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We are writing this openly-published letter to express deep concerns regarding the paper recently published in JAMA Network Open: Estimation of US Children’s Educational Attainment and Years of Life Lost Associated With Primary School Closures During the Coronavirus Disease 2019 Pandemic DOI: 10.1001/jamanetworkopen.2020.28786The paper by Christakis, Van Cleve, and Zimmerman(2020,abbrev. CVZ) is built upon multiple critically flawed assumptions, obvious misuse of the standard analytical tools, and clear mistakes in study design. Additionally, the analysis presented contains crucial mathematical and statistical errors that completely revert the main results, sufficient that if the estimates had been calculated according to the declared methodology, the results would completely contradict the stated conclusions and policy recommendations. These are not idle criticisms. This study has received enormous public attention, and its results immediately appeared in discussions of public health policies around schools worldwide. The central question is resolving an evidence base for the inevitable tradeoff between (a) the very real harms of missed education provoked by policies that decrease viral spread vs. (b) the resumption of education as a social good which increases viral spread. This is an incredibly important public health question, and it demands careful cost-benefit analysis. To that end, this paper adds no usable evidence whatsoever.

In the Covid-19 pandemic, it seems that African countries have been largely spared from the devastating effects observed elsewhere. Working and living in Guinea-Bissau, one of the poorest and most fragile countries in the world located in West Africa, we wonder: How can the world know that there are only few Covid-19 cases in a country where the health system is weak and access to Covid-19 tests very limited? How can the world know that there is a low Covid-19 mortality in a country without a reliable civil registration and vital statistic system? In this article, we explore the (too) many unknowns of Covid-19 in Guinea-Bissau. The article was chosen as the 1st place winner of the 2020 Eye on Global Health Writing Competition.

WHO fungerer som hele verdens sundhedsstyrelse, men har et budget som et middelstort schweizisk universitet. Alligevel lyder kravet, at FN’s Verdenssundhedsorganisation skal gå forrest under den pandemi, der fortsat holder verden fanget i sit greb. Professor fra SDU og overlæge Morten Sodemann har i årtier fulgt WHO og er med til at folde ud, hvad organisationen er særligt god til, og hvad der går knap så godt i en tid, hvor WHO er kommet i klemme i et storpolitisk spil mellem USA og Kina. Bliv også klogere på WHO-historien, der i høj grad er præget af danske værdier. Dine værter er Kirsten Larsen og Lasse Soll Sunde.

Over the covid-19 lockdown period, Dr James Rogers worked with history teachers and academics to keep the learning going in lockdown. He now has a fantastic range of videos and podcasts available. All content is free to access and is explicitly designed to help teachers and students undertake A-Level and GCSE history revision.Podcast - Slavery and Emancipation in the United States, with Dr Cathrine Armstrong.Podcast - The History of Terrorism - The IRA, with Professor Caroline Kennedy-Pipe.Video - The Rise of Hitler - Hitler, Power, and War, with Ms Laurie Matthews.Video - The Home Front in WW2 - The Butterfly Bombing of Grimsby, with Dr James Rogers.

Bakgrund: Det er velkendt at en række kroniske tilstande kan medføre nedsat evne til at varetage gøremål i hverdagen relateret til egenomsorg og huslige gøremål, også kaldet almindelig daglig levevis (ADL), og der er behov for at udvikle og evaluere interventionsprogrammer, der adresserer sådanne problemer. Med afsæt i Britiske Medicinske Forskningsråds vejledning (MRC guiden) for udvikling og evaluering af komplekse interventioner, blev den første version af det ergoterapeutiske program (ABLE 1.0) udviklet med det formål at forbedre ADL-evnen blandt personer med kroniske tilstande. ABLE inkorporerer viden baseret på eksisterende evidens, klinisk ekspertise hos ergoterapeuter og klienters erfaringer og behov. ABLE er et 8-ugers, struktureret og individualiseret forløb, som leveres i klientens hjem som en del af kommunal rehabiliteringspraksis. Forløbet består af 5-8 sessioner, og består af vurdering af ADL-evne, målsætning, intervention baseret på en kompensatorisk tilgang og afsluttes med revurdering af ADL evne. Desuden er programmet udviklet til at kunne anvendes på tværs af alder, køn og diagnoser, dvs. generisk. Et feasibility studie viste, at ABLE 1.0 var gennemførbar med hensyn til indhold og levering, med mindre justeringer af interventionsmanualen og procedurer for rekruttering. Det blev derfor anbefalet at gennemføre et pilot studie før planlægning og gennemførelse af evalueringsstudier. Formålet med denne afhandling var derfor at evaluere de resterende feasibility-aspekter forud for et randomiseret kontrolleret forsøg (RCT), inklusive revidering af ABLE 1.0, og at gennemføre effekt og proces evaluering af ABLE 2.0.Metoder: MRC guiden blev anvendt som ramme. Revidering af ABLE 1.0 omfattede gennemførelse af en kognitiv debriefing med deltagelse af fem ergoterapeuter, med henblik på at identificere uklarheder i ABLE manualens opbygning og indhold, som potentielt kunne føre til forvirring eller misforståelser. Derudover omfattede det inkorporering af opdaterede versioner af teoretiske modeller i programmet.Pilot studiet var designet som et randomiseret kontrolleret studie med to parallelle grupper. Planen var at inkludere 20 personer med én eller flere kroniske tilstande, som oplevede problemer med udførelse af ADL opgaver, i perioden fra december 2019 til april 2020. Følgende progressionskriterier blev anvendt for at vurdere gennemførbarheden at et RCT studie: (i) rekruttering (50 % opfyldte inklusionskriterierne) og fastholdelse (80 %), (ii) randomisering (80 % accepterede randomisering og proceduren blev udført som planlagt), (iii) gennemførbarhed og accept i praksis (100 % fulgte manualen), (iv) resultatmålinger (80 % af deltagerne leverede relevante og fuldt besvarede spørgeskemaer) og (v) sædvanlig ergoterapi (udtræk af nødvendig information fra klientjournaler var vellykket).Den efterfølgende effektevaluering havde et RCT design med blindede testere og forskere. Hjemmeboende klienter med kroniske tilstande og ADL problemer blev randomiseret og allokeret til ABLE 2.0 eller sædvanlig ergoterapi. Data blev indsamlet ved baseline (uge 0), efter endt intervention (uge 10) og ved followup (uge 26). Co-primære outcomes var selvrapporteret ADL evne, målt med ADL-Interviewet (ADL-I Udførelse) og observeret motorisk ADL evne målt med Assessment of Motor and Process Skills (AMPS) ved primært endpoint 10 uger efter baseline. Sekundære outcomes var selvrapporteret ADL evne, målt med ADL-I Udførelse, og observeret motorisk ADL evne, målt med AMPS, ved sekundære endpoint 26 uger efter baseline; og selvrapporteret tilfredshed med ADL evne, målt med ADL-I Tilfredshed, og observeret procesmæssig ADL evne, målt med AMPS, ved primært og sekundært endpoint. Eksplorative outcomes var aktivitetsbalance målt med Occupational Balance Questionnaire (OBQ11), oplevede forandringer målt med Client-Weighted-Problems Questionnaire (CWP-Q) og generelt helbred målt med det første spørgsmål i the MOS 36- item Short Form Survey Instrument (SF36-SF1) ved primært og sekundært endpoint. Alle outcomes blev analyseret i Intention-To-Treat analyser efterfulgt af sensitivitetsanalyser i form af Per-Protocol analyser ved hjælp af analyser af kovarians (ANCOVA) over tid mellem grupper som repeated measures. ADL-I Udførelse ved baseline blev brugt som kovariat.Procesevalueringen var designet som en realistisk evaluering. Ved hjælp af en programteori blev hypoteser om hvordan kontekstuelle faktorer og mekanismer i interventionsprogrammet kunne lede til bestemte outcomes, i såkaldte CMO konfigurationer, beskrevet. Procesevalueringen var baseret på kvalitative data fra interview med 8 klienter, som havde modtaget ABLE 2.0, og de tre ergoterapeuter, der havde leveret det. Desuden blev der indsamlet kvantitative data ved hjælp af registreringsskemaer, som blev udfyldt af de klienter der modtog programmet og de tre ergoterapeuter der leverede det. Resultater: Baseret på data fra kognitiv debriefing og opdateret teori blev manualen revideret, hvilket resulterede i ABLE 2.0. På grund af Covid-19 pandemien blev pilot studiet afbrudt i marts 2020, hvilket resulterede i et begrænset datasæt, som dog blev vurderet til at være tilstrækkeligt til at besvare studiets spørgsmål: (i) 18 ud af 37 som opfyldte inklusionskriterierne (48,6 %) blev rekrutteret; alle inkluderede (n = 6) forblev i programmet (100 %); (ii) 18 accepterede randomisering (100 %), og proceduren var effektiv; (iii) ABLE blev leveret som beskrevet i manualen (100%); (iv) 92,3-100 % af deltagerne gav relevante og fuldstændige svar i to af tre spørgeskemaer; og (v) information om sædvanlig ergoterapi var tilgængelig i syv ud af ni aspekter.I effektevalueringens ITT analyser af primære outcomes fandt vi ingen statistisk signifikante eller klinisk relevante forskelle mellem grupper i gennemsnitlige forandringer i selvrapporteret (ADL-I Udførelse) (-0.16; 95 % CI: -0.38 to 0.06) eller observeret (AMPS) (-0.1; 95 % CI: -0.3 to 0.1) ADL evne fra baseline til uge 10. Ved sekundært endpoint 26 uger efter baseline, fandt vi en statistisk signifikant og klinisk relevant forskel i motorisk ADL evne (AMPS) (LS mean change = -0.3; 95% CI = -0.5 to -0.1) mellem grupperne. Dette fund blev bekræftet i sensitivitetsanalysen (LS mean change = -0.4; 95% CI = -0.7 to -0.1).Procesevalueringen bekræftede overordnet set programteorien og tilføjede informationer om centrale mekanismer associeret med de positive resultater af ABLE 2.0: Aktiv involvering af klienten i problemløsningsprocessen, en velfungerende samarbejdsrelation, gensidig tillid og vejledning i en aktivitetsbaseret proces med brug af kompenserende tiltag. En række kontekstuelle faktorer, herunder understøttende ledelse, visitationsprocedurer der understøttede problemløsningsprocessen, levering i klientens hjem, ergoterapeuter med gode færdigheder, og klienter, der følte sig klar til forandringer, kunne aktivere mekanismerne.Konklusioner: På baggrund af studiernes resultater kan det konkluderes, at ABLE 2.0 havde effekt i forhold til at opnå forbedringer i observeret motorisk ADL evne, det vil sige nedsat anstrengelse i form af klodsethed, fysisk udmattelse og træthed, blandt personer med kroniske tilstande. De opnåede langsigtede effekter på den observerede motoriske ADL evne tilskrives den systematiske tilgang til problemløsningsprocessen, at interventionen leveres i hjemmet og brugen af kompenserende tiltag. Slutteligt, fordi klienternes observerede ADL evne ved baseline var den eneste identificerede forskel mellem de klienter, der opnåede forbedret ADL evne og de der ikke gjorde, og ABLE 2.0 således var effektiv på tværs af køn, alder og diagnoser, understøtter resultaterne ideen om et generisk program. Konklusionerne danner grundlag for at anbefale iværksættelse af forskningsaktiviteter, der sigter mod implementering af ABLE interventionsprogrammet i kommunal rehabiliteringspraksis. Background: Problems related to performance of activities of daily living (ADL) tasks is associated with chronic conditions stressing a need to develop and evaluate intervention programmes addressing such problems. Guided by the United Kingdom Medical Research Council’s (MRC) guidance on how to develop and evaluate complex interventions, the first version of the occupational therapy program (ABLE 1.0) was developed, aiming at enhancing ADL ability among persons with chronic conditions. ABLE incorporates knowledge based on existing evidence, clinical expertise of occupational therapists, and clients’ experiences and needs. ABLE is a structured eight-week, generic, homebased, adaptational program, including five to eight individualised sessions, developed to be delivered in the client’s home as part of community-based rehabilitation services. Following development of the programme, a feasibility study was conducted, showing that ABLE 1.0 was feasible in terms of content and delivery with minor adjustments to the intervention manual and recruitment procedures. Hence, pilot testing of the remaining uncertainties was recommended before proceeding to the evaluation phase. The aim of this doctoral thesis was to evaluate the remaining feasibility aspects prior to a randomised controlled trial (RCT), including minor revision of ABLE 1.0, and to conduct effectiveness and process evaluation of ABLE 2.0.Methods: The MRC framework for developing and evaluating complex interventions was applied. Revision of ABLE 1.0 included conduction of a cognitive debriefing including n=5 occupational therapists to identify any aspect of the ABLE manual leading to confusion or misunderstanding. Further, relevant updates of theoretical models incorporated in ABLE 1.0 were implemented.The pilot study was designed as a two-armed parallel RCT, planning a recruitment strategy including 20 persons with one or more chronic conditions and experiencing problems performing ADL tasks. The pilot study period was scheduled from December 2019 to April 2020. The following progression criteria were used to determine if a future full-scale RCT was feasible: (i) recruitment (50% met the eligibility criteria) and retention (80%), (ii) randomisation (80% accepted randomisation, procedure was executed as planned), (iii) adherence to programme (100% followed the treatment protocol), (iv) outcome measurements (80% of the participants delivered relevantly and fully answered questionnaires), and (v) usual occupational therapy (extraction of needed information was successful).The subsequent effectiveness evaluation was designed as a RCT with blinded assessors and investigators. Home-dwelling persons with chronic conditions experiencing ADL task performance problems were randomly allocated to ABLE 2.0 or usual occupational therapy. Data were collected at baseline (week 0), post intervention (week 10) and at follow-up (week 26). Coprimary outcomes were self-reported ADL ability (ADL-Interview (ADL-I) performance) and observed ADL motor ability (Assessment of Motor and Process Skills (AMPS)) at primary endpoint (week 10). Secondary outcomes were self-reported ADL ability (ADL-I performance), observed ADL motor ability (AMPS) at secondary endpoint (week 26) and perceived satisfaction with ADL ability (ADL-I satisfaction); and observed ADL process ability (AMPS) at primary and secondary endpoint. Explorative outcomes were occupational balance (Occupational Balance Questionnaire); perceived change (Client Weighted Problems Questionnaire) and general health (first question of the MOS 36-item Short Form Survey Instrument) at primary and secondary endpoint. All outcomes were analysed using the principles of Intention-To-Treat (ITT) analyses followed by sensitivity analyses in terms of Per Protocol (PP) analyses, applying analysis of covariance (ANCOVA) with time by programme as repeated measures. ADL-I at baseline was included as covariate. In the process evaluation a realist evaluation approach was applied. A programme theory (ABLE 2.0 initial programme theory) was constructed expressing how contexts (C) and mechanisms (M) in the intervention programme were hypothesised to lead to certain outcomes (O), in so-called CMO configurations. The process evaluation was based on qualitative interview data from a sub-group of clients (n=8) and the occupational therapists delivering the programme (n=3), supplied by quantitative data from registration forms, filled in by clients receiving (n=38) and OTs delivering (n=3) ABLE 2.0.Results: Based on data from the cognitive debriefing and updated theory the manual was revised resulting in ABLE 2.0. Due to the Covid-19 pandemic the pilot study was interrupted in March 2020, resulting in limited but sufficient data to answer most of the study questions. (i) Eighteen of 37 eligible persons (48.6%) were recruited; of those treated (n = 6), all remained in the programme (100%); (ii) 18 accepted randomisation (100%), and procedure was effective; (iii) ABLE was delivered with adherence (100%); (iv) 92.3–100% of the participants gave relevant and complete answers in two of three questionnaires; and (v) the needed information on usual occupational therapy was extractable in seven of nine aspects.In the effectiveness evaluation ITT analysis of primary outcomes identified no statistically significant nor clinically relevant difference between group mean changes on self-reported, i.e. ADL-I performance (-0.16; 95 % CI: - 0.38 to 0.06) and observed ADL ability, i.e. AMPS ADL motor ability (-0.1; 95 % CI: -0.3 to 0.1) from baseline to week 10. However, at the secondary endpoint (week 26) a statistically significant and clinically relevant difference was found in AMPS ADL motor ability (LS mean change = -0.3; 95% CI = -0.5 to -0.1) between groups. This was confirmed in the sensitivity analysis (LS mean change = -0.4; 95% CI = -0.7 to -0.1).The process evaluation overall confirmed the initial programme theory, adding information on core mechanisms associated with the positive effects of the ABLE 2.0. These included active involvement of the client in the problem-solving process, a collaborative working relationship, mutual confidence, and a consultative occupation-based process using adaptational strategies. Several contextual factors were required to activate the desired mechanisms in terms of supportive management, referral procedures encouraging the problem-solving process, delivery in the client’s home, skilled OTs, and clients feeling ready for making changes.Conclusions: Based on the results it was concluded that the ABLE 2.0 was effective in improving observed ADL motor ability, reflecting a decreased level of effort in terms of clumsiness, physical effort, and fatigue among persons with chronic conditions. Sustainability of the improvements in ADL motor ability was obtained based on delivering the individualised systematic problem-solving process in the home of the client and by using adaptational strategies. Finally, because baseline ADL ability was identified as the only area were persons who benefitted differed from those who did not, and the ABLE 2.0 otherwise was effective across age, gender and diagnoses, the idea of developing a generic programme was supported. Based on the conclusions it is recommended to proceed to planning of research activities aiming at implementing the ABLE intervention programme in clinical communitybased rehabilitation settings.

The population-level case-fatality rate (CFR) associated with COVID-19 varies substantially, both across countries time and within countries over time. We analyze the contribution of two key determinants of the variation in the observed CFR: the age-structure of diagnosed infection cases and age-specific case-fatality rates. We use data on diagnosed COVID-19 cases and death counts attributable to COVID-19 by age for China, Germany, Italy, South Korea, Spain, the United States, and New York City. We calculate the CFR for each population at the latest data point and also for Italy over time. We use demographic decomposition to break the difference between CFRs into unique contributions arising from the age-structure of confirmed cases and the age-specific case-fatality. In late April 2020, CFRs varied from 2.2% in South Korea to 13.0% in Italy. The age-structure of detected cases often explains more than two thirds of cross-country variation in the CFR. In Italy, the CFR increased from 4.2% to 13.0% between March 9 and April 22, 2020, and more than 90% of the change was due to increasing age-specific case-fatality rates. The importance of the age-structure of confirmed cases likely reflects several factors, including different testing regimes and differences in transmission trajectories; while increasing age-specific case-fatality rates in Italy could indicate other factors, such as the worsening health outcomes of those infected with COVID-19. Our findings lend support to recommendations for data to be disaggregated by age, and potentially other variables, to facilitate a better understanding of population-level differences in CFRs. They also show the need for well designed seroprevalence studies to ascertain the extent to which differences in testing regimes drive differences in the age-structure of detected cases.