dissertation about covid 19

• Research article
• Open access
• Published: 04 June 2021

Coronavirus disease (COVID-19) pandemic: an overview of systematic reviews

• Israel Júnior Borges do Nascimento 1 , 2 ,
• Dónal P. O’Mathúna 3 , 4 ,
• Thilo Caspar von Groote 5 ,
• Hebatullah Mohamed Abdulazeem 6 ,
• Ishanka Weerasekara 7 , 8 ,
• Ana Marusic 9 ,
• Livia Puljak   ORCID: orcid.org/0000-0002-8467-6061 10 ,
• Vinicius Tassoni Civile 11 ,
• Irena Zakarija-Grkovic 9 ,
• Tina Poklepovic Pericic 9 ,
• Alvaro Nagib Atallah 11 ,
• Santino Filoso 12 ,
• Nicola Luigi Bragazzi 13 &
• Milena Soriano Marcolino 1

On behalf of the International Network of Coronavirus Disease 2019 (InterNetCOVID-19)

BMC Infectious Diseases volume  21 , Article number:  525 ( 2021 ) Cite this article

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Navigating the rapidly growing body of scientific literature on the SARS-CoV-2 pandemic is challenging, and ongoing critical appraisal of this output is essential. We aimed to summarize and critically appraise systematic reviews of coronavirus disease (COVID-19) in humans that were available at the beginning of the pandemic.

Nine databases (Medline, EMBASE, Cochrane Library, CINAHL, Web of Sciences, PDQ-Evidence, WHO’s Global Research, LILACS, and Epistemonikos) were searched from December 1, 2019, to March 24, 2020. Systematic reviews analyzing primary studies of COVID-19 were included. Two authors independently undertook screening, selection, extraction (data on clinical symptoms, prevalence, pharmacological and non-pharmacological interventions, diagnostic test assessment, laboratory, and radiological findings), and quality assessment (AMSTAR 2). A meta-analysis was performed of the prevalence of clinical outcomes.

Eighteen systematic reviews were included; one was empty (did not identify any relevant study). Using AMSTAR 2, confidence in the results of all 18 reviews was rated as “critically low”. Identified symptoms of COVID-19 were (range values of point estimates): fever (82–95%), cough with or without sputum (58–72%), dyspnea (26–59%), myalgia or muscle fatigue (29–51%), sore throat (10–13%), headache (8–12%) and gastrointestinal complaints (5–9%). Severe symptoms were more common in men. Elevated C-reactive protein and lactate dehydrogenase, and slightly elevated aspartate and alanine aminotransferase, were commonly described. Thrombocytopenia and elevated levels of procalcitonin and cardiac troponin I were associated with severe disease. A frequent finding on chest imaging was uni- or bilateral multilobar ground-glass opacity. A single review investigated the impact of medication (chloroquine) but found no verifiable clinical data. All-cause mortality ranged from 0.3 to 13.9%.

Conclusions

In this overview of systematic reviews, we analyzed evidence from the first 18 systematic reviews that were published after the emergence of COVID-19. However, confidence in the results of all reviews was “critically low”. Thus, systematic reviews that were published early on in the pandemic were of questionable usefulness. Even during public health emergencies, studies and systematic reviews should adhere to established methodological standards.

Peer Review reports

The spread of the “Severe Acute Respiratory Coronavirus 2” (SARS-CoV-2), the causal agent of COVID-19, was characterized as a pandemic by the World Health Organization (WHO) in March 2020 and has triggered an international public health emergency [ 1 ]. The numbers of confirmed cases and deaths due to COVID-19 are rapidly escalating, counting in millions [ 2 ], causing massive economic strain, and escalating healthcare and public health expenses [ 3 , 4 ].

The research community has responded by publishing an impressive number of scientific reports related to COVID-19. The world was alerted to the new disease at the beginning of 2020 [ 1 ], and by mid-March 2020, more than 2000 articles had been published on COVID-19 in scholarly journals, with 25% of them containing original data [ 5 ]. The living map of COVID-19 evidence, curated by the Evidence for Policy and Practice Information and Co-ordinating Centre (EPPI-Centre), contained more than 40,000 records by February 2021 [ 6 ]. More than 100,000 records on PubMed were labeled as “SARS-CoV-2 literature, sequence, and clinical content” by February 2021 [ 7 ].

Due to publication speed, the research community has voiced concerns regarding the quality and reproducibility of evidence produced during the COVID-19 pandemic, warning of the potential damaging approach of “publish first, retract later” [ 8 ]. It appears that these concerns are not unfounded, as it has been reported that COVID-19 articles were overrepresented in the pool of retracted articles in 2020 [ 9 ]. These concerns about inadequate evidence are of major importance because they can lead to poor clinical practice and inappropriate policies [ 10 ].

Systematic reviews are a cornerstone of today’s evidence-informed decision-making. By synthesizing all relevant evidence regarding a particular topic, systematic reviews reflect the current scientific knowledge. Systematic reviews are considered to be at the highest level in the hierarchy of evidence and should be used to make informed decisions. However, with high numbers of systematic reviews of different scope and methodological quality being published, overviews of multiple systematic reviews that assess their methodological quality are essential [ 11 , 12 , 13 ]. An overview of systematic reviews helps identify and organize the literature and highlights areas of priority in decision-making.

In this overview of systematic reviews, we aimed to summarize and critically appraise systematic reviews of coronavirus disease (COVID-19) in humans that were available at the beginning of the pandemic.

Methodology

Research question.

This overview’s primary objective was to summarize and critically appraise systematic reviews that assessed any type of primary clinical data from patients infected with SARS-CoV-2. Our research question was purposefully broad because we wanted to analyze as many systematic reviews as possible that were available early following the COVID-19 outbreak.

Study design

We conducted an overview of systematic reviews. The idea for this overview originated in a protocol for a systematic review submitted to PROSPERO (CRD42020170623), which indicated a plan to conduct an overview.

Overviews of systematic reviews use explicit and systematic methods for searching and identifying multiple systematic reviews addressing related research questions in the same field to extract and analyze evidence across important outcomes. Overviews of systematic reviews are in principle similar to systematic reviews of interventions, but the unit of analysis is a systematic review [ 14 , 15 , 16 ].

We used the overview methodology instead of other evidence synthesis methods to allow us to collate and appraise multiple systematic reviews on this topic, and to extract and analyze their results across relevant topics [ 17 ]. The overview and meta-analysis of systematic reviews allowed us to investigate the methodological quality of included studies, summarize results, and identify specific areas of available or limited evidence, thereby strengthening the current understanding of this novel disease and guiding future research [ 13 ].

A reporting guideline for overviews of reviews is currently under development, i.e., Preferred Reporting Items for Overviews of Reviews (PRIOR) [ 18 ]. As the PRIOR checklist is still not published, this study was reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2009 statement [ 19 ]. The methodology used in this review was adapted from the Cochrane Handbook for Systematic Reviews of Interventions and also followed established methodological considerations for analyzing existing systematic reviews [ 14 ].

Approval of a research ethics committee was not necessary as the study analyzed only publicly available articles.

Eligibility criteria

Systematic reviews were included if they analyzed primary data from patients infected with SARS-CoV-2 as confirmed by RT-PCR or another pre-specified diagnostic technique. Eligible reviews covered all topics related to COVID-19 including, but not limited to, those that reported clinical symptoms, diagnostic methods, therapeutic interventions, laboratory findings, or radiological results. Both full manuscripts and abbreviated versions, such as letters, were eligible.

No restrictions were imposed on the design of the primary studies included within the systematic reviews, the last search date, whether the review included meta-analyses or language. Reviews related to SARS-CoV-2 and other coronaviruses were eligible, but from those reviews, we analyzed only data related to SARS-CoV-2.

No consensus definition exists for a systematic review [ 20 ], and debates continue about the defining characteristics of a systematic review [ 21 ]. Cochrane’s guidance for overviews of reviews recommends setting pre-established criteria for making decisions around inclusion [ 14 ]. That is supported by a recent scoping review about guidance for overviews of systematic reviews [ 22 ].

Thus, for this study, we defined a systematic review as a research report which searched for primary research studies on a specific topic using an explicit search strategy, had a detailed description of the methods with explicit inclusion criteria provided, and provided a summary of the included studies either in narrative or quantitative format (such as a meta-analysis). Cochrane and non-Cochrane systematic reviews were considered eligible for inclusion, with or without meta-analysis, and regardless of the study design, language restriction and methodology of the included primary studies. To be eligible for inclusion, reviews had to be clearly analyzing data related to SARS-CoV-2 (associated or not with other viruses). We excluded narrative reviews without those characteristics as these are less likely to be replicable and are more prone to bias.

Scoping reviews and rapid reviews were eligible for inclusion in this overview if they met our pre-defined inclusion criteria noted above. We included reviews that addressed SARS-CoV-2 and other coronaviruses if they reported separate data regarding SARS-CoV-2.

Information sources

Nine databases were searched for eligible records published between December 1, 2019, and March 24, 2020: Cochrane Database of Systematic Reviews via Cochrane Library, PubMed, EMBASE, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Web of Sciences, LILACS (Latin American and Caribbean Health Sciences Literature), PDQ-Evidence, WHO’s Global Research on Coronavirus Disease (COVID-19), and Epistemonikos.

The comprehensive search strategy for each database is provided in Additional file 1 and was designed and conducted in collaboration with an information specialist. All retrieved records were primarily processed in EndNote, where duplicates were removed, and records were then imported into the Covidence platform [ 23 ]. In addition to database searches, we screened reference lists of reviews included after screening records retrieved via databases.

Study selection

All searches, screening of titles and abstracts, and record selection, were performed independently by two investigators using the Covidence platform [ 23 ]. Articles deemed potentially eligible were retrieved for full-text screening carried out independently by two investigators. Discrepancies at all stages were resolved by consensus. During the screening, records published in languages other than English were translated by a native/fluent speaker.

Data collection process

We custom designed a data extraction table for this study, which was piloted by two authors independently. Data extraction was performed independently by two authors. Conflicts were resolved by consensus or by consulting a third researcher.

We extracted the following data: article identification data (authors’ name and journal of publication), search period, number of databases searched, population or settings considered, main results and outcomes observed, and number of participants. From Web of Science (Clarivate Analytics, Philadelphia, PA, USA), we extracted journal rank (quartile) and Journal Impact Factor (JIF).

We categorized the following as primary outcomes: all-cause mortality, need for and length of mechanical ventilation, length of hospitalization (in days), admission to intensive care unit (yes/no), and length of stay in the intensive care unit.

The following outcomes were categorized as exploratory: diagnostic methods used for detection of the virus, male to female ratio, clinical symptoms, pharmacological and non-pharmacological interventions, laboratory findings (full blood count, liver enzymes, C-reactive protein, d-dimer, albumin, lipid profile, serum electrolytes, blood vitamin levels, glucose levels, and any other important biomarkers), and radiological findings (using radiography, computed tomography, magnetic resonance imaging or ultrasound).

We also collected data on reporting guidelines and requirements for the publication of systematic reviews and meta-analyses from journal websites where included reviews were published.

Quality assessment in individual reviews

Two researchers independently assessed the reviews’ quality using the “A MeaSurement Tool to Assess Systematic Reviews 2 (AMSTAR 2)”. We acknowledge that the AMSTAR 2 was created as “a critical appraisal tool for systematic reviews that include randomized or non-randomized studies of healthcare interventions, or both” [ 24 ]. However, since AMSTAR 2 was designed for systematic reviews of intervention trials, and we included additional types of systematic reviews, we adjusted some AMSTAR 2 ratings and reported these in Additional file 2 .

Adherence to each item was rated as follows: yes, partial yes, no, or not applicable (such as when a meta-analysis was not conducted). The overall confidence in the results of the review is rated as “critically low”, “low”, “moderate” or “high”, according to the AMSTAR 2 guidance based on seven critical domains, which are items 2, 4, 7, 9, 11, 13, 15 as defined by AMSTAR 2 authors [ 24 ]. We reported our adherence ratings for transparency of our decision with accompanying explanations, for each item, in each included review.

One of the included systematic reviews was conducted by some members of this author team [ 25 ]. This review was initially assessed independently by two authors who were not co-authors of that review to prevent the risk of bias in assessing this study.

Synthesis of results

For data synthesis, we prepared a table summarizing each systematic review. Graphs illustrating the mortality rate and clinical symptoms were created. We then prepared a narrative summary of the methods, findings, study strengths, and limitations.

For analysis of the prevalence of clinical outcomes, we extracted data on the number of events and the total number of patients to perform proportional meta-analysis using RStudio© software, with the “meta” package (version 4.9–6), using the “metaprop” function for reviews that did not perform a meta-analysis, excluding case studies because of the absence of variance. For reviews that did not perform a meta-analysis, we presented pooled results of proportions with their respective confidence intervals (95%) by the inverse variance method with a random-effects model, using the DerSimonian-Laird estimator for τ 2 . We adjusted data using Freeman-Tukey double arcosen transformation. Confidence intervals were calculated using the Clopper-Pearson method for individual studies. We created forest plots using the RStudio© software, with the “metafor” package (version 2.1–0) and “forest” function.

Managing overlapping systematic reviews

Some of the included systematic reviews that address the same or similar research questions may include the same primary studies in overviews. Including such overlapping reviews may introduce bias when outcome data from the same primary study are included in the analyses of an overview multiple times. Thus, in summaries of evidence, multiple-counting of the same outcome data will give data from some primary studies too much influence [ 14 ]. In this overview, we did not exclude overlapping systematic reviews because, according to Cochrane’s guidance, it may be appropriate to include all relevant reviews’ results if the purpose of the overview is to present and describe the current body of evidence on a topic [ 14 ]. To avoid any bias in summary estimates associated with overlapping reviews, we generated forest plots showing data from individual systematic reviews, but the results were not pooled because some primary studies were included in multiple reviews.

Our search retrieved 1063 publications, of which 175 were duplicates. Most publications were excluded after the title and abstract analysis ( n = 860). Among the 28 studies selected for full-text screening, 10 were excluded for the reasons described in Additional file 3 , and 18 were included in the final analysis (Fig. 1 ) [ 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 ]. Reference list screening did not retrieve any additional systematic reviews.

PRISMA flow diagram

Characteristics of included reviews

Summary features of 18 systematic reviews are presented in Table 1 . They were published in 14 different journals. Only four of these journals had specific requirements for systematic reviews (with or without meta-analysis): European Journal of Internal Medicine, Journal of Clinical Medicine, Ultrasound in Obstetrics and Gynecology, and Clinical Research in Cardiology . Two journals reported that they published only invited reviews ( Journal of Medical Virology and Clinica Chimica Acta ). Three systematic reviews in our study were published as letters; one was labeled as a scoping review and another as a rapid review (Table 2 ).

All reviews were published in English, in first quartile (Q1) journals, with JIF ranging from 1.692 to 6.062. One review was empty, meaning that its search did not identify any relevant studies; i.e., no primary studies were included [ 36 ]. The remaining 17 reviews included 269 unique studies; the majority ( N = 211; 78%) were included in only a single review included in our study (range: 1 to 12). Primary studies included in the reviews were published between December 2019 and March 18, 2020, and comprised case reports, case series, cohorts, and other observational studies. We found only one review that included randomized clinical trials [ 38 ]. In the included reviews, systematic literature searches were performed from 2019 (entire year) up to March 9, 2020. Ten systematic reviews included meta-analyses. The list of primary studies found in the included systematic reviews is shown in Additional file 4 , as well as the number of reviews in which each primary study was included.

Population and study designs

Most of the reviews analyzed data from patients with COVID-19 who developed pneumonia, acute respiratory distress syndrome (ARDS), or any other correlated complication. One review aimed to evaluate the effectiveness of using surgical masks on preventing transmission of the virus [ 36 ], one review was focused on pediatric patients [ 34 ], and one review investigated COVID-19 in pregnant women [ 37 ]. Most reviews assessed clinical symptoms, laboratory findings, or radiological results.

Systematic review findings

The summary of findings from individual reviews is shown in Table 2 . Overall, all-cause mortality ranged from 0.3 to 13.9% (Fig. 2 ).

A meta-analysis of the prevalence of mortality

Clinical symptoms

Seven reviews described the main clinical manifestations of COVID-19 [ 26 , 28 , 29 , 34 , 35 , 39 , 41 ]. Three of them provided only a narrative discussion of symptoms [ 26 , 34 , 35 ]. In the reviews that performed a statistical analysis of the incidence of different clinical symptoms, symptoms in patients with COVID-19 were (range values of point estimates): fever (82–95%), cough with or without sputum (58–72%), dyspnea (26–59%), myalgia or muscle fatigue (29–51%), sore throat (10–13%), headache (8–12%), gastrointestinal disorders, such as diarrhea, nausea or vomiting (5.0–9.0%), and others (including, in one study only: dizziness 12.1%) (Figs. 3 , 4 , 5 , 6 , 7 , 8 and 9 ). Three reviews assessed cough with and without sputum together; only one review assessed sputum production itself (28.5%).

A meta-analysis of the prevalence of fever

A meta-analysis of the prevalence of cough

A meta-analysis of the prevalence of dyspnea

A meta-analysis of the prevalence of fatigue or myalgia

A meta-analysis of the prevalence of headache

A meta-analysis of the prevalence of gastrointestinal disorders

A meta-analysis of the prevalence of sore throat

Diagnostic aspects

Three reviews described methodologies, protocols, and tools used for establishing the diagnosis of COVID-19 [ 26 , 34 , 38 ]. The use of respiratory swabs (nasal or pharyngeal) or blood specimens to assess the presence of SARS-CoV-2 nucleic acid using RT-PCR assays was the most commonly used diagnostic method mentioned in the included studies. These diagnostic tests have been widely used, but their precise sensitivity and specificity remain unknown. One review included a Chinese study with clinical diagnosis with no confirmation of SARS-CoV-2 infection (patients were diagnosed with COVID-19 if they presented with at least two symptoms suggestive of COVID-19, together with laboratory and chest radiography abnormalities) [ 34 ].

Therapeutic possibilities

Pharmacological and non-pharmacological interventions (supportive therapies) used in treating patients with COVID-19 were reported in five reviews [ 25 , 27 , 34 , 35 , 38 ]. Antivirals used empirically for COVID-19 treatment were reported in seven reviews [ 25 , 27 , 34 , 35 , 37 , 38 , 41 ]; most commonly used were protease inhibitors (lopinavir, ritonavir, darunavir), nucleoside reverse transcriptase inhibitor (tenofovir), nucleotide analogs (remdesivir, galidesivir, ganciclovir), and neuraminidase inhibitors (oseltamivir). Umifenovir, a membrane fusion inhibitor, was investigated in two studies [ 25 , 35 ]. Possible supportive interventions analyzed were different types of oxygen supplementation and breathing support (invasive or non-invasive ventilation) [ 25 ]. The use of antibiotics, both empirically and to treat secondary pneumonia, was reported in six studies [ 25 , 26 , 27 , 34 , 35 , 38 ]. One review specifically assessed evidence on the efficacy and safety of the anti-malaria drug chloroquine [ 27 ]. It identified 23 ongoing trials investigating the potential of chloroquine as a therapeutic option for COVID-19, but no verifiable clinical outcomes data. The use of mesenchymal stem cells, antifungals, and glucocorticoids were described in four reviews [ 25 , 34 , 35 , 38 ].

Laboratory and radiological findings

Of the 18 reviews included in this overview, eight analyzed laboratory parameters in patients with COVID-19 [ 25 , 29 , 30 , 32 , 33 , 34 , 35 , 39 ]; elevated C-reactive protein levels, associated with lymphocytopenia, elevated lactate dehydrogenase, as well as slightly elevated aspartate and alanine aminotransferase (AST, ALT) were commonly described in those eight reviews. Lippi et al. assessed cardiac troponin I (cTnI) [ 25 ], procalcitonin [ 32 ], and platelet count [ 33 ] in COVID-19 patients. Elevated levels of procalcitonin [ 32 ] and cTnI [ 30 ] were more likely to be associated with a severe disease course (requiring intensive care unit admission and intubation). Furthermore, thrombocytopenia was frequently observed in patients with complicated COVID-19 infections [ 33 ].

Chest imaging (chest radiography and/or computed tomography) features were assessed in six reviews, all of which described a frequent pattern of local or bilateral multilobar ground-glass opacity [ 25 , 34 , 35 , 39 , 40 , 41 ]. Those six reviews showed that septal thickening, bronchiectasis, pleural and cardiac effusions, halo signs, and pneumothorax were observed in patients suffering from COVID-19.

Quality of evidence in individual systematic reviews

Table 3 shows the detailed results of the quality assessment of 18 systematic reviews, including the assessment of individual items and summary assessment. A detailed explanation for each decision in each review is available in Additional file 5 .

Using AMSTAR 2 criteria, confidence in the results of all 18 reviews was rated as “critically low” (Table 3 ). Common methodological drawbacks were: omission of prospective protocol submission or publication; use of inappropriate search strategy: lack of independent and dual literature screening and data-extraction (or methodology unclear); absence of an explanation for heterogeneity among the studies included; lack of reasons for study exclusion (or rationale unclear).

Risk of bias assessment, based on a reported methodological tool, and quality of evidence appraisal, in line with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) method, were reported only in one review [ 25 ]. Five reviews presented a table summarizing bias, using various risk of bias tools [ 25 , 29 , 39 , 40 , 41 ]. One review analyzed “study quality” [ 37 ]. One review mentioned the risk of bias assessment in the methodology but did not provide any related analysis [ 28 ].

This overview of systematic reviews analyzed the first 18 systematic reviews published after the onset of the COVID-19 pandemic, up to March 24, 2020, with primary studies involving more than 60,000 patients. Using AMSTAR-2, we judged that our confidence in all those reviews was “critically low”. Ten reviews included meta-analyses. The reviews presented data on clinical manifestations, laboratory and radiological findings, and interventions. We found no systematic reviews on the utility of diagnostic tests.

Symptoms were reported in seven reviews; most of the patients had a fever, cough, dyspnea, myalgia or muscle fatigue, and gastrointestinal disorders such as diarrhea, nausea, or vomiting. Olfactory dysfunction (anosmia or dysosmia) has been described in patients infected with COVID-19 [ 43 ]; however, this was not reported in any of the reviews included in this overview. During the SARS outbreak in 2002, there were reports of impairment of the sense of smell associated with the disease [ 44 , 45 ].

The reported mortality rates ranged from 0.3 to 14% in the included reviews. Mortality estimates are influenced by the transmissibility rate (basic reproduction number), availability of diagnostic tools, notification policies, asymptomatic presentations of the disease, resources for disease prevention and control, and treatment facilities; variability in the mortality rate fits the pattern of emerging infectious diseases [ 46 ]. Furthermore, the reported cases did not consider asymptomatic cases, mild cases where individuals have not sought medical treatment, and the fact that many countries had limited access to diagnostic tests or have implemented testing policies later than the others. Considering the lack of reviews assessing diagnostic testing (sensitivity, specificity, and predictive values of RT-PCT or immunoglobulin tests), and the preponderance of studies that assessed only symptomatic individuals, considerable imprecision around the calculated mortality rates existed in the early stage of the COVID-19 pandemic.

Few reviews included treatment data. Those reviews described studies considered to be at a very low level of evidence: usually small, retrospective studies with very heterogeneous populations. Seven reviews analyzed laboratory parameters; those reviews could have been useful for clinicians who attend patients suspected of COVID-19 in emergency services worldwide, such as assessing which patients need to be reassessed more frequently.

All systematic reviews scored poorly on the AMSTAR 2 critical appraisal tool for systematic reviews. Most of the original studies included in the reviews were case series and case reports, impacting the quality of evidence. Such evidence has major implications for clinical practice and the use of these reviews in evidence-based practice and policy. Clinicians, patients, and policymakers can only have the highest confidence in systematic review findings if high-quality systematic review methodologies are employed. The urgent need for information during a pandemic does not justify poor quality reporting.

We acknowledge that there are numerous challenges associated with analyzing COVID-19 data during a pandemic [ 47 ]. High-quality evidence syntheses are needed for decision-making, but each type of evidence syntheses is associated with its inherent challenges.

The creation of classic systematic reviews requires considerable time and effort; with massive research output, they quickly become outdated, and preparing updated versions also requires considerable time. A recent study showed that updates of non-Cochrane systematic reviews are published a median of 5 years after the publication of the previous version [ 48 ].

Authors may register a review and then abandon it [ 49 ], but the existence of a public record that is not updated may lead other authors to believe that the review is still ongoing. A quarter of Cochrane review protocols remains unpublished as completed systematic reviews 8 years after protocol publication [ 50 ].

Rapid reviews can be used to summarize the evidence, but they involve methodological sacrifices and simplifications to produce information promptly, with inconsistent methodological approaches [ 51 ]. However, rapid reviews are justified in times of public health emergencies, and even Cochrane has resorted to publishing rapid reviews in response to the COVID-19 crisis [ 52 ]. Rapid reviews were eligible for inclusion in this overview, but only one of the 18 reviews included in this study was labeled as a rapid review.

Ideally, COVID-19 evidence would be continually summarized in a series of high-quality living systematic reviews, types of evidence synthesis defined as “ a systematic review which is continually updated, incorporating relevant new evidence as it becomes available ” [ 53 ]. However, conducting living systematic reviews requires considerable resources, calling into question the sustainability of such evidence synthesis over long periods [ 54 ].

Research reports about COVID-19 will contribute to research waste if they are poorly designed, poorly reported, or simply not necessary. In principle, systematic reviews should help reduce research waste as they usually provide recommendations for further research that is needed or may advise that sufficient evidence exists on a particular topic [ 55 ]. However, systematic reviews can also contribute to growing research waste when they are not needed, or poorly conducted and reported. Our present study clearly shows that most of the systematic reviews that were published early on in the COVID-19 pandemic could be categorized as research waste, as our confidence in their results is critically low.

Our study has some limitations. One is that for AMSTAR 2 assessment we relied on information available in publications; we did not attempt to contact study authors for clarifications or additional data. In three reviews, the methodological quality appraisal was challenging because they were published as letters, or labeled as rapid communications. As a result, various details about their review process were not included, leading to AMSTAR 2 questions being answered as “not reported”, resulting in low confidence scores. Full manuscripts might have provided additional information that could have led to higher confidence in the results. In other words, low scores could reflect incomplete reporting, not necessarily low-quality review methods. To make their review available more rapidly and more concisely, the authors may have omitted methodological details. A general issue during a crisis is that speed and completeness must be balanced. However, maintaining high standards requires proper resourcing and commitment to ensure that the users of systematic reviews can have high confidence in the results.

Furthermore, we used adjusted AMSTAR 2 scoring, as the tool was designed for critical appraisal of reviews of interventions. Some reviews may have received lower scores than actually warranted in spite of these adjustments.

Another limitation of our study may be the inclusion of multiple overlapping reviews, as some included reviews included the same primary studies. According to the Cochrane Handbook, including overlapping reviews may be appropriate when the review’s aim is “ to present and describe the current body of systematic review evidence on a topic ” [ 12 ], which was our aim. To avoid bias with summarizing evidence from overlapping reviews, we presented the forest plots without summary estimates. The forest plots serve to inform readers about the effect sizes for outcomes that were reported in each review.

Several authors from this study have contributed to one of the reviews identified [ 25 ]. To reduce the risk of any bias, two authors who did not co-author the review in question initially assessed its quality and limitations.

Finally, we note that the systematic reviews included in our overview may have had issues that our analysis did not identify because we did not analyze their primary studies to verify the accuracy of the data and information they presented. We give two examples to substantiate this possibility. Lovato et al. wrote a commentary on the review of Sun et al. [ 41 ], in which they criticized the authors’ conclusion that sore throat is rare in COVID-19 patients [ 56 ]. Lovato et al. highlighted that multiple studies included in Sun et al. did not accurately describe participants’ clinical presentations, warning that only three studies clearly reported data on sore throat [ 56 ].

In another example, Leung [ 57 ] warned about the review of Li, L.Q. et al. [ 29 ]: “ it is possible that this statistic was computed using overlapped samples, therefore some patients were double counted ”. Li et al. responded to Leung that it is uncertain whether the data overlapped, as they used data from published articles and did not have access to the original data; they also reported that they requested original data and that they plan to re-do their analyses once they receive them; they also urged readers to treat the data with caution [ 58 ]. This points to the evolving nature of evidence during a crisis.

Our study’s strength is that this overview adds to the current knowledge by providing a comprehensive summary of all the evidence synthesis about COVID-19 available early after the onset of the pandemic. This overview followed strict methodological criteria, including a comprehensive and sensitive search strategy and a standard tool for methodological appraisal of systematic reviews.

In conclusion, in this overview of systematic reviews, we analyzed evidence from the first 18 systematic reviews that were published after the emergence of COVID-19. However, confidence in the results of all the reviews was “critically low”. Thus, systematic reviews that were published early on in the pandemic could be categorized as research waste. Even during public health emergencies, studies and systematic reviews should adhere to established methodological standards to provide patients, clinicians, and decision-makers trustworthy evidence.

Availability of data and materials

All data collected and analyzed within this study are available from the corresponding author on reasonable request.

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Acknowledgments

We thank Catherine Henderson DPhil from Swanscoe Communications for pro bono medical writing and editing support. We acknowledge support from the Covidence Team, specifically Anneliese Arno. We thank the whole International Network of Coronavirus Disease 2019 (InterNetCOVID-19) for their commitment and involvement. Members of the InterNetCOVID-19 are listed in Additional file 6 . We thank Pavel Cerny and Roger Crosthwaite for guiding the team supervisor (IJBN) on human resources management.

This research received no external funding.

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University Hospital and School of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil

Israel Júnior Borges do Nascimento & Milena Soriano Marcolino

Medical College of Wisconsin, Milwaukee, WI, USA

Israel Júnior Borges do Nascimento

Helene Fuld Health Trust National Institute for Evidence-based Practice in Nursing and Healthcare, College of Nursing, The Ohio State University, Columbus, OH, USA

Dónal P. O’Mathúna

School of Nursing, Psychotherapy and Community Health, Dublin City University, Dublin, Ireland

Department of Anesthesiology, Intensive Care and Pain Medicine, University of Münster, Münster, Germany

Thilo Caspar von Groote

Department of Sport and Health Science, Technische Universität München, Munich, Germany

Hebatullah Mohamed Abdulazeem

School of Health Sciences, Faculty of Health and Medicine, The University of Newcastle, Callaghan, Australia

Ishanka Weerasekara

Department of Physiotherapy, Faculty of Allied Health Sciences, University of Peradeniya, Peradeniya, Sri Lanka

Cochrane Croatia, University of Split, School of Medicine, Split, Croatia

Ana Marusic, Irena Zakarija-Grkovic & Tina Poklepovic Pericic

Center for Evidence-Based Medicine and Health Care, Catholic University of Croatia, Ilica 242, 10000, Zagreb, Croatia

Livia Puljak

Cochrane Brazil, Evidence-Based Health Program, Universidade Federal de São Paulo, São Paulo, Brazil

Vinicius Tassoni Civile & Alvaro Nagib Atallah

Yorkville University, Fredericton, New Brunswick, Canada

Santino Filoso

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IJBN conceived the research idea and worked as a project coordinator. DPOM, TCVG, HMA, IW, AM, LP, VTC, IZG, TPP, ANA, SF, NLB and MSM were involved in data curation, formal analysis, investigation, methodology, and initial draft writing. All authors revised the manuscript critically for the content. The author(s) read and approved the final manuscript.

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Correspondence to Livia Puljak .

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Supplementary Information

Additional file 1: appendix 1..

Search strategies used in the study.

Additional file 2: Appendix 2.

Adjusted scoring of AMSTAR 2 used in this study for systematic reviews of studies that did not analyze interventions.

Additional file 3: Appendix 3.

List of excluded studies, with reasons.

Additional file 4: Appendix 4.

Table of overlapping studies, containing the list of primary studies included, their visual overlap in individual systematic reviews, and the number in how many reviews each primary study was included.

Additional file 5: Appendix 5.

A detailed explanation of AMSTAR scoring for each item in each review.

Additional file 6: Appendix 6.

List of members and affiliates of International Network of Coronavirus Disease 2019 (InterNetCOVID-19).

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Borges do Nascimento, I.J., O’Mathúna, D.P., von Groote, T.C. et al. Coronavirus disease (COVID-19) pandemic: an overview of systematic reviews. BMC Infect Dis 21 , 525 (2021). https://doi.org/10.1186/s12879-021-06214-4

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Coronavirus disease 2019 (COVID-19): A literature review

Affiliations.

• 1 Medical Research Unit, School of Medicine, Universitas Syiah Kuala, Banda Aceh, Indonesia; Tropical Disease Centre, School of Medicine, Universitas Syiah Kuala, Banda Aceh, Indonesia; Department of Microbiology, School of Medicine, Universitas Syiah Kuala, Banda Aceh, Indonesia. Electronic address: [email protected].
• 2 Division of Infectious Diseases, AichiCancer Center Hospital, Chikusa-ku Nagoya, Japan. Electronic address: [email protected].
• 3 Department of Family Medicine, School of Medicine, Universitas Syiah Kuala, Banda Aceh, Indonesia. Electronic address: [email protected].
• 4 Department of Pulmonology and Respiratory Medicine, School of Medicine, Universitas Syiah Kuala, Banda Aceh, Indonesia. Electronic address: [email protected].
• 5 School of Medicine, The University of Western Australia, Perth, Australia. Electronic address: [email protected].
• 6 Siem Reap Provincial Health Department, Ministry of Health, Siem Reap, Cambodia. Electronic address: [email protected].
• 7 Department of Microbiology and Parasitology, Faculty of Medicine and Health Sciences, Warmadewa University, Denpasar, Indonesia; Department of Medical Microbiology and Immunology, University of California, Davis, CA, USA. Electronic address: [email protected].
• 8 Medical Research Unit, School of Medicine, Universitas Syiah Kuala, Banda Aceh, Indonesia; Tropical Disease Centre, School of Medicine, Universitas Syiah Kuala, Banda Aceh, Indonesia; Department of Microbiology, School of Medicine, Universitas Syiah Kuala, Banda Aceh, Indonesia; Department of Clinical Microbiology, School of Medicine, Universitas Syiah Kuala, Banda Aceh, Indonesia. Electronic address: [email protected].
• 9 Department of Epidemiology, University of Michigan, Ann Arbor, Michigan, MI 48109, USA. Electronic address: [email protected].
• 10 Medical Research Unit, School of Medicine, Universitas Syiah Kuala, Banda Aceh, Indonesia; Tropical Disease Centre, School of Medicine, Universitas Syiah Kuala, Banda Aceh, Indonesia; Department of Microbiology, School of Medicine, Universitas Syiah Kuala, Banda Aceh, Indonesia. Electronic address: [email protected].
• PMID: 32340833
• PMCID: PMC7142680
• DOI: 10.1016/j.jiph.2020.03.019

In early December 2019, an outbreak of coronavirus disease 2019 (COVID-19), caused by a novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), occurred in Wuhan City, Hubei Province, China. On January 30, 2020 the World Health Organization declared the outbreak as a Public Health Emergency of International Concern. As of February 14, 2020, 49,053 laboratory-confirmed and 1,381 deaths have been reported globally. Perceived risk of acquiring disease has led many governments to institute a variety of control measures. We conducted a literature review of publicly available information to summarize knowledge about the pathogen and the current epidemic. In this literature review, the causative agent, pathogenesis and immune responses, epidemiology, diagnosis, treatment and management of the disease, control and preventions strategies are all reviewed.

Keywords: 2019-nCoV; COVID-19; Novel coronavirus; Outbreak; SARS-CoV-2.

Copyright © 2020 The Authors. Published by Elsevier Ltd.. All rights reserved.

Publication types

• Betacoronavirus
• Clinical Trials as Topic
• Coronavirus Infections* / epidemiology
• Coronavirus Infections* / immunology
• Coronavirus Infections* / therapy
• Coronavirus Infections* / virology
• Disease Outbreaks* / prevention & control
• Pneumonia, Viral* / epidemiology
• Pneumonia, Viral* / immunology
• Pneumonia, Viral* / therapy
• Pneumonia, Viral* / virology

Global Health (GHWG)

Content from global health (ghwg) working group, do you want to write a covid dissertation.

Professor Sophie Harman, a member of our Global Health Working Group, gives some advice about coming up with dissertation topics related to COVID.

Part of the joy and point of writing a dissertation is for students to come up with their own subject and research question. Both students and supervisors know this is often the most painful part of the process (second only to the week before deadline – start early, marathon not a sprint etc!). I know good supervisors can support students writing dissertations in all manner of subjects and this is what makes it so rewarding. However, in a year where we’re all dealing with increased pressure, demands on our time, and managing screen headaches, I thought I’d put my 15 years global health politics experience to good use and make some suggestions/pointers to help you when a student comes to you as says the inevitable: [1]

‘I was thinking of writing my dissertation on COVID-19’

Below are 10 suggested questions with suggested literature and methods, covering institutions, security, race, policy, vaccines, gender, aesthetics, expertise, knowledge. These by no means cover everything and by no means prescribe how I think a dissertation on that topic should be written. If helpful, see them as jump-off points to think about these topics. The only caution I have is make sure all projects are only focused on the start/first 6 months of COVID-19 – we are only at the end of the beginning. This is also a pre-emptive move to stop you getting your students to email me for ideas.

Institutions and global governance

1. Is the WHO capable of preventing and responding to major pandemics?

Literature: WHO, IHR, GOARN, global health security + previous outbreaks (Ebola, pandemic flu, HIV/AIDS)

Methods: Case Studies – look at the tools/instruments e.g. IHR, GOARN, Regional offices etc

2. Why did states pursue different responses to the COVID-19 outbreak?

Literature: Global health security, state compliance in IR, international law and international organisations

Methods: Pick two contrasting case studies e.g. England/Scotland, Canada/US, Germany/UK, Sweden/Denmark and then look at different levels of policy and decision making per chapter – Global, National, Regional/local and rationales behind decisions from – expert evidence, speeches, policy decisions, policy timelines

3. How can we understand the gender dimensions of COVID-19?

Literature: Gender and global health, Feminist IPE, Black Feminism, WPS (if looking at violence)

Methods: Explore 1 – 3 key themes from the literature – Care and domestic burden, Health Care Workers, Domestic violence in depth. Depending on networks and contacts, could run focus groups (ethics! And definitely NOT if doing violence), or analyse survey data – lots of surveys done on this and the raw data is always made available if have the skills to play with it.

Political economy

4. Are states the main barrier to vaccine equity?

Literature: Vaccine access and nationalism, access to treatment, IPE of health and trade, pharmaceutical companies, Bill and Melinda Gates Foundation

Methods: Look at the different stages of vaccine development for 2/3 trials and consider the role of States (where putting money, public statements, any actions e.g. email hacks), Researchers (where get money from, how collaborating, knowledge sharing), Institutions (CEPI, GAVI, WHO), and the Private Sector (pharma and foundations – who’s investing, what is their return – and private security companies – who protects the commodity?). Think: interests, investment, barriers/opportunities.

Security and foreign policy

5. Were state security strategies prepared for major pandemics prior to COVID-19? If not, why not?

Literature: Global health security, securitisation and desecuritisation of health

Methods: 2 – 3 state case studies or 1 in detail, think about Strategy, Training/Preparedness, Actors. Content analysis of security strategies and defence planning and budget allocations, speeches, training, simulations etc.

6. What is the role of images in responding to outbreaks?

Literature: Aesthetics and IR, behaviour change communication and images in public health

Methods: 3 case studies on different types of images in COVID-19, e.g. 1. Global public health messaging; 2. National public health messaging; 3. Community Expression – OR pick one of these options and explore in depth.

Race and racism

7. Could the racial inequalities of COVID-19 been foreseen and prevented?

Literature: Racism and global health, racism and domestic health systems, Black Feminism, Critical Trans Politics

Method: Option 1 – look maternal health as a proxy in three case study countries e.g. Brazil, US, UK; Option 2 – pick one country and look at three health issues prior to COVID-19 e.g. Maternal Health, Diabetes, Heart Disease.

Knowledge, discourse, and experts

8. Is COVID-19 the biggest global pandemic of a generation?

Literature: Postcolonial/decolonial theory, poststructuralism, Politics of HIV/AIDS, pandemic flu

Method: Discourse analysis around ‘once in a lifetime rhetoric’ – who says it, when, and why; contrast with discourse around COVID-19 from countries with previous outbreaks e.g. Sierra Leone, DRC, China, Indonesia, South Africa, Brazil (you’ll need to be selective as can’t measure discourse from all states! Think through why you make your choices here and how they relate to each other) OR contrast COVID-19 with a previous pandemic, e.g. HIV/AIDS

9. What knowledge counts in COVID-19?

Literature: Postcolonial/decolonial theory, post-structuralism, IR and Global Health, politics of experts

Methods: Review lessons learned from previous outbreaks (there are lots of source material on this after Ebola and SARS for example) and how they led to changes/what learned for COVID-19; Stakeholder mapping and/or network analysis – Who are the experts? Look at backgrounds, types of knowledge and expertise, did they work on the Ebola response/HIV/AIDS in the early 2000s for example?; Case Study – UK/US – where have high concentration of public health experts and institutions, export knowledge to low and middle income countries, evidence of importing knowledge from these countries, especially given the experience?

UK/State responses

10. How can we understand/explain the first 6 months of the US/UK/Sweden/Australia/South Africa/China/Brazil/you choose! response to COVID-19?

WARNING! This is the question that could descend into a polemic so approach with absolute caution. I would strongly advise against, but have included to give a clearer steer.

The key with this question is to remember you are not submitting a public health or epidemiology dissertation, so bear in mind you probably don’t have the skills and knowledge to assess what was a good/bad public health decision (other than obvious ones such as PPE stocks for example). What you do have the skills to do is to look at the politics as to  why  a decision was taken and  how  it was taken – investigate what the different recommendations/guidance suggested, who followed/ignored/subverted it and what outcomes this produced.

Literature: health policy, public policy, state compliance IR

Methods: 1. Global – map what global advice there was and how did the state follow (or not) in preparedness and response and what was the rationale for doing so – political circumstances at the time, stated rationale for decision, who was making decision; 2. National – key public health decisions, commodities, social-economic consequences – how were these planned for/overlooked and why. To look at these two levels may require mixed methods of global and national policy timelines, stakeholder analysis, content analysis of speeches and recommendations, mapping changes to data presentation and access.

[1]  For the first two years of my career I supervised countless projects loosely based around ‘Is the War in Iraq illegal?’ I’m hoping some of the variety here will stop two years of ‘Is the UK government’s respond to COVID-19 a national scandal?’ or ‘Is the WHO fit for purpose?’ – two great topics, but tiresome after a bit.

Reproduced with kind permission from Global Politics Unbound at QMU.

Photo by iMattSmart on Unsplash

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Collecting Dissertation Data during COVID 19

• Matthew J. Sroka Ed.D. Student at Salisbury University

This essay describes my personal experience as a doctoral candidate collecting data for my dissertation during the COVID-19 pandemic. After providing the context for my own study, I lay out three main ideas that emerged while collecting data. These main ideas involve including participants in the decision-making process, sharing one another’s challenging contexts to understand and connect, and the importance of teacher learning communities in times of isolation. My essay highlights some of the challenges and opportunities of collecting data during difficult circumstances and discusses the importance of professional learning communities to assist teachers with long-term coping within an unexpected context.

Author Biography

Matthew j. sroka, ed.d. student at salisbury university.

Matthew Sroka teaches English at Queen Anne’s County High School in Centreville, Maryland. He is currently pursuing a doctorate of education at Salisbury University. The focus of his research is on the reading lives of secondary English teachers.

Herr, K., & Anderson, G. L. (2015). The action research dissertation. Sage.

Kerkhoff, S., Broere, M., & Premont, D. (2020). Average and avid: Preservice English teachers' reading identities. English Teaching: Practice & Critique, 19, 197-215.

Rubin, J.C. & Land, C.L. (2017), “This is English class”: Evolving identities and a literacy teacher’s shifts in practice across figured worlds. Teaching and Teacher Education, 68, 190-199.

Scholes, R. E. (1998). The rise and fall of English: Reconstructing English as a discipline. Yale University Press.

Trust, T., Krutka, D. G., & Carpenter, J. P. (2016). “Together we are better”: Professional learning networks for teachers. Computers & Education, 102, 15-34.

Trust, T., Carpenter, J. P., Krutka, D. G., & Kimmons, R. (2020). #RemoteTeaching & #RemoteLearning: educator tweeting during the COVID-19 pandemic. Journal of Technology and Teacher Education, 28(2), 151-159.

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• Volume 10, Issue 12
• Impact of the COVID-19 pandemic on mental health and well-being of communities: an exploratory qualitative study protocol
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• http://orcid.org/0000-0003-0180-0213 Anam Shahil Feroz 1 , 2 ,
• Naureen Akber Ali 3 ,
• Noshaba Akber Ali 1 ,
• Ridah Feroz 4 ,
• Salima Nazim Meghani 1 ,
• Sarah Saleem 1
• 1 Community Health Sciences , Aga Khan University , Karachi , Pakistan
• 2 Institute of Health Policy, Management and Evaluation , University of Toronto , Toronto , Ontario , Canada
• 3 School of Nursing and Midwifery , Aga Khan University , Karachi , Pakistan
• 4 Aga Khan University Institute for Educational Development , Karachi , Pakistan
• Correspondence to Ms Anam Shahil Feroz; anam.sahyl{at}gmail.com

Introduction The COVID-19 pandemic has certainly resulted in an increased level of anxiety and fear in communities in terms of disease management and infection spread. Due to fear and social stigma linked with COVID-19, many individuals in the community hide their disease and do not access healthcare facilities in a timely manner. In addition, with the widespread use of social media, rumours, myths and inaccurate information about the virus are spreading rapidly, leading to intensified irritability, fearfulness, insomnia, oppositional behaviours and somatic complaints. Considering the relevance of all these factors, we aim to explore the perceptions and attitudes of community members towards COVID-19 and its impact on their daily lives and mental well-being.

Methods and analysis This formative research will employ an exploratory qualitative research design using semistructured interviews and a purposive sampling approach. The data collection methods for this formative research will include indepth interviews with community members. The study will be conducted in the Karimabad Federal B Area and in the Garden (East and West) community settings in Karachi, Pakistan. The community members of these areas have been selected purposively for the interview. Study data will be analysed thematically using NVivo V.12 Plus software.

Ethics and dissemination Ethical approval for this study has been obtained from the Aga Khan University Ethical Review Committee (2020-4825-10599). The results of the study will be disseminated to the scientific community and to the research subjects participating in the study. The findings will help us explore the perceptions and attitudes of different community members towards the COVID-19 pandemic and its impact on their daily lives and mental well-being.

• mental health
• public health

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/bmjopen-2020-041641

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Strengths and limitations of this study

The mental health impact of the COVID-19 pandemic is likely to last much longer than the physical health impact, and this study is positioned well to explore the perceptions and attitudes of community members towards the pandemic and its impact on their daily lives and mental well-being.

This study will guide the development of context-specific innovative mental health programmes to support communities in the future.

One limitation is that to minimise the risk of infection all study respondents will be interviewed online over Zoom and hence the authors will not have the opportunity to build rapport with the respondents or obtain non-verbal cues during interviews.

The COVID-19 pandemic has affected almost 180 countries since it was first detected in Wuhan, China in December 2019. 1 2 The COVID-19 outbreak has been declared a public health emergency of international concern by the WHO. 3 The WHO estimates the global mortality to be about 3.4% 4 ; however, death rates vary between countries and across age groups. 5 In Pakistan, a total of 10 880 cases and 228 deaths due to COVID-19 infection have been reported to date. 6

The worldwide COVID-19 pandemic has not only incurred massive challenges to the global supply chains and healthcare systems but also has a detrimental effect on the overall health of individuals. 7 The pandemic has led to lockdowns and has created destructive impact on the societies at large. Most company employees, including daily wage workers, have been prohibited from going to their workplaces or have been asked to work from home, which has caused job-related insecurities and financial crises in the communities. 8 Educational institutions and training centres have also been closed, which resulted in children losing their routine of going to schools, studying and socialising with their peers. Delay in examinations is likewise a huge stressor for students. 8 Alongside this, parents have been struggling with creating a structured milieu for their children. 9 COVID-19 has hindered the normal routine life of every individual, be it children, teenagers, adults or the elderly. The crisis is engendering burden throughout populations and communities, particularly in developing countries such as Pakistan which face major challenges due to fragile healthcare systems and poor economic structures. 10

The COVID-19 pandemic has certainly resulted in an increased level of anxiety and fear in communities in terms of disease management and infection spread. 8 Further, the highly contagious nature of COVID-19 has also escalated confusion, fear and panic among community residents. Moreover, social distancing is often an unpleasant experience for community members and for patients as it adds to mental suffering, particularly in the local setting where get-togethers with friends and families are a major source of entertainment. 9 Recent studies also showed that individuals who are following social distancing rules experience loneliness, causing a substantial level of distress in the form of anxiety, stress, anger, misperception and post-traumatic stress symptoms. 8 11 Separation from family members, loss of autonomy, insecurity over disease status, inadequate supplies, inadequate information, financial loss, frustration, stigma and boredom are all major stressors that can create drastic impact on an individual’s life. 11 Due to fear and social stigma linked with COVID-19, many individuals in the community hide their disease and do not access healthcare facilities in a timely manner. 12 With the widespread use of social media, 13 rumours, myths and inaccurate information about COVID-19 are also spreading rapidly, not only among adults but are also carried on to children, leading to intensified irritability, fearfulness, insomnia, oppositional behaviours and somatic complaints. 9 The psychological symptoms associated with COVID-19 at the community level are also manifested as anxiety-driven panic buying, resulting in exhaustion of resources from the market. 14 Some level of panic also dwells in the community due to the unavailability of essential protective equipment, particularly masks and sanitisers. 15 Similarly, mental health issues, including depression, anxiety, panic attacks, psychotic symptoms and even suicide, were reported during the early severe acute respiratory syndrome outbreak. 16 17 COVID-19 is likely posing a similar risk throughout the world. 12

The fear of transmitting the disease or a family member falling ill is a probable mental function of human nature, but at some point the psychological fear of the disease generates more anxiety than the disease itself. Therefore, mental health problems are likely to increase among community residents during an epidemic situation. Considering the relevance of all these factors, we aim to explore the perceptions and attitudes towards COVID-19 among community residents and the impact of these perceptions and attitude on their daily lives and mental well-being.

Methods and analysis

Study design.

This study will employ an exploratory qualitative research design using semistructured interviews and a purposive sampling approach. The data collection methods for this formative research will include indepth interviews (IDIs) with community members. The IDIs aim to explore perceptions of community members towards COVID-19 and its impact on their mental well-being.

Study setting and study participants

The study will be conducted in two communities in Karachi City: Karimabad Federal B Area Block 3 Gulberg Town, and Garden East and Garden West. Karimabad is a neighbourhood in the Karachi Central District of Karachi, Pakistan, situated in the south of Gulberg Town bordering Liaquatabad, Gharibabad and Federal B Area. The population of this neighbourhood is predominantly Ismailis. People living here belong mostly to the middle class to the lower middle class. It is also known for its wholesale market of sports goods and stationery. Garden is an upmarket neighbourhood in the Karachi South District of Karachi, Pakistan, subdivided into two neighbourhoods: Garden East and Garden West. It is the residential area around the Karachi Zoological Gardens; hence, it is popularly known as the ‘Garden’ area. The population of Garden used to be primarily Ismailis and Goan Catholics but has seen an increasing number of Memons, Pashtuns and Baloch. These areas have been selected purposively because the few members of these communities are already known to one of the coinvestigators. The coinvestigator will serve as a gatekeeper for providing entrance to the community for the purpose of this study. Adult community members of different ages and both genders will be interviewed from both sites, as mentioned in table 1 . Interview participants will be selected following the eligibility criteria.

• View inline

Study participants for indepth interviews

IDIs with community members

We will conduct IDIs with community members to explore the perceptions and attitudes of community members towards COVID-19 and its effects on their daily lives and mental well-being. IDI participants will be identified via the community WhatsApp group, and will be invited for an interview via a WhatsApp message or email. Consent will be taken over email or WhatsApp before the interview begins, where they will agree that the interview can be audio-recorded and that written notes can be taken. The interviews will be conducted either in Urdu or in English language, and each interview will last around 40–50 min. Study participants will be assured that their information will remain confidential and that no identifying features will be mentioned on the transcript. The major themes will include a general discussion about participants’ knowledge and perceptions about the COVID-19 pandemic, perceptions on safety measures, and perceived challenges in the current situation and its impact on their mental well-being. We anticipate that 24–30 interviews will be conducted, but we will cease interviews once data saturation has been achieved. Data saturation is the point when no new themes emerge from the additional interviews. Data collection will occur concurrently with data analysis to determine data saturation point. The audio recordings will be transcribed by a transcriptionist within 24 hours of the interviews.

An interview guide for IDIs is shown in online supplemental annex 1 .

Supplemental material

Eligibility criteria.

The following are the criteria for inclusion and exclusion of study participants:

Inclusion criteria

Residents of Garden (East and West) and Karimabad Federal B Area of Karachi who have not contracted the disease.

Exclusion criteria

Those who refuse to participate in the study.

Those who have experienced COVID-19 and are undergoing treatment.

Those who are suspected for COVID-19 and have been isolated/quarantined.

Family members of COVID-19-positive cases.

Data collection procedure

A semistructured interview guide has been developed for community members. The initial questions on the guide will help to explore participants’ perceptions and attitudes towards COVID-19. Additional questions on the guide will assess the impact of these perceptions and attitude on the daily lives and mental health and well-being of community residents. All semistructured interviews will be conducted online via Zoom or WhatsApp. Interviews will be scheduled at the participant’s convenient day and time. Interviews are anticipated to begin on 1 December 2020.

Patient and public involvement

No patients were involved.

Data analysis

We will transcribe and translate collected data into English language by listening to the audio recordings in order to conduct a thematic analysis. NVivo V.12 Plus software will be used to import, organise and explore data for analysis. Two independent researchers will read the transcripts at various times to develop familiarity and clarification with the data. We will employ an iterative process which will help us to label data and generate new categories to identify emergent themes. The recorded text will be divided into shortened units and labelled as a ‘code’ without losing the main essence of the research study. Subsequently, codes will be analysed and merged into comparable categories. Lastly, the same categories will be grouped into subthemes and final themes. To ensure inter-rater reliability, two independent investigators will perform the coding, category creation and thematic analyses. Discrepancies between the two investigators will be resolved through consensus meetings to reduce researcher bias.

Ethics and dissemination

Study participants will be asked to provide informed, written consent prior to participation in the study. The informed consent form can be submitted by the participant via WhatsApp or email. Participants who are unable to write their names will be asked to provide a thumbprint to symbolise their consent to participate. Ethical approval for this study has been obtained from the Aga Khan University Ethical Review Committee (2020-4825-10599). The study results will be disseminated to the scientific community and to the research subjects participating in the study. The findings will help us explore the perceptions and attitudes of different community members towards the COVID-19 pandemic and its impact on their daily lives and mental well-being.

The findings of this study will help us to explore the perceptions and attitudes towards the COVID-19 pandemic and its impact on the daily lives and mental well-being of individuals in the community. Besides, an indepth understanding of the needs of the community will be identified, which will help us develop context-specific innovative mental health programmes to support communities in the future. The study will provide insights into how communities are managing their lives under such a difficult situation.

• World Health Organization
• Nielsen-Saines K , et al
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• Gozzer E , et al
• Snoswell CL ,
• Harding LE , et al
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• van Weel C ,
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• Brooks SK ,
• Webster RK ,
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Supplementary materials

Supplementary data.

This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

• Data supplement 1

ASF and NAA are joint first authors.

Contributors ASF and NAA conceived the study. ASF, NAA, RF, NA, SNM and SS contributed to the development of the study design and final protocols for sample selection and interviews. ASF and NAA contributed to writing the manuscript. All authors reviewed and approved the final version of the paper.

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests None declared.

Patient consent for publication Not required.

Provenance and peer review Not commissioned; externally peer reviewed

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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Harvard University COVID-19 updates

Department News

Neuroscience concentrator melissa meng wins glushko undergraduate thesis prize.

• May 24, 2024

Neuroscience concentrator Melissa Meng has been awarded the Glushko Undergraduate Thesis Prize , which honors students who write theses in cognitive science. It is issued by the Mind Brain Behavior Interfaculty Initiative. Meng conducted her research in the Uchida Lab . 

In her thesis, Meng investigated whether distributional reinforcement learning, a mathematical construct for describing how learning might happen, occurs in the mammalian brain. “The field of RL [reinforcement learning] asks how agents – humans, animals, or machines – can learn from trial and error to maximize the total reward they obtain,” explains Uchida Lab graduate student Adam Lowet , who mentored Meng. “This reward may be a random variable – that is, it is drawn from some probability distribution, rather than being fixed. Traditional RL simply averages over this randomness, but recent work in machine learning has demonstrated that learning the entire distribution of rewards, rather than just the mean, can be beneficial.”

To find out, Meng started with a traditional laboratory task for mice. “I recorded neural activity from the striatum of well-trained mice performing a classical conditioning task that associates random odors with different reward distributions,” she explains. “For the second part of my thesis, I decided to look into the neural basis behind distributional coding in the striatum. To investigate this, I induced a unilateral lesion using a neurotoxin to ablate dopaminergic neurons in the ventral striatum of mice as they performed the same classical conditioning task. From these experiments, we were able to provide direct evidence for distributional RL in the mammalian brain, show that striatal populations encode for not only mean, but also variance, and conclude that dopamine serves as a teaching signal for distributional RL in the striatum.” 

“Entrusting undergraduates with so much responsibility is extremely rare in the Uchida laboratory, but Melissa’s combination of enthusiasm, commitment, reliability, and curiosity left us no choice,” Lowet says. “As often happens in science, this passion was rewarded by the discovery that distributional representations were in fact impaired in dopamine-depleted brains, compared to intact brains. Melissa’s contribution has been recognized in the form of co-authorship on three posters presented at top conferences in the field, two contributed talks, and an in-revision manuscript .”

“Melissa spent a lot of time in the lab performing many difficult experiments,” adds MCB faculty Naoshige Uchida . “She was very much dedicated and grew her interest and passion in neurobiology research as she learns new experiments and gets exciting results. Melissa’s experiments led to important discoveries such as that dopamine plays a crucial role in learning to acquire neural activity reflecting the probability distribution of rewards, above and beyond the average reward.” 

Meng will pursue a Ph.D. in Neuroscience at Yale in the fall. Over the summer, she’ll be spending time with her family in Blacksburg, Virginia and traveling in China and South Korea. 

“I am extremely honored and grateful to receive the Glushko Prize, especially among such an incredible group of nominees, and I would like to thank several individuals for making this entire thesis possible,” she says. “I’d first like to thank my PI and supervisor, Dr. Naoshige Uchida, for providing me the incredible opportunity to be a part of this lab and for helping me learn and grow significantly as a student, researcher, and person during my time at Harvard. I’d also like to thank my mentor, Adam Lowet, who is a graduate student in the Uchida Lab, for teaching me everything I know and for always showing me so much encouragement and support with all of my endeavors. I also want to thank the entire Uchida Lab for welcoming me with open arms and for being not only inspirational, but also incredibly kind role models.”

Meng adds, “Additionally, I’d like to thank Dr. Laura Magnotti , my concentration advisor, and Dr. Ryan Draft , Dr. Kristina Penikis , and Mr. James Poolner for facilitating the wonderful undergraduate neuroscience community that I’m so proud to be a part of. Lastly, I’d like to thank all of my friends and family (particularly my mom, my dad, and my brother) for supporting me unconditionally every step of the way throughout my entire college career.” 

(l to r) Wen Li (mom), Xiang-Jin Meng (dad), Melissa Meng, and Bowen Meng (brother)

(l to r) Nao Uchida, Melissa Meng, and Adam Lowet

Developing Technological Platforms for Targeted Cancer Therapies, Protein Drug Delivery, and Pathogen Detection

 Biomedical engineering has made remarkable progress in enhancing human healthcare, contributing significantly to the fight against human diseases. However, we still confront grand challenges in accurate disease diagnosis, efficient therapeutic delivery, and the development of targeted therapies. For example, the diagnosis of coronavirus disease (COVID-19) remains challenging in low-resource settings where access to specialized medical equipment and trained personnel is severely limited. Cystic fibrosis patients carrying cystic fibrosis transmembrane conductance regulator (CFTR) mutations that lead to non-functional CFTR protein production remain ineligible for CFTR modulator treatments. Traditional cancer chemotherapies, though effective, frequently encounter "on-target, off-tissue" cytotoxicity associated with target molecule prevalence on healthy tissue. 

To tackle the critical challenges in disease diagnosis, therapeutic delivery, and targeted therapies in various human disease, in this thesis, we engineered disease diagnostic device for COVID-19 detection in low-resource settings, efficient therapeutic delivery system for cystic fibrosis patients carrying CFTR mutations, and targeted therapy for cancer treatment. In chapter 1, we developed TASE (TArgeted Split Enzyme), an innovative cancer treatment strategy featuring an AND-gated dual-targeting mechanism. TASE effectively reduces off-tissue cytotoxicity by utilizing a tunable payload, leveraging a pair of split human simplex virus (HSV) thymidine kinase (TK). This enzyme converts the prodrug ganciclovir (GCV) into a cytotoxic form exclusively within cancer cells, thus enhancing targeted therapy efficacy. Chapter 2 developed an innovative extracellular vesicle-based protein drug delivery system for the direct transport of CFTR protein to the plasma membrane of human bronchial epithelial cells. It holds significant promise for treating cystic fibrosis patients with non-functional CFTR protein production. Chapter 3 developed a Surfactant-Infused Space-Domain RT-qPCR (SiSd-RT-qPCR) device for ultrafast, one-step SARS-CoV-2 virus detection in low-resource settings. 

Degree Type

• Dissertation
• Biomedical Engineering

Degree Name

• Doctor of Philosophy (PhD)

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• Biomedical Engineering not elsewhere classified