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  • Open Access English
    Authors: 
    Moritz U. G. Kraemer; Chia-Hung Yang; Bernardo Gutierrez; Chieh-Hsi Wu; Brennan Klein; David M. Pigott; Louis du Plessis; Nuno R. Faria; Ruoran Li; William P. Hanage; +7 more
    Publisher: American Association for the Advancement of Science
    Countries: France, United Kingdom, United Kingdom, United Kingdom
    Project: NIH | MIDAS Center for Communic... (1U54GM088558-01)

    The ongoing COVID-19 outbreak has expanded rapidly throughout China. Major behavioral, clinical, and state interventions are underway currently to mitigate the epidemic and prevent the persistence of the virus in human populations in China and worldwide. It remains unclear how these unprecedented interventions, including travel restrictions, have affected COVID-19 spread in China. We use real-time mobility data from Wuhan and detailed case data including travel history to elucidate the role of case importation on transmission in cities across China and ascertain the impact of control measures. Early on, the spatial distribution of COVID-19 cases in China was well explained by human mobility data. Following the implementation of control measures, this correlation dropped and growth rates became negative in most locations, although shifts in the demographics of reported cases are still indicative of local chains of transmission outside Wuhan. This study shows that the drastic control measures implemented in China have substantially mitigated the spread of COVID-19. One sentence summary: The spread of COVID-19 in China was driven by human mobility early on and mitigated substantially by drastic control measures implemented since the end of January.

  • Open Access English
    Authors: 
    Paul Brandily; Clément Brébion; Simon Briole; Laura Khoury;
    Publisher: HAL CCSD
    Country: France
    Project: ANR | PGSE (ANR-17-EURE-0001)

    Mortality inequalities remain substantial in many countries, and large shocks such as pandemics could amplify them further. The unequal distribution of COVID-19 confirmed cases suggests that this is the case. Yet, evidence on the causal effect of the epidemic on mortality inequalities remains scarce. In this paper, we exploit exhaustive municipality-level data in France, one of the most severely hit country in the world, to identify a negative relationship between income and excess mortality within urban areas, that persists over COVID-19 waves. Over the year 2020, the poorest municipalities experienced a 30% higher increase in excess mortality. Our analyses can rule out an independent contribution of lockdown policies to this heterogeneous impact. Finally, we find evidence that both labour-market exposure and housing conditions are major determinants of the epidemic-induced effects of COVID-19 on mortality inequalities, but that their respective role depends on the state of the epidemic.

  • English
    Authors: 
    Abidi, Hani; Amami, Rim; Trabelsi, Chiraz;
    Publisher: HAL CCSD
    Country: France

    The model descibes the epidemic dynamics of Covid-19 in a population after vaccination. Using the maximum principale, our goal is to prove the existence of an optimal strategy such that it minimize the number of infected people after vaccination. Finally, some numerical results are provided.

  • Publication . Article . Preprint . 2020
    Open Access English
    Authors: 
    Alberto Alemanno;
    Publisher: HAL CCSD
    Country: France

    The European response to COVID-19 has revealed an inconvenient truth. Despite having integrated public health concerns across all its policies – be it agriculture, consumer protection, or security –, the Union cannot directly act to save people’s lives. Only member states can do so. Yet when they adopted unilateral measures to counter the spread of the virus, those proved not only ineffective but also disruptive on vital supply chains, by ultimately preventing the flow of essential goods and people across the Union. These fragmented efforts in tackling cross-border health threats have almost immediately prompted political calls for the urgent creation of a European Health Union. Yet this call raises more questions than answers. With the aim to offer a rigorous and timely blueprint to decision-makers and the public at large, this Special Issue of the European Journal of Risk Regulation contextualizes such a new political project within the broader constitutional and institutional framework of EU public health law and policy. By introducing the Special, this paper argues that unless the envisaged Health Union will tackle the root causes of what prevented the Union from effectively responding to COVID-19 – the divergent health capacity across the Union –, it might fall short of its declared objective of strengthening the EU’resilience for cross-border health threats.

  • Publication . Article . Other literature type . Preprint . 2020
    Open Access English
    Authors: 
    Margaret Chitiga; Martin Henseler; Ramos Mabugu; Helene Maisonnave;
    Publisher: Palgrave Macmillan UK
    Country: France

    To contribute towards addressing the problem of relatively few general equilibrium studies focusing on gender impacts of disease pandemics, this paper uses a gendered Computable General Equilibrium model linked to a microsimulation model to study the short run economic effects of COVID-19 pandemic in South Africa. A mild and severe scenario is run to represent the pandemic. Findings suggest that while COVID-19 leads to negative economic effects irrespective of scenario, female-headed households bear a disproportionately higher burden of the brunt. Because women tend to be more concentrated in employment in sectors that are hurt the most by COVID-19 response measures as well as that they predominate in unskilled categories, the simulation results show that women suffer disproportionately more from higher unemployment than their male counterparts though the differences are not as pronounced. The poverty outcomes show worsened vulnerability for female-headed households given that, even prior to the pandemic, poverty was already higher amongst women. These results are important in informing evidence-based responses by government to the COVID-19 pandemic.

  • Open Access English
    Authors: 
    Achraf Ammar; Michael Brach; Khaled Trabelsi; Hamdi Chtourou; Omar Boukhris; Liwa Masmoudi; Bassem Bouaziz; Ellen Bentlage; Daniella How; Mona A. Ahmed; +47 more
    Publisher: HAL CCSD
    Country: France

    AbstractBackgroundPublic health recommendations and governmental measures during the COVID-19 pandemic have enforced numerous restrictions on daily living including social distancing, isolation and home confinement. While these measures are imperative to abate the spreading of COVID-19, the impact of these restrictions on health behaviours and lifestyle at home is undefined. Therefore, an international online survey was launched in April 2020 in seven languages to elucidate the behavioral and lifestyle consequences of COVID-19 restrictions. This report presents the preliminary results from the first thousand responders on physical activity (PA) and nutrition behaviours.MethodsThirty-five research organisations from Europe, North-Africa, Western Asia and the Americas promoted the survey through their networks to the general society, in English, German, French, Arabic, Spanish, Portugese, and Slovenian languages. Questions were presented in a differential format with questions related to responses “before” and “during” confinement conditions.Results1047 replies (54% women) from Asia (36%), Africa (40%), Europe (21%) and other (3%) were included into a general analysis. The COVID-19 home confinement had a negative effect on all intensities of PA (vigorous, moderate, walking and overall). Conversely, daily sitting time increased from 5 to 8 hours per day. Additionally, food consumption and meal patterns (the type of food, eating out of control, snacks between meals, number of meals) were more unhealthy during confinement with only alcohol binge drink decreasing significantly.ConclusionWhile isolation is a necessary measure to protect public health, our results indicate that it alters physical activity and eating behaviours in a direction that would compromise health. A more detailed analysis of survey data will allow for a segregation of these responses in different age groups, countries and other subgroups which will help develop bespoke interventions to mitigate the negative lifestyle behaviors manifest during the COVID-19 confinement.

  • Open Access English
    Authors: 
    Valéry Ridde; Lara Gautier; Christian Dagenais; Fanny Chabrol; Renyou Hou; Emmanuel Bonnet; Pierre-Marie David; Patrick Cloos; Arnaud Duhoux; Jean-Christophe Lucet; +12 more
    Publisher: HAL CCSD
    Country: France

    AbstractBackgroundAll prevention efforts currently being implemented for COVID-19 are aimed at reducing the burden on strained health systems and human resources. There has been little research conducted to understand how SARS-CoV-2 has affected health care systems and professionals in terms of their work. Finding effective ways to share the knowledge and insight between countries, including lessons learned, is paramount to the international containment and management of the COVID-19 pandemic. The aim of this project is to compare the pandemic response to COVID-19 in Brazil, Canada, China, France, Japan, and Mali. This comparison will be used to identify strengths and weaknesses in the response, including challenges for health professionals and health systems.MethodsWe will use a multiple case study approach with multiple levels of nested analysis. We have chosen these countries as they represent different continents and different stages of the pandemic. We will focus on several major hospitals and two public health interventions (contact tracing and testing). It will employ a multidisciplinary research approach that will use qualitative data through observations, document analysis, and interviews, as well as quantitative data based on disease surveillance data and other publicly available data. Given that the methodological approaches of the project will be largely qualitative, the ethical risks are minimal. For the quantitative component, the data being used will be made publicly available.DiscussionWe will deliver lessons learned based on a rigorous process and on strong evidence to enable operational-level insight for national and international stakeholders.

  • Open Access English
    Authors: 
    Stuart P. Weisberg; Thomas J. Connors; Yun Zhu; Matthew R. Baldwin; Wen-Hsuan W. Lin; Sandeep N. Wontakal; Peter A. Szabo; Steven B. Wells; Pranay Dogra; Joshua I. Gray; +18 more
    Publisher: HAL CCSD
    Country: France
    Project: NIH | Tissue Resident Immune Ce... (1K08DK122130-01), NIH | Development of therapeuti... (5R01NS105699-03), NIH | Bioinformatics (5P01AI106697-02), NIH | Development of Localized ... (5K23AI141686-03), NIH | Human anti-viral immune r... (3U19AI128949-05S1)

    ABSTRACTClinical manifestations of COVID-19 caused by the novel coronavirus SARS-CoV-2 are associated with age. While children are largely spared from severe respiratory disease, they can present with a SARS-CoV-2-associated multisystem inflammatory syndrome (MIS-C) similar to Kawasaki’s disease. Here, we show distinct antibody (Ab) responses in children with MIS-C compared to adults with severe COVID-19 causing acute respiratory distress syndrome (ARDS), and those who recovered from mild disease. There was a reduced breadth and specificity of anti-SARS-CoV-2-specific antibodies in MIS-C patients compared to the COVID patient groups; MIS-C predominantly generated IgG Abs specific for the Spike (S) protein but not for the nucleocapsid (N) protein, while the COVID-19 cohorts had anti-S IgG, IgM and IgA Abs, as well as anti-N IgG Abs. Moreover, MIS-C patients had reduced neutralizing activity compared to both COVID-19 cohorts, indicating a reduced protective serological response. These results suggest a distinct infection course and immune response in children and adults who develop severe disease, with implications for optimizing treatments based on symptom and age.

  • English
    Authors: 
    Collin, Annabelle; Prague, Mélanie; Moireau, Philippe;
    Publisher: HAL CCSD
    Country: France

    International audience; Estimation of dynamical systems - in particular, identification of their parameters - is fundamental in computational biology, e.g., pharmacology, virology, or epidemiology, to reconcile model runs with available measurements. Unfortunately, the mean and variance priorities of the parameters must be chosen very appropriately to balance our distrust of the measurements when the data are sparse or corrupted by noise. Otherwise, the identification procedure fails. One option is to use repeated measurements collected in configurations with common priorities - for example, with multiple subjects in a clinical trial or clusters in an epidemiological investigation. This shared information is beneficial and is typically modeled in statistics using nonlinear mixed-effects models. In this paper, we present a data assimilation method that is compatible with such a mixed-effects strategy without being compromised by the potential curse of dimensionality. We define population-based estimators through maximum likelihood estimation. We then develop an equivalent robust sequential estimator for large populations based on filtering theory that sequentially integrates data. Finally, we limit the computational complexity by defining a reduced-order version of this population-based Kalman filter that clusters subpopulations with common observational backgrounds. The performance of the resulting algorithm is evaluated against classical pharmacokinetics benchmarks. Finally, the versatility of the proposed method is tested in an epidemiological study using real data on the hospitalisation of COVID-19 patients in the regions and departments of France.

  • Open Access English
    Authors: 
    Bastien Reyné; Christian Selinger; Mircea T. Sofonea; Stéphanie Miot; Amandine Pisoni; Edouard Tuaillon; Jean Bousquet; Hubert Blain; Samuel Alizon;
    Publisher: HAL CCSD
    Country: France

    AbstractBackgroundCOVID-19 is spreading rapidly in nursing homes (NHs). It is urgent to evaluate the effect of infection prevention and control (IPC) measures to reduce COVID spreading.MethodsWe analysed COVID-19 outbreaks in 12 NH using rRT-PCR for SARS-CoV-2. We estimated secondary attack risks (SARs) and identified cofactors associated with the proportion of infected residents.ResultsThe SAR was below 5%, suggesting a high efficiency of IPC measures. Mask-wearing or establishment of COVID-19 zones for infected residents were associated with lower SAR.ConclusionsWearing masks and isolating potentially infected residents appear to limit SARS-CoV-2 spread in nursing homes.

Advanced search in
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arrow_drop_down
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arrow_drop_down
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arrow_drop_down
Include:
613 Research products, page 1 of 62
  • Open Access English
    Authors: 
    Moritz U. G. Kraemer; Chia-Hung Yang; Bernardo Gutierrez; Chieh-Hsi Wu; Brennan Klein; David M. Pigott; Louis du Plessis; Nuno R. Faria; Ruoran Li; William P. Hanage; +7 more
    Publisher: American Association for the Advancement of Science
    Countries: France, United Kingdom, United Kingdom, United Kingdom
    Project: NIH | MIDAS Center for Communic... (1U54GM088558-01)

    The ongoing COVID-19 outbreak has expanded rapidly throughout China. Major behavioral, clinical, and state interventions are underway currently to mitigate the epidemic and prevent the persistence of the virus in human populations in China and worldwide. It remains unclear how these unprecedented interventions, including travel restrictions, have affected COVID-19 spread in China. We use real-time mobility data from Wuhan and detailed case data including travel history to elucidate the role of case importation on transmission in cities across China and ascertain the impact of control measures. Early on, the spatial distribution of COVID-19 cases in China was well explained by human mobility data. Following the implementation of control measures, this correlation dropped and growth rates became negative in most locations, although shifts in the demographics of reported cases are still indicative of local chains of transmission outside Wuhan. This study shows that the drastic control measures implemented in China have substantially mitigated the spread of COVID-19. One sentence summary: The spread of COVID-19 in China was driven by human mobility early on and mitigated substantially by drastic control measures implemented since the end of January.

  • Open Access English
    Authors: 
    Paul Brandily; Clément Brébion; Simon Briole; Laura Khoury;
    Publisher: HAL CCSD
    Country: France
    Project: ANR | PGSE (ANR-17-EURE-0001)

    Mortality inequalities remain substantial in many countries, and large shocks such as pandemics could amplify them further. The unequal distribution of COVID-19 confirmed cases suggests that this is the case. Yet, evidence on the causal effect of the epidemic on mortality inequalities remains scarce. In this paper, we exploit exhaustive municipality-level data in France, one of the most severely hit country in the world, to identify a negative relationship between income and excess mortality within urban areas, that persists over COVID-19 waves. Over the year 2020, the poorest municipalities experienced a 30% higher increase in excess mortality. Our analyses can rule out an independent contribution of lockdown policies to this heterogeneous impact. Finally, we find evidence that both labour-market exposure and housing conditions are major determinants of the epidemic-induced effects of COVID-19 on mortality inequalities, but that their respective role depends on the state of the epidemic.

  • English
    Authors: 
    Abidi, Hani; Amami, Rim; Trabelsi, Chiraz;
    Publisher: HAL CCSD
    Country: France

    The model descibes the epidemic dynamics of Covid-19 in a population after vaccination. Using the maximum principale, our goal is to prove the existence of an optimal strategy such that it minimize the number of infected people after vaccination. Finally, some numerical results are provided.

  • Publication . Article . Preprint . 2020
    Open Access English
    Authors: 
    Alberto Alemanno;
    Publisher: HAL CCSD
    Country: France

    The European response to COVID-19 has revealed an inconvenient truth. Despite having integrated public health concerns across all its policies – be it agriculture, consumer protection, or security –, the Union cannot directly act to save people’s lives. Only member states can do so. Yet when they adopted unilateral measures to counter the spread of the virus, those proved not only ineffective but also disruptive on vital supply chains, by ultimately preventing the flow of essential goods and people across the Union. These fragmented efforts in tackling cross-border health threats have almost immediately prompted political calls for the urgent creation of a European Health Union. Yet this call raises more questions than answers. With the aim to offer a rigorous and timely blueprint to decision-makers and the public at large, this Special Issue of the European Journal of Risk Regulation contextualizes such a new political project within the broader constitutional and institutional framework of EU public health law and policy. By introducing the Special, this paper argues that unless the envisaged Health Union will tackle the root causes of what prevented the Union from effectively responding to COVID-19 – the divergent health capacity across the Union –, it might fall short of its declared objective of strengthening the EU’resilience for cross-border health threats.

  • Publication . Article . Other literature type . Preprint . 2020
    Open Access English
    Authors: 
    Margaret Chitiga; Martin Henseler; Ramos Mabugu; Helene Maisonnave;
    Publisher: Palgrave Macmillan UK
    Country: France

    To contribute towards addressing the problem of relatively few general equilibrium studies focusing on gender impacts of disease pandemics, this paper uses a gendered Computable General Equilibrium model linked to a microsimulation model to study the short run economic effects of COVID-19 pandemic in South Africa. A mild and severe scenario is run to represent the pandemic. Findings suggest that while COVID-19 leads to negative economic effects irrespective of scenario, female-headed households bear a disproportionately higher burden of the brunt. Because women tend to be more concentrated in employment in sectors that are hurt the most by COVID-19 response measures as well as that they predominate in unskilled categories, the simulation results show that women suffer disproportionately more from higher unemployment than their male counterparts though the differences are not as pronounced. The poverty outcomes show worsened vulnerability for female-headed households given that, even prior to the pandemic, poverty was already higher amongst women. These results are important in informing evidence-based responses by government to the COVID-19 pandemic.

  • Open Access English
    Authors: 
    Achraf Ammar; Michael Brach; Khaled Trabelsi; Hamdi Chtourou; Omar Boukhris; Liwa Masmoudi; Bassem Bouaziz; Ellen Bentlage; Daniella How; Mona A. Ahmed; +47 more
    Publisher: HAL CCSD
    Country: France

    AbstractBackgroundPublic health recommendations and governmental measures during the COVID-19 pandemic have enforced numerous restrictions on daily living including social distancing, isolation and home confinement. While these measures are imperative to abate the spreading of COVID-19, the impact of these restrictions on health behaviours and lifestyle at home is undefined. Therefore, an international online survey was launched in April 2020 in seven languages to elucidate the behavioral and lifestyle consequences of COVID-19 restrictions. This report presents the preliminary results from the first thousand responders on physical activity (PA) and nutrition behaviours.MethodsThirty-five research organisations from Europe, North-Africa, Western Asia and the Americas promoted the survey through their networks to the general society, in English, German, French, Arabic, Spanish, Portugese, and Slovenian languages. Questions were presented in a differential format with questions related to responses “before” and “during” confinement conditions.Results1047 replies (54% women) from Asia (36%), Africa (40%), Europe (21%) and other (3%) were included into a general analysis. The COVID-19 home confinement had a negative effect on all intensities of PA (vigorous, moderate, walking and overall). Conversely, daily sitting time increased from 5 to 8 hours per day. Additionally, food consumption and meal patterns (the type of food, eating out of control, snacks between meals, number of meals) were more unhealthy during confinement with only alcohol binge drink decreasing significantly.ConclusionWhile isolation is a necessary measure to protect public health, our results indicate that it alters physical activity and eating behaviours in a direction that would compromise health. A more detailed analysis of survey data will allow for a segregation of these responses in different age groups, countries and other subgroups which will help develop bespoke interventions to mitigate the negative lifestyle behaviors manifest during the COVID-19 confinement.

  • Open Access English
    Authors: 
    Valéry Ridde; Lara Gautier; Christian Dagenais; Fanny Chabrol; Renyou Hou; Emmanuel Bonnet; Pierre-Marie David; Patrick Cloos; Arnaud Duhoux; Jean-Christophe Lucet; +12 more
    Publisher: HAL CCSD
    Country: France

    AbstractBackgroundAll prevention efforts currently being implemented for COVID-19 are aimed at reducing the burden on strained health systems and human resources. There has been little research conducted to understand how SARS-CoV-2 has affected health care systems and professionals in terms of their work. Finding effective ways to share the knowledge and insight between countries, including lessons learned, is paramount to the international containment and management of the COVID-19 pandemic. The aim of this project is to compare the pandemic response to COVID-19 in Brazil, Canada, China, France, Japan, and Mali. This comparison will be used to identify strengths and weaknesses in the response, including challenges for health professionals and health systems.MethodsWe will use a multiple case study approach with multiple levels of nested analysis. We have chosen these countries as they represent different continents and different stages of the pandemic. We will focus on several major hospitals and two public health interventions (contact tracing and testing). It will employ a multidisciplinary research approach that will use qualitative data through observations, document analysis, and interviews, as well as quantitative data based on disease surveillance data and other publicly available data. Given that the methodological approaches of the project will be largely qualitative, the ethical risks are minimal. For the quantitative component, the data being used will be made publicly available.DiscussionWe will deliver lessons learned based on a rigorous process and on strong evidence to enable operational-level insight for national and international stakeholders.

  • Open Access English
    Authors: 
    Stuart P. Weisberg; Thomas J. Connors; Yun Zhu; Matthew R. Baldwin; Wen-Hsuan W. Lin; Sandeep N. Wontakal; Peter A. Szabo; Steven B. Wells; Pranay Dogra; Joshua I. Gray; +18 more
    Publisher: HAL CCSD
    Country: France
    Project: NIH | Tissue Resident Immune Ce... (1K08DK122130-01), NIH | Development of therapeuti... (5R01NS105699-03), NIH | Bioinformatics (5P01AI106697-02), NIH | Development of Localized ... (5K23AI141686-03), NIH | Human anti-viral immune r... (3U19AI128949-05S1)

    ABSTRACTClinical manifestations of COVID-19 caused by the novel coronavirus SARS-CoV-2 are associated with age. While children are largely spared from severe respiratory disease, they can present with a SARS-CoV-2-associated multisystem inflammatory syndrome (MIS-C) similar to Kawasaki’s disease. Here, we show distinct antibody (Ab) responses in children with MIS-C compared to adults with severe COVID-19 causing acute respiratory distress syndrome (ARDS), and those who recovered from mild disease. There was a reduced breadth and specificity of anti-SARS-CoV-2-specific antibodies in MIS-C patients compared to the COVID patient groups; MIS-C predominantly generated IgG Abs specific for the Spike (S) protein but not for the nucleocapsid (N) protein, while the COVID-19 cohorts had anti-S IgG, IgM and IgA Abs, as well as anti-N IgG Abs. Moreover, MIS-C patients had reduced neutralizing activity compared to both COVID-19 cohorts, indicating a reduced protective serological response. These results suggest a distinct infection course and immune response in children and adults who develop severe disease, with implications for optimizing treatments based on symptom and age.

  • English
    Authors: 
    Collin, Annabelle; Prague, Mélanie; Moireau, Philippe;
    Publisher: HAL CCSD
    Country: France

    International audience; Estimation of dynamical systems - in particular, identification of their parameters - is fundamental in computational biology, e.g., pharmacology, virology, or epidemiology, to reconcile model runs with available measurements. Unfortunately, the mean and variance priorities of the parameters must be chosen very appropriately to balance our distrust of the measurements when the data are sparse or corrupted by noise. Otherwise, the identification procedure fails. One option is to use repeated measurements collected in configurations with common priorities - for example, with multiple subjects in a clinical trial or clusters in an epidemiological investigation. This shared information is beneficial and is typically modeled in statistics using nonlinear mixed-effects models. In this paper, we present a data assimilation method that is compatible with such a mixed-effects strategy without being compromised by the potential curse of dimensionality. We define population-based estimators through maximum likelihood estimation. We then develop an equivalent robust sequential estimator for large populations based on filtering theory that sequentially integrates data. Finally, we limit the computational complexity by defining a reduced-order version of this population-based Kalman filter that clusters subpopulations with common observational backgrounds. The performance of the resulting algorithm is evaluated against classical pharmacokinetics benchmarks. Finally, the versatility of the proposed method is tested in an epidemiological study using real data on the hospitalisation of COVID-19 patients in the regions and departments of France.

  • Open Access English
    Authors: 
    Bastien Reyné; Christian Selinger; Mircea T. Sofonea; Stéphanie Miot; Amandine Pisoni; Edouard Tuaillon; Jean Bousquet; Hubert Blain; Samuel Alizon;
    Publisher: HAL CCSD
    Country: France

    AbstractBackgroundCOVID-19 is spreading rapidly in nursing homes (NHs). It is urgent to evaluate the effect of infection prevention and control (IPC) measures to reduce COVID spreading.MethodsWe analysed COVID-19 outbreaks in 12 NH using rRT-PCR for SARS-CoV-2. We estimated secondary attack risks (SARs) and identified cofactors associated with the proportion of infected residents.ResultsThe SAR was below 5%, suggesting a high efficiency of IPC measures. Mask-wearing or establishment of COVID-19 zones for infected residents were associated with lower SAR.ConclusionsWearing masks and isolating potentially infected residents appear to limit SARS-CoV-2 spread in nursing homes.

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