay (LFIA) tests for estimating individual disease risk is unclear. The REACT-2 study in England, UK, obtained self-administered SARS-CoV-2 LFIA test results from 361,801 adults in January-May 2021. Here, we link to routine data on subsequent hospitalisation (to September 2021), and death (to December 2021). Among those who had received one or more vaccines, a negative LFIA is associated with increased risk of hospitalisation with COVID-19 (HR: 2.73 [95% confidence interval: 1.15,6.48]), death (all-cause) (HR: 1.59, 95% CI:1.07, 2.37), and death with COVID-19 as underlying cause (20.6 [1.83,232]). For people designated at high risk from COVID-19, who had received one or more vaccines, there is an additional risk of all-cause mortality of 1.9 per 1000 for those testing antibody negative compared to positive. However, the LFIA does not provide substantial predictive information over and above that which is available from detailed sociodemographic and health-related variables. Nonetheless, this simple test provides a marker which could be a valuable addition to understanding population and individual-level risk.

Background The rapid spread of SARS-CoV-2 infection caused high levels of hospitalisation and deaths in late 2020 and early 2021 during the second wave in England. Severe disease during this period was associated with marked health inequalities across ethnic and sociodemographic subgroups. Methods We analysed risk factors for test-positivity for SARS-CoV-2, based on self-administered throat and nose swabs in the community during rounds 5 to 10 of the REal-time Assessment of Community Transmission-1 (REACT-1) study between 18 September 2020 and 30 March 2021. Results Compared to white ethnicity, people of Asian and black ethnicity had a higher risk of infection during rounds 5 to 10, with odds of 1.46 (1.27, 1.69) and 1.35 (1.11, 1.64) respectively. Among ethnic subgroups, the highest and the second-highest odds were found in Bangladeshi and Pakistan participants at 3.29 (2.23, 4.86) and 2.15 (1.73, 2.68) respectively when compared to British whites. People in larger (compared to smaller) households had higher odds of infection. Health care workers with direct patient contact and care home workers showed higher odds of infection compared to other essential/key workers. Additionally, the odds of infection among participants in public-facing activities or settings were greater than among those not working in those activities or settings. Interpretation Planning for future severe waves of respiratory pathogens should include policies to reduce inequality in risk of infection by ethnicity, household size, and occupational activity.

Background The COVID-19 pandemic is having a lasting impact on health and well-being. We compare current self-reported health, quality of life and symptom profiles for people with ongoing symptoms following COVID-19 to those who have never had COVID-19 or have recovered. Methods A cohort study was established with participants from the REACT programme. A sample (N=800,000) of adults were contacted between August and December 2022 to complete a questionnaire about their current health and COVID-19 history. We used logistic regression to identify predictors of persistent symptoms lasting ≥12 weeks following COVID-19. We fitted Accelerated Failure Time models to assess factors associated with rate of recovery from persistent symptoms. Findings Overall, 276,840/800,000 (34.6%) of invited participants completed the questionnaire. Median duration of COVID-related symptoms (N=130,251) was 1.3 weeks (inter-quartile range 6 days to 2 weeks), with 7.5% and 5.2% reporting ongoing symptoms ≥12 weeks and ≥52 weeks respectively. Female sex, having ≥1 comorbidity, more severe symptoms at time of COVID-19 and being infected when Wild-type variant was dominant were associated with higher probability of symptoms lasting ≥12 weeks. Longer time to recovery in those with persistent symptoms was found for females, people with comorbidities, living in more deprived areas, current smokers and for Wild-type compared to later variants. Mental health and health-related quality of life were significantly worse among participants with ongoing persistent COVID-19 symptoms compared with those who had never had COVID-19 or had recovered. Interpretation Although COVID-19 is usually of short duration, some adults experience persistent and burdensome illness. Funding This work is independent research funded by the National Institute for Health and Care Research (NIHR) (REACT Long COVID (REACT-LC) (COV-LT-0040)). This research is part of the Data and Connectivity National Core Study, led by Health Data Research UK in partnership with the Office for National Statistics and funded by UK Research and Innovation (UKRI) (MC_PC_20029). The views expressed in this publication are those of the author(s) and not necessarily those of NIHR or UKRI.

Objectives: HIV pre‐exposure prophylaxis (PrEP) delivery in the UK is inequitable; over 95% of PrEP users were men who have sex with men (MSM) despite making up less than 50% of new HIV diagnoses. We conducted a systematic review to identify modifiable barriers and facilitators to PrEP delivery in the UK among underserved populations.Methods: We searched bibliographic/conference databases using the terms HIV, PrEP, barriers, facilitators, underserved populations, and UK. Modifiable factors were mapped along the PrEP Care Continuum (PCC) to identify targets for interventions.Results: In total, 44 studies were eligible: 29 quantitative, 12 qualitative and three mixed‐methods studies. Over half (n = 24 [54.5%]) exclusively recruited MSM, whereas 11 were in mixed populations (all included MSM as a sub‐population) and the other nine were in other underserved populations (gender and ethnicity minorities, women, and people who inject drugs). Of the 15 modifiable factors identified, two‐thirds were at the PrEP contemplation and PrEParation steps of the PCC. The most reported barriers were lack of PrEP awareness (n = 16), knowledge (n = 19), willingness (n = 16), and access to a PrEP provider (n = 16), whereas the more reported facilitators were prior HIV testing (n = 8), agency and self‐care (n = 8). All but three identified factors were at the patient rather than provider or structural level.Conclusions: This review highlights that the bulk of the scientific literature focuses on MSM and on patient‐level factors. Future research needs to ensure underserved populations are included and prioritized (e.g. ethnicity and gender minorities, people who inject drugs) and provider and structural factors are investigated.