Cover -- The Sustainable City XIV -- Copyright Page -- Preface -- Contents -- Section 1: Urban strategies -- Role of municipalities in the urban planning of post-oil Gulf cities: The case of Dubai, United Arab Emirates -- Revisiting the urban definition for the island of Mauritius -- Moving towards sustainable agricultural land management and practices in Kosovo -- Sustainable urbanization in Patagonia to address climate change and country NDCs: A case study of a mixed coastal urbanization project -- Section 2: The community and the city
Abstract. This paper is the second part in a series of two articles, which aims at presenting a data-driven modeling strategy for forecasting wildfire spread scenarios based on the assimilation of the observed fire front location and on the sequential correction of model parameters or model state. This model relies on an estimation of the local rate of fire spread (ROS) as a function of environmental conditions based on Rothermel's semi-empirical formulation, in order to propagate the fire front with an Eulerian front-tracking simulator. In Part I, a data assimilation (DA) system based on an ensemble Kalman filter (EnKF) was implemented to provide a spatially uniform correction of biomass fuel and wind parameters and thereby, produce an improved forecast of the wildfire behavior (addressing uncertainties in the input parameters of the ROS model only). In Part II, the objective of the EnKF algorithm is to sequentially update the two-dimensional coordinates of the markers along the discretized fire front, in order to provide a spatially distributed correction of the fire front location and thereby, a more reliable initial condition for further model time-integration (addressing all sources of uncertainties in the ROS model). The resulting prototype data-driven wildfire spread simulator is first evaluated in a series of verification tests using synthetically generated observations; tests include representative cases with spatially varying biomass properties and temporally varying wind conditions. In order to properly account for uncertainties during the EnKF update step and to accurately represent error correlations along the fireline, it is shown that members of the EnKF ensemble must be generated through variations in estimates of the fire's initial location as well as through variations in the parameters of the ROS model. The performance of the prototype simulator based on state estimation (SE) or parameter estimation (PE) is then evaluated by comparison with data taken from a reduced-scale controlled grassland fire experiment. Results indicate that data-driven simulations are capable of correcting inaccurate predictions of the fire front location and of subsequently providing an optimized forecast of the wildfire behavior at future lead times. The complementary benefits of both PE and SE approaches, in terms of analysis and forecast performance, are also emphasized. In particular, it is found that the size of the assimilation window must be specified adequately with the persistence of the model initial condition and/or with the temporal and spatial variability of the environmental conditions in order to track sudden changes in wildfire behavior. The present prototype data-driven forecast system is still at an early stage of development. In this regard, this preliminary investigation provides valuable information on how to combine observations with a fire spread model in an efficient way, as well as guidelines to design the future system evolution in order to meet the operational requirements of wildfire spread monitoring.
Abstract. This paper is the first part in a series of two articles and presents a data-driven wildfire simulator for forecasting wildfire spread scenarios, at a reduced computational cost that is consistent with operational systems. The prototype simulator features the following components: an Eulerian front propagation solver FIREFLY that adopts a regional-scale modeling viewpoint, treats wildfires as surface propagating fronts, and uses a description of the local rate of fire spread (ROS) as a function of environmental conditions based on Rothermel's model; a series of airborne-like observations of the fire front positions; and a data assimilation (DA) algorithm based on an ensemble Kalman filter (EnKF) for parameter estimation. This stochastic algorithm partly accounts for the nonlinearities between the input parameters of the semi-empirical ROS model and the fire front position, and is sequentially applied to provide a spatially uniform correction to wind and biomass fuel parameters as observations become available. A wildfire spread simulator combined with an ensemble-based DA algorithm is therefore a promising approach to reduce uncertainties in the forecast position of the fire front and to introduce a paradigm-shift in the wildfire emergency response. In order to reduce the computational cost of the EnKF algorithm, a surrogate model based on a polynomial chaos (PC) expansion is used in place of the forward model FIREFLY in the resulting hybrid PC-EnKF algorithm. The performance of EnKF and PC-EnKF is assessed on synthetically generated simple configurations of fire spread to provide valuable information and insight on the benefits of the PC-EnKF approach, as well as on a controlled grassland fire experiment. The results indicate that the proposed PC-EnKF algorithm features similar performance to the standard EnKF algorithm, but at a much reduced computational cost. In particular, the re-analysis and forecast skills of DA strongly relate to the spatial and temporal variability of the errors in the ROS model parameters.
Abstract. Mediterranean catchments in southern France are threatened by potentially devastating fast floods which are difficult to anticipate. In order to improve the skill of rainfall-runoff models in predicting such flash floods, hydrologists use data assimilation techniques to provide real-time updates of the model using observational data. This approach seeks to reduce the uncertainties present in different components of the hydrological model (forcing, parameters or state variables) in order to minimize the error in simulated discharges. This article presents a data assimilation procedure, the best linear unbiased estimator (BLUE), used with the goal of improving the peak discharge predictions generated by an event-based hydrological model Soil Conservation Service lag and route (SCS-LR). For a given prediction date, selected model inputs are corrected by assimilating discharge data observed at the basin outlet. This study is conducted on the Lez Mediterranean basin in southern France. The key objectives of this article are (i) to select the parameter(s) which allow for the most efficient and reliable correction of the simulated discharges, (ii) to demonstrate the impact of the correction of the initial condition upon simulated discharges, and (iii) to identify and understand conditions in which this technique fails to improve the forecast skill. The correction of the initial moisture deficit of the soil reservoir proves to be the most efficient control parameter for adjusting the peak discharge. Using data assimilation, this correction leads to an average of 12% improvement in the flood peak magnitude forecast in 75% of cases. The investigation of the other 25% of cases points out a number of precautions for the appropriate use of this data assimilation procedure.
Los procesos penales relacionados con la evaluación del comportamiento en casos de abuso sexual que afectan a menores incluyen, entre sus etapas más delicadas, la recopilación de las declaraciones de la joven víctima, especialmente si ésta tiene pocos años. La recopilación del testimonio de un menor debe seguir reglas y procedimientos cuyo objetivo principal es salvaguardarle. Hasta ahora, el sistema de la justicia penal italiana no proporciona un sistema orgánico para la protección de la víctima joven; por parte del legislador, faltan reglas y regulaciones específicas para el testimonio del menor. Según el artículo 196, párrafos 1 y 2 del Código de Procedimiento Penal italiano, "toda persona es competente para testificar", pero "para evaluar la declaración del testigo, el juez puede ordenar verificaciones apropiadas utilizando todos los medios legales, incluso ex oficio". Más efectivamente, el artículo 10 de la Carta de Noto recomienda, para niños menores de 12 años y demás casos excepcionales, "que siempre se realice una valoración para verificar la aptitud de la víctima para testificar sobre los asuntos", a menos que el juez pueda evaluar la fiabilidad del testimonio. Por lo tanto, ¿es posible que el juez establezca la veracidad del testimonio del menor aparte del consejo técnico de un experto, es decir, sin hacer una evaluación psicológica del niño primero? La orientación jurisprudencial prevaleciente en los últimos años confirma la prevalencia del llamado principio de la evaluación global, según el cual "en materia de delitos sexuales contra niños pequeños, es ilegal, por violación del principio de la formación de pruebas en contradictorio, la negativa del juez a organizar un examen psicológico, a fin de determinar la adherencia a la realidad o no de la narración de los hechos, dependiendo de posibles elaboraciones imaginarias de la edad o de la estructura personológica del menor". ; Criminal proceedings concerning the assessment of sexual abusive behaviour affecting minors includes, among its most delicate stages, the collection of the young victim's statements, especially if the victims are in their earliest years. The collection of a minor's testimony must follow rules and procedures whose main goal is to safeguard the minor. Up to now, Italian Criminal Justice System does not provide an organic system for the young victim's protection; on the part of the legislator, there is a lack of specific rules and regolations for the minor's testimony. According to Article 196, paragraph 1 and 2 of the Italian Code of Criminal Procedures, "every person is competent to testify", but "in order to evaluate the witness' statement, the judge can order appropriate verifications using all lawful means, even ex oficio". More effectively, Article 10 of the Carta of Noto recommend, for children under 12 and apart from exceptional cases, "that a valuation must always occur in order to verify the victim's fitness to testify about the matters", unless the judge can evaluate the reliability of the testimony. Therefore, is it possible for the judge to establish the truthfulness of the minor's testimony apart from a technical advice of an expert, that is without making a psychological evaluation of the child first? The prevailing jurisprudential orientation in recent years confirms the prevalence of the so-called principle of the all-encompassing evaluation, whereby "on the subject of sexual offenses against young children, it is illegal, for violation of the principle of the formation of evidence in contradictory, the refusal of judge to arrange a psychological examination, in order to ascertain the adherence to the reality or not of the narration of the facts, depending on possible fanciful elaborations of the age or of the personological structure of the minor". ; Nei procedimenti penali aventi ad oggetto l'accertamento della condotta di abuso sessuale a danno di minore, fra le fasi più delicate, vi è quella inerente l'acquisizione delle dichiarazioni della giovane vittima specie se in tenera età. E' pacifico che l'assunzione della testimonianza di un minore, perché tale, deve avvenire con criteri e modalità che abbiano quale obiettivo principale, quello della tutela del minore stesso. Il sistema penale italiano a tutt'oggi rileva l'assenza di un organico sistema di protezione del minore vittima di abusi; manca una specifica disciplina da parte del legislatore, della testimonianza del soggetto minore di età. Secondo quanto disposto dall'art. 196, comma 1 e 2 c.p.p. "Ogni persona ha la capacità di testimoniare" tuttavia "qualora, al fine di valutare le dichiarazioni del testimone, sia necessario verificarne l'idoneità fisica o mentale a rendere testimonianza, il giudice anche di ufficio può ordinare gli accertamenti opportuni con i mezzi consentiti dalla legge". Più efficacemente la Carta di Noto all'art. 10 raccomanda per i minori di anni dodici e salvo casi eccezionali "che sia sempre disposta perizia al fine di verificarne la idoneità a testimoniare sui fatti oggetto d'indagine", salvo al giudice valutare l'attendibilità della testimonianza resa. E' possibile allora per il decidente, accertare la veridicità della condotta abusante dal racconto del minore, prescindendo dall'ausilio del parere tecnico di un perito, ovvero senza aver prima disposto una perizia psicologica sul bambino? L'orientamento giurisprudenziale prevalente negli ultimi anni, conferma il prevalere del principio cosiddetto della valutazione onnicomprensiva, per cui "in tema di reati sessuali su minori in tenera età, è illegittimo, per violazione del principio della formazione della prova in contraddittorio, il rifiuto dei giudice di disporre una perizia psicologica, al fine di accertare l'aderenza alla realtà o meno della narrazione dei fatti, in dipendenza di eventuali elaborazioni fantasiose proprie dell'età o della struttura personologica del minore". ; peerReviewed
Background Healthy life expectancy (HALE) and disability-adjusted life-years (DALYs) provide summary measures of health across geographies and time that can inform assessments of epidemiological patterns and health system performance, help to prioritise investments in research and development, and monitor progress toward the Sustainable Development Goals (SDGs). We aimed to provide updated HALE and DALYs for geographies worldwide and evaluate how disease burden changes with development. Methods We used results from the Global Burden of Diseases, Injuries, and Risk Factors Study 2015 (GBD 2015) for all-cause mortality, cause-specific mortality, and non-fatal disease burden to derive HALE and DALYs by sex for 195 countries and territories from 1990 to 2015. We calculated DALYs by summing years of life lost (YLLs) and years of life lived with disability (YLDs) for each geography, age group, sex, and year. We estimated HALE using the Sullivan method, which draws from age-specific death rates and YLDs per capita. We then assessed how observed levels of DALYs and HALE differed from expected trends calculated with the Socio-demographic Index (SDI), a composite indicator constructed from measures of income per capita, average years of schooling, and total fertility rate. Findings Total global DALYs remained largely unchanged from 1990 to 2015, with decreases in communicable, neonatal, maternal, and nutritional (Group 1) disease DALYs offset by increased DALYs due to non-communicable diseases (NCDs). Much of this epidemiological transition was caused by changes in population growth and ageing, but it was accelerated by widespread improvements in SDI that also correlated strongly with the increasing importance of NCDs. Both total DALYs and age-standardised DALY rates due to most Group 1 causes significantly decreased by 2015, and although total burden climbed for the majority of NCDs, age-standardised DALY rates due to NCDs declined. Nonetheless, age-standardised DALY rates due to several high-burden NCDs (including osteoarthritis, drug use disorders, depression, diabetes, congenital birth defects, and skin, oral, and sense organ diseases) either increased or remained unchanged, leading to increases in their relative ranking in many geographies. From 2005 to 2015, HALE at birth increased by an average of 2·9 years (95% uncertainty interval 2·9–3·0) for men and 3·5 years (3·4–3·7) for women, while HALE at age 65 years improved by 0·85 years (0·78–0·92) and 1·2 years (1·1–1·3), respectively. Rising SDI was associated with consistently higher HALE and a somewhat smaller proportion of life spent with functional health loss; however, rising SDI was related to increases in total disability. Many countries and territories in central America and eastern sub-Saharan Africa had increasingly lower rates of disease burden than expected given their SDI. At the same time, a subset of geographies recorded a growing gap between observed and expected levels of DALYs, a trend driven mainly by rising burden due to war, interpersonal violence, and various NCDs. Interpretation Health is improving globally, but this means more populations are spending more time with functional health loss, an absolute expansion of morbidity. The proportion of life spent in ill health decreases somewhat with increasing SDI, a relative compression of morbidity, which supports continued efforts to elevate personal income, improve education, and limit fertility. Our analysis of DALYs and HALE and their relationship to SDI represents a robust framework on which to benchmark geography-specific health performance and SDG progress. Country-specific drivers of disease burden, particularly for causes with higher-than-expected DALYs, should inform financial and research investments, prevention efforts, health policies, and health system improvement initiatives for all countries along the development continuum. Funding Bill & Melinda Gates Foundation. ; We would like to thank the countless individuals who have contributed to the Global Burden of Disease Study 2015 in various capacities. The data reported here have been supplied by the US Renal Data System (USRDS). Data for this research was provided by MEASURE Evaluation, funded by the United States Agency for International Development (USAID). Collection of these data was made possible by the US Agency for International Development (USAID) under the terms of cooperative agreement GPO-A-00-08-000_D3-00. Views expressed do not necessarily reflect those of USAID, the US Government, or MEASURE Evaluation. Parts of this material are based on data and information provided by the Canadian institute for Health Information. However, the analyses, conclusions, opinions and statements expressed herein are those of the author and not those of the Canadian Institute for Health information. The Palestinian Central Bureau of Statistics granted the researchers access to relevant data in accordance with license no SLN2014-3-170, after subjecting data to processing aiming to preserve the confidentiality of individual data in accordance with the General Statistics Law, 2000. The researchers are solely responsible for the conclusions and inferences drawn upon available data. This paper uses data from SHARE Waves 1, 2, 3 (SHARELIFE), 4 and 5 (DOIs: 10.6103/SHARE.w1.500, 10.6103/SHARE.w2.500, 10.6103/SHARE.w3.500, 10.6103/SHARE.w4.500, 10.6103/SHARE.w5.500), see Börsch-Supan and colleagues, 2013, for methodological details. The SHARE data collection has been primarily funded by the European Commission through FP5 (QLK6-CT-2001-00360), FP6 (SHARE-I3: RII-CT-2006-062193, COMPARE: CIT5-CT-2005-028857, SHARELIFE: CIT4-CT-2006-028812) and FP7 (SHARE-PREP: number 211909, SHARE-LEAP: number 227822, SHARE M4: number 261982). Additional funding from the German Ministry of Education and Research, the US National Institute on Aging (U01_AG09740-13S2, P01_AG005842, P01_AG08291, P30_AG12815, R21_AG025169, Y1-AG-4553-01, IAG_BSR06-11, and OGHA_04-064) and from various national funding sources is gratefully acknowledged. This study has been realised using the data collected by the Swiss Household Panel (SHP), which is based at the Swiss Centre of Expertise in the Social Sciences FORS. The project is financed by the Swiss National Science Foundation. The following individuals would like to acknowledge various forms of institutional support: Simon I Hay is funded by a Senior Research Fellowship from the Wellcome Trust (#095066), and grants from the Bill & Melinda Gates Foundation (OPP1119467, OPP1093011, OPP1106023 and OPP1132415). Amanda G Thrift is supported by a fellowship from the National Health and Medical Research Council (GNT1042600). Panniyammakal Jeemon is supported by the Wellcome Trust-DBT India Alliance, Clinical and Public Health, Intermediate Fellowship (2015–2020). Boris Bikbov, Norberto Percio, and Giuseppe Remuzzi acknowledge that work related to this paper has been done on the behalf of the GBD Genitourinary Disease Expert Group supported by the International Society of Nephrology (ISN). Amador Goodridge acknowledges funding from Sistema Nacional de Investigadores de Panamá-SNI. José das Neves was supported in his contribution to this work by a Fellowship from Fundação para a Ciência e a Tecnologia, Portugal (SFRH/BPD/92934/2013). Lijing L Yan is supported by the National Natural Sciences Foundation of China grants (71233001 and 71490732). Olanrewaju Oladimeji is an African Research Fellow at Human Sciences Research Council (HSRC) and Doctoral Candidate at the University of KwaZulu-Natal (UKZN), South Africa, and would like to acknowledge the institutional support by leveraging on the existing organisational research infrastructure at HSRC and UKZN. Nicholas Steel received funding from Public Health England as a Visiting Scholar in the Institute for Health Metrics and Evaluation in 2016. No individuals acknowledged received additional compensation for their efforts. ; Peer-reviewed ; Publisher Version
Background Improving survival and extending the longevity of life for all populations requires timely, robust evidence on local mortality levels and trends. The Global Burden of Disease 2015 Study (GBD 2015) provides a comprehensive assessment of all-cause and cause-specific mortality for 249 causes in 195 countries and territories from 1980 to 2015. These results informed an in-depth investigation of observed and expected mortality patterns based on sociodemographic measures. Methods We estimated all-cause mortality by age, sex, geography, and year using an improved analytical approach originally developed for GBD 2013 and GBD 2010. Improvements included refinements to the estimation of child and adult mortality and corresponding uncertainty, parameter selection for under-5 mortality synthesis by spatiotemporal Gaussian process regression, and sibling history data processing. We also expanded the database of vital registration, survey, and census data to 14 294 geography–year datapoints. For GBD 2015, eight causes, including Ebola virus disease, were added to the previous GBD cause list for mortality. We used six modelling approaches to assess cause-specific mortality, with the Cause of Death Ensemble Model (CODEm) generating estimates for most causes. We used a series of novel analyses to systematically quantify the drivers of trends in mortality across geographies. First, we assessed observed and expected levels and trends of cause-specific mortality as they relate to the Socio-demographic Index (SDI), a summary indicator derived from measures of income per capita, educational attainment, and fertility. Second, we examined factors affecting total mortality patterns through a series of counterfactual scenarios, testing the magnitude by which population growth, population age structures, and epidemiological changes contributed to shifts in mortality. Finally, we attributed changes in life expectancy to changes in cause of death. We documented each step of the GBD 2015 estimation processes, as well as data sources, in accordance with Guidelines for Accurate and Transparent Health Estimates Reporting (GATHER). Findings Globally, life expectancy from birth increased from 61·7 years (95% uncertainty interval 61·4–61·9) in 1980 to 71·8 years (71·5–72·2) in 2015. Several countries in sub-Saharan Africa had very large gains in life expectancy from 2005 to 2015, rebounding from an era of exceedingly high loss of life due to HIV/AIDS. At the same time, many geographies saw life expectancy stagnate or decline, particularly for men and in countries with rising mortality from war or interpersonal violence. From 2005 to 2015, male life expectancy in Syria dropped by 11·3 years (3·7–17·4), to 62·6 years (56·5–70·2). Total deaths increased by 4·1% (2·6–5·6) from 2005 to 2015, rising to 55·8 million (54·9 million to 56·6 million) in 2015, but age-standardised death rates fell by 17·0% (15·8–18·1) during this time, underscoring changes in population growth and shifts in global age structures. The result was similar for non-communicable diseases (NCDs), with total deaths from these causes increasing by 14·1% (12·6–16·0) to 39·8 million (39·2 million to 40·5 million) in 2015, whereas age-standardised rates decreased by 13·1% (11·9–14·3). Globally, this mortality pattern emerged for several NCDs, including several types of cancer, ischaemic heart disease, cirrhosis, and Alzheimer's disease and other dementias. By contrast, both total deaths and age-standardised death rates due to communicable, maternal, neonatal, and nutritional conditions significantly declined from 2005 to 2015, gains largely attributable to decreases in mortality rates due to HIV/AIDS (42·1%, 39·1–44·6), malaria (43·1%, 34·7–51·8), neonatal preterm birth complications (29·8%, 24·8–34·9), and maternal disorders (29·1%, 19·3–37·1). Progress was slower for several causes, such as lower respiratory infections and nutritional deficiencies, whereas deaths increased for others, including dengue and drug use disorders. Age-standardised death rates due to injuries significantly declined from 2005 to 2015, yet interpersonal violence and war claimed increasingly more lives in some regions, particularly in the Middle East. In 2015, rotaviral enteritis (rotavirus) was the leading cause of under-5 deaths due to diarrhoea (146 000 deaths, 118 000–183 000) and pneumococcal pneumonia was the leading cause of under-5 deaths due to lower respiratory infections (393 000 deaths, 228 000–532 000), although pathogen-specific mortality varied by region. Globally, the effects of population growth, ageing, and changes in age-standardised death rates substantially differed by cause. Our analyses on the expected associations between cause-specific mortality and SDI show the regular shifts in cause of death composition and population age structure with rising SDI. Country patterns of premature mortality (measured as years of life lost [YLLs]) and how they differ from the level expected on the basis of SDI alone revealed distinct but highly heterogeneous patterns by region and country or territory. Ischaemic heart disease, stroke, and diabetes were among the leading causes of YLLs in most regions, but in many cases, intraregional results sharply diverged for ratios of observed and expected YLLs based on SDI. Communicable, maternal, neonatal, and nutritional diseases caused the most YLLs throughout sub-Saharan Africa, with observed YLLs far exceeding expected YLLs for countries in which malaria or HIV/AIDS remained the leading causes of early death. Interpretation At the global scale, age-specific mortality has steadily improved over the past 35 years; this pattern of general progress continued in the past decade. Progress has been faster in most countries than expected on the basis of development measured by the SDI. Against this background of progress, some countries have seen falls in life expectancy, and age-standardised death rates for some causes are increasing. Despite progress in reducing age-standardised death rates, population growth and ageing mean that the number of deaths from most non-communicable causes are increasing in most countries, putting increased demands on health systems. Funding Bill & Melinda Gates Foundation. ; We thank the countless individuals who have contributed to the Global Burden of Disease Study 2015 in various capacities. The data reported here have been supplied by the United States Renal Data System (USRDS). Data for this research was provided by MEASURE Evaluation, funded by the United States Agency for International Development (USAID). Collection of these data was made possible by USAID under the terms of cooperative agreement GPO-A-00-08-000_D3-00. Views expressed do not necessarily reflect those of USAID, the US Government, or MEASURE Evaluation. Parts of this material are based on data and information provided by the Canadian institute for Health Information. However, the analyses, conclusions, opinions and statements expressed herein are those of the author and not those of the Canadian Institute for Health information. The Palestinian Central Bureau of Statistics granted the researchers access to relevant data in accordance with licence number SLN2014-3-170, after subjecting data to processing aiming to preserve the confidentiality of individual data in accordance with the General Statistics Law–2000. The researchers are solely responsible for the conclusions and inferences drawn upon available data. The following individuals acknowledge various forms of institutional support. Simon I Hay is funded by a Senior Research Fellowship from the Wellcome Trust (#095066), and grants from the Bill & Melinda Gates Foundation (OPP1119467, OPP1093011, OPP1106023 and OPP1132415). Panniyammakal Jeemon is supported by a Clinical and Public Health Intermediate Fellowship from the Wellcome Trust-DBT India Alliance (2015–20). Luciano A Sposato is partly supported by the Edward and Alma Saraydar Neurosciences Fund, London Health Sciences Foundation, London, ON, Canada. George A Mensah notes that the views expressed in this Article are those of the authors and do not necessarily represent the views of the National Heart, Lung, and Blood Institute, National Institutes of Health, or the United States Department of Health and Human Services. Boris Bikbov acknowledges that work related to this paper has been done on the behalf of the GBD Genitourinary Disease Expert Group supported by the International Society of Nephrology (ISN). Ana Maria Nogales Vasconcelos acknowledges that her team in Brazil received funding from Ministry of Health (process number 25000192049/2014-14). Rodrigo Sarmiento-Suarez receives institutional support from Universidad de Ciencias Aplicadas y Ambientales, UDCA, Bogotá, Colombia. Ulrich O Mueller and Andrea Werdecker gratefully acknowledge funding by the German National Cohort BMBF (grant number OIER 1301/22). Peter James was supported by the National Cancer Institute of the National Institutes of Health (Award K99CA201542). Brett M Kissela would like to acknowledge NIH/NINDS R-01 30678. Louisa Degenhardt is supported by an Australian National Health and Medical Research Council Principal Research fellowship. Daisy M X Abreu received institutional support from the Brazilian Ministry of Health (Proc number 25000192049/2014-14). Jennifer H MacLachlan receives funding support from the Australian Government Department of Health and Royal Melbourne Hospital Research Funding Program. Miriam Levi acknowledges institutional support received from CeRIMP, Regional Centre for Occupational Diseases and Injuries, Tuscany Region, Florence, Italy. Tea Lallukka reports funding from The Academy of Finland (grant 287488). No individuals acknowledged received additional compensation for their efforts. ; Peer-reviewed ; Publisher Version
Background Surgery is the main modality of cure for solid cancers and was prioritised to continue during COVID-19 outbreaks. This study aimed to identify immediate areas for system strengthening by comparing the delivery of elective cancer surgery during the COVID-19 pandemic in periods of lockdown versus light restriction. Methods This international, prospective, cohort study enrolled 20 006 adult (≥18 years) patients from 466 hospitals in 61 countries with 15 cancer types, who had a decision for curative surgery during the COVID-19 pandemic and were followed up until the point of surgery or cessation of follow-up (Aug 31, 2020). Average national Oxford COVID-19 Stringency Index scores were calculated to define the government response to COVID-19 for each patient for the period they awaited surgery, and classified into light restrictions (index 60). The primary outcome was the non-operation rate (defined as the proportion of patients who did not undergo planned surgery). Cox proportional-hazards regression models were used to explore the associations between lockdowns and non-operation. Intervals from diagnosis to surgery were compared across COVID-19 government response index groups. This study was registered at ClinicalTrials.gov, NCT04384926. Findings Of eligible patients awaiting surgery, 2003 (10·0%) of 20 006 did not receive surgery after a median follow-up of 23 weeks (IQR 16–30), all of whom had a COVID-19-related reason given for non-operation. Light restrictions were associated with a 0·6% non-operation rate (26 of 4521), moderate lockdowns with a 5·5% rate (201 of 3646; adjusted hazard ratio [HR] 0·81, 95% CI 0·77–0·84; p<0·0001), and full lockdowns with a 15·0% rate (1775 of 11 827; HR 0·51, 0·50–0·53; p<0·0001). In sensitivity analyses, including adjustment for SARS-CoV-2 case notification rates, moderate lockdowns (HR 0·84, 95% CI 0·80–0·88; p<0·001), and full lockdowns (0·57, 0·54–0·60; p<0·001), remained independently associated with non-operation. Surgery beyond 12 weeks from diagnosis in patients without neoadjuvant therapy increased during lockdowns (374 [9·1%] of 4521 in light restrictions, 317 [10·4%] of 3646 in moderate lockdowns, 2001 [23·8%] of 11 827 in full lockdowns), although there were no differences in resectability rates observed with longer delays. Interpretation Cancer surgery systems worldwide were fragile to lockdowns, with one in seven patients who were in regions with full lockdowns not undergoing planned surgery and experiencing longer preoperative delays. Although short-term oncological outcomes were not compromised in those selected for surgery, delays and non-operations might lead to long-term reductions in survival. During current and future periods of societal restriction, the resilience of elective surgery systems requires strengthening, which might include protected elective surgical pathways and long-term investment in surge capacity for acute care during public health emergencies to protect elective staff and services. Funding National Institute for Health Research Global Health Research Unit, Association of Coloproctology of Great Britain and Ireland, Bowel and Cancer Research, Bowel Disease Research Foundation, Association of Upper Gastrointestinal Surgeons, British Association of Surgical Oncology, British Gynaecological Cancer Society, European Society of Coloproctology, Medtronic, Sarcoma UK, The Urology Foundation, Vascular Society for Great Britain and Ireland, and Yorkshire Cancer Research.
Background Surgery is the main modality of cure for solid cancers and was prioritised to continue during COVID-19 outbreaks. This study aimed to identify immediate areas for system strengthening by comparing the delivery of elective cancer surgery during the COVID-19 pandemic in periods of lockdown versus light restriction. Methods This international, prospective, cohort study enrolled 20 006 adult (≥18 years) patients from 466 hospitals in 61 countries with 15 cancer types, who had a decision for curative surgery during the COVID-19 pandemic and were followed up until the point of surgery or cessation of follow-up (Aug 31, 2020). Average national Oxford COVID-19 Stringency Index scores were calculated to define the government response to COVID-19 for each patient for the period they awaited surgery, and classified into light restrictions (index 60). The primary outcome was the non-operation rate (defined as the proportion of patients who did not undergo planned surgery). Cox proportional-hazards regression models were used to explore the associations between lockdowns and non-operation. Intervals from diagnosis to surgery were compared across COVID-19 government response index groups. This study was registered at ClinicalTrials.gov, NCT04384926. Findings Of eligible patients awaiting surgery, 2003 (10·0%) of 20 006 did not receive surgery after a median follow-up of 23 weeks (IQR 16–30), all of whom had a COVID-19-related reason given for non-operation. Light restrictions were associated with a 0·6% non-operation rate (26 of 4521), moderate lockdowns with a 5·5% rate (201 of 3646; adjusted hazard ratio [HR] 0·81, 95% CI 0·77–0·84; p<0·0001), and full lockdowns with a 15·0% rate (1775 of 11 827; HR 0·51, 0·50–0·53; p<0·0001). In sensitivity analyses, including adjustment for SARS-CoV-2 case notification rates, moderate lockdowns (HR 0·84, 95% CI 0·80–0·88; p<0·001), and full lockdowns (0·57, 0·54–0·60; p<0·001), remained independently associated with non-operation. Surgery beyond 12 weeks from diagnosis in patients without neoadjuvant therapy increased during lockdowns (374 [9·1%] of 4521 in light restrictions, 317 [10·4%] of 3646 in moderate lockdowns, 2001 [23·8%] of 11827 in full lockdowns), although there were no differences in resectability rates observed with longer delays. Interpretation Cancer surgery systems worldwide were fragile to lockdowns, with one in seven patients who were in regions with full lockdowns not undergoing planned surgery and experiencing longer preoperative delays. Although short-term oncological outcomes were not compromised in those selected for surgery, delays and non-operations might lead to long-term reductions in survival. During current and future periods of societal restriction, the resilience of elective surgery systems requires strengthening, which might include protected elective surgical pathways and long- term investment in surge capacity for acute care during public health emergencies to protect elective staff and services. Funding National Institute for Health Research Global Health Research Unit, Association of Coloproctology of Great Britain and Ireland, Bowel and Cancer Research, Bowel Disease Research Foundation, Association of Upper Gastrointestinal Surgeons, British Association of Surgical Oncology, British Gynaecological Cancer Society, European Society of Coloproctology, Medtronic, Sarcoma UK, The Urology Foundation, Vascular Society for Great Britain and Ireland, and Yorkshire Cancer Research.
