Trisha Greenhalgh and colleagues argue that it is time to apply the precautionary principle

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The question of whether and when to mandate the wearing of masks or face coverings by the lay public to prevent the spread of Covid-19 remains controversial. A vast research literature, across a range of academic disciplines, has accumulated in the past six months. We summarise that literature, which (whilst not universally accepted) points consistently to some important conclusions. First, there is growing evidence that the SARS-CoV-2 virus is airborne and hence may spread long distances and be inhaled. Infection control policy must therefore go beyond ‘contact and droplet’ measures such as hand-washing and cleaning surfaces. Second, masks and face coverings, if widely worn, appear to significantly reduce population transmission of the virus. Third, randomized controlled trials of the preventive impact of population masking in Covid-19 remain sparse and have yet to address the question of source control. Fourth, the harms of wearing masks appear to be relatively minor (though by no means trivial) and were over-estimated in the early months of the pandemic; harms are outweighed by benefits when COVID-19 is spreading in a population. Fifth, face shields, valved respirators and flimsy or ill-fitting face coverings are unsuitable for source control. Finally, mandated masking involves a trade-off with personal freedom so such policies should be pursued only if the threat is severe and the benefits cannot be achieved through less intrusive means.

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Background In October 2020, amidst the second COVID-19 epidemic wave and before the second-national lockdown, Austria introduced a policy of population-wide point-of-care lateral flow antigen testing (POC-LFT). This study explores the impact of this policy by quantifying the association between trends in POC-LFT-activity with trends in PCR-positivity (as a proxy for symptomatic infection), hospitalisations and deaths related to COVID-19 between October 22 and December 06, 2020. Methods We stratified 94 Austrian districts according to POC-LFT-activity (number of POC-LFTs performed per 100,000 inhabitants over the study period), into three population cohorts: (i) high(N = 24), (ii) medium(N = 45) and (iii) low(N = 25). Across the cohorts we a) compared trends in POC-LFT-activity with PCR-positivity, hospital admissions and deaths related to COVD-19; b) compared the epidemic growth rate before and after the epidemic peak; and c) calculated the Pearson correlation coefficients between PCR-positivity with COVID-19 hospitalisations and with COVID -19 related deaths. Results The trend in POC-LFT activity was similar to PCR-positivity and hospitalisations trends across high, medium and low POC-LFT activity cohorts, with association with deaths only present in cohorts with high POC-LFT activity. Compared to the low POC-LFT-activity cohort, the high-activity cohort had steeper pre-peak daily increase in PCR-positivity (2.24 more cases per day, per district and per 100,000 inhabitants; 95% CI: 2.0–2.7; p < 0.001) and hospitalisations (0.10; 95% CI: 0.02, 0.18; p = 0.014), and 6 days earlier peak of PCR-positivity. The high-activity cohort also had steeper daily reduction in the post-peak trend in PCR-positivity (-3.6; 95% CI: -4.8, -2.3; p < 0.001) and hospitalisations (-0.2; 95% CI: -0.32, -0.08; p = 0.001). PCR-positivity was positively correlated to both hospitalisations and deaths, but with lags of 6 and 14 days respectively. Conclusions High POC-LFT-use was associated with increased and earlier case finding during the second Austrian COVID-19 epidemic wave, and early and significant reduction in cases and hospitalisations during the second national lockdown. A national policy promoting symptomatic POC-LFT in primary care, can capture trends in PCR-positivity and hospitalisations. Symptomatic POC-LFT delivered at scale and combined with immediate self-quarantining and contact tracing can thus be a proxy for epidemic status, and hence a useful tool that can replace large-scale PCR testing.

BackgroundIn October 2020, amidst the second COVID-19 epidemic wave and before the second-national lockdown, Austria introduced a policy of population-wide point-of-care lateral flow antigen testing (POC-LFT). This study explores the impact of this policy by quantifying the association between trends in POC-LFT-activity with trends in PCR-positivity (as a proxy for symptomatic infection), hospitalisations and deaths related to COVID-19 between October 22 and December 06, 2020. MethodsWe stratified 94 Austrian districts according to POC-LFT-activity (number of POC-LFTs performed per 100,000 inhabitants over the study period), into three population cohorts: (i) high(N=24), (ii) medium(N=45) and (iii) low(N=25). Across the cohorts we a) compared trends in POC-LFT-activity with PCR-positivity, hospital admissions and deaths related to COVD-19; b) compared the epidemic growth rate before and after the epidemic peak; and c) calculated the Pearson correlation coefficients between PCR-positivity with COVID-19 hospitalisations and with COVID -19 related deaths. ResultsThe trend in POC-LFT activity was similar to PCR-positivity and hospitalisations trends across high, medum and low POC-LFT activity cohorts, with association with deaths only present in cohorts with high POC-LFT activity. Compared to the low POC-LFT-activity cohort, the high-activity cohort had steeper pre-peak daily increase in PCR-positivity (2.24 more cases per day, per district and per 100,000 inhabitants; 95% CI: 2.0-2.7; p<0.001) and hospitalisations (0.10; 95% CI: 0.02, 0.18; p<0.15), and 6 days earlier peak of PCR-positivity. Th high-activity cohort also had steeper daily reduction in the post-peak trend in PCR-positivity (-3.6; 95% CI: -4.8, -2.3; p<0.001) and hospitalisations (-0.2; 95% CI: -0.32, -0.08; p<0.05). PCR-positivity was positively correlated to both hospitalisations and deaths, but with lags of 6 and 14 days respectively. ConclusionsHigh POC-LFT-use was associated with increased and earlier case finding during the second Austrian COVID-19 epidemic wave, and early and significant reduction in cases and hospitalisations during the second national lockdown. A national policy promoting symptomatic POC-LFT in primary care, can capture trends in PCR-positivity and hospitalisations. Symptomatic POC-LFT delivered at scale and combined with immediate self-quarantining and contact tracing can thus be a proxy for epidemic status, and hence a useful tool that can replace large-scale PCR testing.

We report of our work on a "thick description" of a population oriented integrated care programme in Austria, the Health Network Tennengau (HNT). The HNT is a bottom-up network comprised of social and health service providers and voluntary organisations in the Tennengau region, which is a rural area in the state of Salzburg. The HNT has its origin in a pilot project for medical home nursing care introduced in 1995 and has since gradually evolved into a comprehensive network, targeting all inhabitants of the Tennengau region. However, the activities are especially geared towards senior citizens with multiple medical and social requirements. Document analysis and interviews conducted during the Horizon 2020 project SELFIE show that the HTN puts the patient at the centre of the care process and aims to facilitate integrated care around the patient, namely to provide information, counselling, coordination and interface management through case and care management and improved communication.The interconnectedness with non-medical service providers is a central concern for all stakeholder of the HNT. Thus, the HNT is at its core not a medical programme, but a network between doctors, hospitals, care facilities and diverse social institutions in the region.The HNT has been successful for more than 20 years due to voluntary work and a culture of respect between all stakeholders. However, the sustainability has always been at risk as despite its success, continuous financing has been hard to secure, resulting in limited compensation for the involved partners, a lack of resources for public relations work, as well as a lack of funding especially at the start of pilot projects. As a consequence, the HNT still relies to a high degree on voluntary work. However, this also constitutes a weakness of the HNT, as it is not easily transferable. In other regions, not only the culture, but also voluntary stakeholders are lacking to build up integrated care without proper payment. Thus, the HNT offers manifold points for development that can only be spread by securing a sustainable financing. However, the fact that the HNT has persevered despite a lot of such adverse factors makes it an interesting case to learn from.

Issue Despite their geographical and cultural proximity, Germany, Austria, and Switzerland can teach very different lessons on how to handle the COVID-19 pandemic. Timing and severity of outbreaks during the first wave were fairly similar in Germany and Austria, whereas Switzerland faced a higher infection rate at the peak of the crisis (although far from rates in France or Italy). Description The aim of this presentation is to examine the outbreak responses of the three countries in the spring of 2020 and give insight into the dynamics and rationales behind these responses. Results Although the three countries are all prime examples of federalism, Austria and Switzerland showed a decisive, uniform public health response resulting from epidemic laws granting the central level precedence under such circumstances. In Germany, by contrast, individual state governments played a central role. Response measures eventually taken by the three countries were not too different but how decisions were made and subsequently communicated to the public varied considerably. The three countries fared well in reducing transmission rates and never came close to reaching capacity limits in their health systems during the first wave. However, while all of them experienced a resurgence of infections in fall, the epidemiological development took a diverging course across the three countries in the following months. Lessons While all countries were successful in the first wave, differences in the paths chosen are likely to impact adherence to measures and may help explain divergent developments in the subsequent waves. Main messages Swift and decisive actions seem to have been successful answers to the first wave of the pandemic, but approaches to implementation and communication of these approaches to the public may make the difference in the further course of the pandemic.