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Use of wearable sensors to assess compliance of asthmatic children in response to lockdown measures for the COVID-19 epidemic

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Between March and April 2020, Cyprus and Greece health authorities enforced three escalated levels of public health interventions to control the COVID-19 pandemic. We quantified compliance of 108 asthmatic schoolchildren (53 from Cyprus, 55 from Greece, mean age 9.7 years) from both countries to intervention levels, using wearable sensors to continuously track personal location and physical activity. Changes in ‘fraction time spent at home’ and ‘total steps/day’ were assessed with a mixed-effects model adjusting for confounders. We observed significant mean increases in ‘fraction time spent at home’ in Cyprus and Greece, during each intervention level by 41.4% and 14.3% (level 1), 48.7% and 23.1% (level 2) and 45.2% and 32.0% (level 3), respectively. Physical activity in Cyprus and Greece demonstrated significant mean decreases by − 2,531 and − 1,191 (level 1), − 3,638 and − 2,337 (level 2) and − 3,644 and − 1,961 (level 3) total steps/day, respectively. Significant independent effects of weekends and age were found on ‘fraction time spent at home’. Similarly, weekends, age, humidity and gender had an independent effect on physical activity. We suggest that wearable technology provides objective, continuous, real-time location and activity data making possible to inform in a timely manner public health officials on compliance to various tiers of public health interventions during a pandemic.
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
Scientic Reports | (2021) 11:5895 | 
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Use of wearable sensors to assess
compliance of asthmatic children
in response to lockdown measures
for the COVID‑19 epidemic
Panayiotis Kouis1, Antonis Michanikou1, Pinelopi Anagnostopoulou 1,2,
Emmanouil Galanakis3, Eleni Michaelidou3, Helen Dimitriou3, Andreas M. Matthaiou1,
Paraskevi Kinni1, Souzana Achilleos4, Harris Zacharatos5,6, Stefania I. Papatheodorou 7,
Petros Koutrakis8, Georgios K. Nikolopoulos9 & Panayiotis K. Yiallouros1*
Between March and April 2020, Cyprus and Greece health authorities enforced three escalated levels
of public health interventions to control the COVID‑19 pandemic. We quantied compliance of 108
asthmatic schoolchildren (53 from Cyprus, 55 from Greece, mean age 9.7 years) from both countries
to intervention levels, using wearable sensors to continuously track personal location and physical
activity. Changes in ‘fraction time spent at home’ and ‘total steps/day’ were assessed with a mixed‑
eects model adjusting for confounders. We observed signicant mean increases in ‘fraction time
spent at home’ in Cyprus and Greece, during each intervention level by 41.4% and 14.3% (level 1),
48.7% and 23.1% (level 2) and 45.2% and 32.0% (level 3), respectively. Physical activity in Cyprus and
Greece demonstrated signicant mean decreases by − 2,531 and 1,191 (level 1), − 3,638 and 2,337
(level 2) and − 3,644 and 1,961 (level 3) total steps/day, respectively. Signicant independent eects
of weekends and age were found on ‘fraction time spent at home’. Similarly, weekends, age, humidity
and gender had an independent eect on physical activity. We suggest that wearable technology
provides objective, continuous, real‑time location and activity data making possible to inform in a
timely manner public health ocials on compliance to various tiers of public health interventions
during a pandemic.
Following several coronavirus outbreaks during the last years1, a novel coronavirus named SARS-CoV-2 pre-
sented in Wuhan, China in December 2019, causing severe disease (COVID-19) with high fatality rates, espe-
cially, amongst the elderly and people with comorbidities2. e virus rapidly spread all over the world and on
the 11th of March 2020, WHO characterized COVID-19 outbreak as a pandemic3.
In the absence of an eective vaccine or specic antiviral drugs against COVID-194, it seems that the only
strategy to control the pandemic are public health interventions implemented at the community or national
level. e interventions may range from simple isolation of disease carriers, quarantine of contacts and hand
hygiene measures to ban of mass gatherings, social distancing and nally to complete lockdown and community
quarantine (cordon sanitaire)57. ese measures coupled with extraordinary travel restrictions from national
governments are oen in disaccord with international and human rights law8. During the rst peak of the pan-
demic, aected countries chose dierent levels of interventions based, among others, on national risk assessments
of estimated number of patients and capacity for hospitalization and critical care support9,10. e evolution of
the pandemic over the last months demonstrated that timely interventions were eective to delay the spread of
COVID-1911,12, as it was also shown in previous u and SARS epidemics1315.
OPEN
Respiratory Physiology Laboratory, Medical School, Shacolas Educational Center of Clinical Medicine,
           Institute
       Medical School, University of Crete, Heraklion, Crete,
Greece. Cyprus International Institute for Environmental and Public Health, Cyprus University of Technology,
Limassol, Cyprus.          Department of
           Department
            Medical
 *email: yiallouros.panayiotis@ucy.ac.cy
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e compliance of the population to non-pharmaceutical interventions plays a catalytic role in the success-
ful containment of the virus16. However, it is dicult to monitor and understand population’s compliance to
behavioural changes forced by interventions during an emerging pandemic1719. To date, several parameters have
been used as indirect indicators of societal behaviour and compliance to public health measures, such as the
reduction of outdoor pollution20,21, decrease in trac accidents22 or even quietening of human activity signals
as measured by seismometers worldwide23. In the context of complete lockdown measures, where citizens are
advised to reduce their mobility and stay at home, wearable sensors measuring physical activity levels and time
spent at home may serve as a direct indicator for citizens’ compliance to the measures.
Patients with chronic respiratory disorders, like asthma, are considered to be at increased risk for severe
COVID-19 disease24,25 and from the beginning of the pandemic they were advised to meticulously comply to
restriction measures. In the pediatric population, asthma is the most common chronic disorder and although
COVID-19 is milder in children, the burden of the disease on public health may be signicant26. Furthermore,
it is known that children may have more diculties to comply to restriction measures27, with their compliance
depending substantially on the whole family’s attitude towards the measures. e aim of our study was to quantify
mobility changes in response to COVID-19 lockdown measures of schoolchildren with asthma in Cyprus and
Greece, by continuously tracking their location and activity, using wearable sensors.
Results
Participants’ characteristics. For 2020 study period, a total of 108 (57% males) asthmatic children, 53
in Cyprus and 55 in Greece, with an average age of 9.2years were enrolled in the study, and contributed data
between February 3rd and April 26th, 2020. All children had a physician’s diagnosis of asthma, while 53% also
reported wheezing episode(s) during the past 12months, 45% unscheduled medical visit(s) for asthma, 26%
emergency room visits for asthma, and 20% daily preventive anti-asthma medication during the past 12months.
Among study participants, 43% were characterized as having asthma severity 1, 43% asthma severity 2 and 15%
asthma severity 3 (Table1). For the 2019 study period, from February 3rd to April 26th, we measured mobil-
ity for 39 and 52 asthmatic children (59% males) in Cyprus and Greece, respectively, with an average age of
9.3years.
Unadjusted analysis. Overall, in both countries there were signicant changes in the observed fraction
time spent at home and total steps/day with introduction of public health intervention levels for the study year
2020. e observed mean fraction time spent at home among asthmatic children in Cyprus and Greece during
baseline period was 43.8% (95%CI: 40.5–47.1%) and 52.4% (95%CI: 49.4–55.4%) respectively. In Cyprus, the
observed fraction time spent at home signicantly increased to 88.9% (95%CI: 85.7–92.1%) during level 1, to
95.5% (95%CI: 93.8–97.2%) during level 2 and 94.1% (95%CI: 92.5–95.7%) during level 3 of interventions. In
Greece, introduction of level 1 public health interventions was characterized by an increase in the observed frac-
tion time spent at home to 71.4% (95%CI: 60.4–82.5%), while during level 2 and 3 interventions the fraction time
spent at home increased further to 84.9% (95%CI: 80.3–89.4%) and 89.6% (95%CI: 87.0–92.3%) respectively
(Table2, Fig.1). In Cyprus, the observed total steps/day reduced signicantly with introduction of each level
of public health interventions from 8,996 (95%CI: 8,567–9,425) at baseline, to 6,499 (95%CI: 5,832–7,166) at
Table 1. Basic demographic and clinical characteristics of asthmatic children in Cyprus and Greece included
in the study for the 2020 study period. *Values are presented as Mean (Standard Deviation). ER: Emergency
Department. Asthma Severity 1: Physician diagnosis plus one other eligibility criterion, Asthma Severity 2:
Physician diagnosis plus two other eligibility criteria, Asthma Severity 3: Physician diagnosis plus three or
more other eligibility criteria.
Parameter Asthmatic children (Cyprus, n = 53) Asthmatic children (Greece, n = 55)
Demographic
M (%) 35 (66%) 27 (49%)
Age, years* 9.3 (1.7) 9.11 (1.8)
Weight, kg* 39.3 (19.0) 35.9 (9.6)
Height, cm* 137.2 (21) 134.8 (10.2)
BMI, kg/m2* 20.3 (8.3) 19.5 (3.3)
Asthma eligibility criteria
Physician diagnosis of Asthma 53 (100%) 55 (100%)
Wheezing episodes 35 (66%) 22 (40%)
Daily preventive medication 10 (19%) 12 (22%)
Unscheduled physician visits for Asthma 34 (64%) 15 (27%)
ER visits for Asthma 10 (19%) 18 (33%)
Asthma severity status‡
Asthma severity 1 25 (47%) 21 (38%)
Asthma severity 2 20 (38%) 26 (47%)
Asthma severity 3 8 (15%) 8 (15%)
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Table 2. Observed fraction time spent at home and total steps per day across levels of intervention for Covid-
19 in Cyprus and Greece. Values are presented as mean (95% Condence Interval).
Intervention
Parameter Statistical signicance Parameter Statistical signicance
Fraction time spent at
home Compared to baseline Compared to
previous le vel Steps per day Compared to baseline Compare d to
previous le vel
Asthmatic children (Cyprus) (n = 53)
Baseline (Level 0) 43.8% (40.5%; 47.1%) 8996 (8567; 9425)
Level 1 88.9% (85.7%; 92.1%) < 0.001 < 0.001 6499 (5832; 7166) < 0.001 < 0.001
Level 2 95.5% (93.8%; 97.2%) < 0.001 0.151 6248 (5683; 6812) < 0.001 0.999
Level 3 94.1% (92.5%; 95.7%) < 0.001 0.999 6270 (5814; 6727) < 0.001 0.999
Fraction time spent at home Steps per day
Asthmatic children (Greece) (n = 55)
Baseline (Level 0) 52.4% (49.4%; 55.4%) 8527 (8145; 8908)
Level 1 71.4% (60.4%; 82.5%) 0.003 0.003 6864 (5689; 8040) 0.060 0.060
Level 2 84.9% (80.3%; 89.4%) < 0.001 0.357 5533 (4769; 6297) < 0.001 0.613
Level 3 89.6% (87.0%; 92.3%) < 0.001 0.999 5439 (5051; 5829) < 0.001 0.999
Figure1. Changes in mobility in response to public health interventions among asthmatic children.
Weekly averages of fraction time spent at home and steps/day, before and during three levels of public health
interventions in asthmatic children in Cyprus (A) and Greece (B).
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level 1, 6,248 (95%CI: 5,683–6,812) at level 2 and 6,270 (95%CI: 5,814–6,727) at level 3. Similarly, in Greece, the
observed total steps/day reduced with each level of public health interventions from 8,527 (95%CI: 8,145–8,908)
at baseline, to 6,864 (95%CI: 5,689–8,040) at level 1, 5,533 (95%CI: 4,769–6,297) at level 2 and 5,439 (95%CI:
5,051–5,829) at level 3 (Table2, Fig.1). e same trend was also observed for fraction time spent at home and
total steps per day in both countries when the change across levels of intervention were calculated separately
for each category of asthma severity. Data are presented in detail in Supplementary Table1. is pattern was in
sharp contrast to the normal mobility pattern of the asthmatic children cohorts in Cyprus and Greece during the
same study period for the study year 2019, where the fraction time spent at home and total steps per day were
quite stable throughout the same weeks of the year (Fig.2).
Adjusted analysis. Based on the mixed eects model, aer controlling for several confounders, the adjusted
mean increase in time-fractions spent at home in Cyprus were: 41.4% (95%CI: 34.5–48.2%, pvalue < 0.001 com-
pared to baseline) during level 1, 48.7% (95%CI: 42.0–55.5%, pvalue < 0.001 compared to baseline) during level
2, and 45.2% (95%CI: 39.3–51.2%, pvalue < 0.001 compared to baseline) during level 3 of interventions (Table3).
ere was no signicant increase between level 2 and 3 periods (pvalue = 0.298), while the increase between level
1 and 2 periods was almost signicant (pvalue = 0.055). In Greece, the adjusted mean changes in fraction time
spent at home were more gradual and moderate, increasing by 14.3% (95%CI: 2.2–26.3%, pvalue = 0.02 com-
pared to baseline) during level 1, 23.1% (95%CI: 11.2–34.9%, pvalue < 0.001 compared to baseline) during level 2,
and 32.0% (95%CI: 24.8–39.3%, pvalue < 0.001 compared to baseline) during level 3 interventions (Table4). e
changes between levels 1 and 2 as well as levels 2 and 3 were not statistically signicant.
In Cyprus, physical activity, expressed in total steps per day, demonstrated an adjusted mean decrease of − 2,531
(95%CI: − 3,364; − 1,698, pvalue < 0.001 compared to baseline) during level 1, − 3,638 (95%CI: − 4,521; − 2,755,
Figure2. Comparison of mobility of asthmatic children recorded in February–April 2019 and February–April
2020 in Cyprus and Crete. Weekly averages of fraction time spent at home and steps/day during the same period
of 2019 and 2020 in Cyprus (A) and Greece (B) (February–April).
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pvalue < 0.001 compared to baseline) during le vel 2, and − 3,644 (95%CI: − 4,428; − 2,859, pvalue < 0.001 compared
to baseline) during level 3 (Table3). e decreases in total steps per day for levels 1 and 2 were statistically sig-
nicant (pvalue = 0.019), but not for levels 2 and 3 (pvalue = 0.954). In Greece, the adjusted mean decrease of physical
activity during level 1 period was − 1,191 (95%CI: − 2,641; − 259, pvalue = 0.108 compared to baseline) steps per
day. During level 2 and 3 periods the corresponding decreases were − 2,337 (95%CI: 3,679; − 995, pvalue = 0.001
compared to baseline) and − 1,961 (95%CI: − 2,933; − 990, pvalue < 0.001 compared to baseline) steps/day, respec-
tively (Table4). e dierences in total steps decreases per day between levels 1 and 2 (pvalue = 0.212) and levels
2 and 3 (pvalue = 0.576) did not reach statistical signicance.
During the baseline period, in the cohort of asthmatic children in Cyprus, we found that fraction time
spent at home was signicantly higher during weekends as compared to weekdays (mean increase compared to
weekdays: 10.9%. 95%CI: 8.0; 13.8%) and with every year of increasing age (mean increase: 1.4%. 95%CI: 0.2;
2.6%). Furthermore, total steps per day were signicantly lower during weekends (mean decrease compared
to weekdays: − 1,002. 95%CI: − 1,374; − 630), with increasing age (mean decrease: − 378. 95% CI: − 615; − 143),
increasing humidity (mean decrease: 29. 95%CI: 42; 15) and in year 2020 as compared to year 2019
(mean decrease: 1,560. 95%CI: 2,796; − 324). Finally, total steps per day were signicantly higher in males
as compared to females (mean increase: 1,024. 95%CI: 53; 1,944) (Table3). In asthmatic children in Greece,
Table 3. Fraction time spent at home and total steps per day in response to interventions for Covid-19 among
asthmatic children in Cyprus. *p < 0.001, compared to previous level. p = 0.055, compared to the previous level.
p = 0.021, compared to the previous level, §p > 0.05, compared to the previous level.
Parameter
Fraction time spent at home Total Steps per day
β coecient (95% CI) Compared to baseline β coecient (95% CI) Compared to baseline
Baseline (Level 0) (intercept) 47.1% (18.2%; 76.0%) 13,520 (9123–17,917)
Level 1 41.4% (34.5%; 48.2%) < 0.001* − 2531 (− 3364; − 1698) < 0.001*
Level 2 48.7% (42.0%; 55.5%) < 0.001 − 3638 (− 4521; − 2755) < 0.001
Level 3 45.2% (39.3%; 51.2%) < 0.001§ − 3644 (− 4428; − 2859) < 0.001§
Gender (male) 1.7% (− 3.2%; 6.5%) 0.502 1024 (53;1944) 0.039
Age (per year increase) 1.4% (0.2%; 2.6%) 0.019 − 378 (− 615; − 143) 0.002
Year (2020) − 0.6% (− 6.4%; 5.1%) 0.826 − 1560 (− 2796; − 324) 0.013
Weekend 10.9% (8.0%; 13.8%) < 0.001 − 1002 (1374; − 630) < 0.001
Temperature (per degree C0
increase) − 0.03% (− 0.07%; 0.15%) 0.909 58.0 (− 6; 122) 0.075
Humidity (per % increase 0.04% (− 0.07%; 0.15%) 0.539 − 29 (− 42; − 15) < 0.001
Interaction term β coecient (95% CI) Compared to baseline β coecient (95% CI) Compared to baseline
Weekend # Level 1 − 22.8% (− 33.8%; − 11.8%) < 0.001 1870 (539; 3202) 0.006
Weekend # Level 2 − 13.0% (− 25.9%; − 0.1%) 0.047 1196 (− 535; 2927) 0.176
Weekend # Level 3 − 18.6% (− 27.4%; − 9.8%) < 0.001 1361 (191; 2531) < 0.001
Table 4. Fraction time spent at home and total steps per day in response to interventions for Covid-19 among
asthmatic children in Greece. *p = 0.020, compared to previous level. p > 0.05, compared to the previous level.
Parameter
Fraction time spent at home Total Steps per day
β coecient (95% CI) Compared to baseline β coecient (95% CI) Compared to baseline
Baseline (Level 0) (intercept) 74.6% (52.3%; 97.0%) 13,342 (9182; 17,501)
Level 1 14.3% (2.2%; 26.3%) 0.020* − 1191 (− 2641; − 259) 0.108
Level 2 23.1% (11.2%; 34.9%) < 0.001 − 2337 (− 3679; − 995) 0.001
Level 3 32.0% (24.8%; − 39.3%) < 0.001 − 1961 (− 2933; − 990) < 0.001
Gender (male) 2.2% (− 3.4%; 7.7%) 0.442 1064 (− 63; 2191) 0.064
Age (per year increase) − 1.0% (− 2.6%; 0.5%) 0.191 57 (− 257; 370) 0.722
Year (2020) − 0.7% (− 7.9%; 6.6%) 0.859 − 2791 (− 4090; − 1492) < 0.001
Weekend 8.32% (5.2%; 11.4%) < 0.001 − 1212 (1615; − 809) < 0.001
Temperature (per degree C0
increase) − 0.6% (− 1.3%; 0.0%) 0.059 21 (− 64; 107) 0.628
Humidity (per % increase) − 0.1% (− 0.2%; 0.0%) 0.061 − 2 (− 16; 12) 0.763
Interaction term β coecient (95% CI) Compared to baseline β coecient (95% CI) Compared to baseline
Weekend # Level 1 − 12.7% (− 37.2%; − 11.8%) 0.310 149 (− 2739; 3037) 0.006
Weekend # Level 2 − 9.5% (− 32.5%; 13.5%) 0.416 3704 (1115; 6292) 0.005
Weekend # Level 3 − 9.6% (− 19.8%; 0.5%) 0.063 1433 (96; 2772) 0.036
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the fraction of time spent at home was also found to be signicantly higher during weekends as compared
to weekdays (mean increase: 8.32%. 95%CI: 5.2; 11.4%), while steps per day were signicantly lower during
weekends (mean decrease: 1,212. 95%CI: − 1,615; − 809) and in year 2020 as compared to year 2019 (mean
decrease: − 2,791. 95%CI: − 4,090; − 1,492) (Table4). In asthmatic children in Cyprus, we found a signicant
interaction eect of weekends across all levels of interventions on both the fraction time spent indoors and
total steps per day. e eect of weekends on fraction time spent indoors changed, signicantly, from positive
during level 0 (mean increase: 10.9%) to negative during level 1 (mean decrease: − 22.8%, pvalue: < 0.001), level 2
(mean decrease: − 13.0%, pvalue: 0.047) and level 3 (mean decrease: − 18.6%, pvalue: < 0.001). A similar interaction
eect was observed on the eect of weekends on total steps per day which changed from negative during level
0 (mean decrease: 1002) to positive during level 1 (mean increase: 1863, pvalue: 0.006), level 2 (mean increase:
1180, pvalue: 0.181) and level 3 (mean increase: 1359, pvalue: < 0.023), (Table3). In asthmatic children in Greece
we found a signicant interaction eect for weekends only in regards to total steps per day. During the baseline
period, weekends were associated with a mean decrease of 1212 steps per day while this eect was reversed in
level 1 (mean increase: 149, pvalue: 0.919), level 2 (mean increase: 3704, pvalue: 0.005) and level 3 (mean increase:
1434, pvalue: 0.036), (Table4).
Discussion
In this study, we have assessed changes in mobility of asthmatic children in Cyprus and Greece in response to
dierent levels of public health interventions for the COVID-19 pandemic using GPS tracking, pedometer and
heart rate sensors embedded in wearable watches. Our data imply that asthmatic children in both countries were
highly compliant to public health measures, by changing their everyday routine and limiting their activity and
mobility outside their homes.
In asthmatic children in Cyprus, we recorded a steep increase in the fraction of time spent at home from
44% to the very high 95% and a steep decrease in total steps per day from 8,996 to 6,270, demonstrating high
compliance to the implemented three levels of interventions. In asthmatic children in Greece, we observed a
more gradual, stepwise increase in fraction time spent at home from 52% at baseline to the also high 90% and
a similar pattern of gradual decrease of physical activity from 8,527 to 5,439 steps/day. e subtle dierences in
the ndings between the two countries can be explained by dierences in the actual measures implemented in
each country rather than by real dierences in the compliance of asthmatic children to the interventions. In fact,
intervention measures in Greece were slightly dierent to those in Cyprus. In Greece level 2 measures included
only ban of public gatherings and closure of shops and worship places, and escalated to include personal transport
and movement restrictions only in level 3 period. In Cyprus, personal mobility restrictions were implemented
from level 2 measures and became stricter (only one movement per day) in level 3, although the corresponding
changes in fraction time spent at home and steps per day between level 2 and level 3 periods were not signicant
in our study group.
e successful management of the pandemic spread in Cyprus and Greece is probably due to the early intro-
duction of lockdown measures in both countries by March 25 and 23, 2020 respectively, and the high compli-
ance of vulnerable groups, and possibly the general population, who spent the majority of their time at home.
e eectiveness of lockdown measures to reduce transmission of COVID-19 in several European countries
including Greece was previously reported28. A recent modelling study evaluated the impact of the sequence of
restrictions posed to mobility and human-to-human interactions on the virus transmission in Italy and found
that they have reduced transmission by 45%29. As of 26 April 2020, 1.43 and 1.22 deaths per 100,000 popula-
tion were reported for Cyprus and Greece respectively, which places them among the countries with the lowest
mortality rates for COVID-19 in the EU/EEA and UK30. Our ndings may also relate to those of several recent
studies that reported reduced asthma morbidity in children during the COVID-19 pandemic, attributed to the
reduction of the overall viral infections because of signicant changes in their daily activity3134.
It is well documented that wearable technology is a reliable, objective tool for monitoring numerous dis-
eases and estimating adherence to medication35. However, to the best of our knowledge, there are no previ-
ous studies examining compliance to public health interventions using wearable devices. Previous reports on
adherence to public health interventions during epidemics were based on telephone or mailed interviews and
questionnaires1719,36. ese conventional tools have inherent limitations such as non-response, recall biases, lack
of validation of self-reports, inuence by concerns about being recognized as breaching quarantine and low-level
spatio-temporal information. In contrast, the use of wearable devices provides objective, continuous, real-time
location and activity data making possible to timely inform public health ocials on the results of various tiers
of public health interventions and ensure adequate decision making in escalating or de-escalating interventions.
Using a mixed eects model, we were able to nd independent quantitative eects of several factors on the
time participants spent at home (weekends, increasing age) and their physical activity (weekends, increasing
age, humidity and gender). We also found an interaction eect of weekends on higher fraction of time spent
at home and lower physical activity, which was reversed during the implementation of intervention measures
in both countries. One possible explanation is that, under normal conditions, families spend more time out of
home on weekdays and more time at home during weekends. During the pandemic period this was reversed, as
working parents and children had to work or study at home during weekdays and spend more time for outdoor
activities on weekends. However, the change of participants’ daily behavior in both countries and the increase
in their mobility on weekends during the enforcement of the lockdown measures requires further investigation.
e independent eect of age on increasing fraction time spent at home and lower physical activity and female
gender on lower physical activity in asthmatic children in Cyprus, agree with previous studies that reported
lower physical activity in asthmatic girls37 and older asthmatic children38. Year 2020 has been associated with
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lower physical activity in asthmatic children in both countries, which may relate to a systematic eect of either
the recording devices used or implication of environmental factors we have not accounted for in the analysis.
Digital technology has been widely used in the COVID-19 management, including tracking positive cases,
informing citizens about the current epidemiological status in their region, performing virtual clinics and diag-
nostics through telemedicine and in disease modelling using big data analysis39,40. Our study presents another
promising application of digital technology in the ght against the pandemic, by employing wearable sensors to
provide objective and real-time information about population compliance to public health measures. erefore,
in a public health emergency, it is possible to employ wearable technology in a greater sample of the general
population and enable rapid measurements of the public reaction to a particular set of interventions. GPS and
physical activity data for example, are collected anonymously by telephone companies from their smartphone
customers and theoretically may provide information about populations attitude and adherence to interventions
taken in pandemics and/or natural disasters. Towards this aim, in Israel a cell-phone tracking system was used
in SARS-CoV-2 positive individuals to facilitate contacts tracing41, while data from smartphone users in Italy
have been analysed to estimate citizen mobility during the lockdown42. In this direction, future applications of
wearable digital technology may include the development of appropriate tools and infrastructure for ecient,
systematic integration and interoperability of dierent health and behaviour data sources into existing public
health systems. is approach will facilitate the link between symptom-tracking apps, behavior-tracking apps,
contact tracing, aggregate population mobility monitoring, healthcare access and e-health monitoring40.
Nevertheless, this kind of monitoring raises important ethical issues, as it could be considered as limiting
individual freedoms and rights4346. In our case, monitoring of these patients with wearable devices was already
established as part of the ongoing MEDEA project that started much before the spread of COVID-19, and thus
we had obtained timely ethical approval and written consent from participants. In the case of pandemics, where
decisions and measures are taken within days or even hours, it is extremely dicult to obtain fast-track consent
from individuals to record their attitudes with wearable technology. For this reason, future health surveillance
tracking and contact-tracing tools and applications should be designed in a way that can preserve individual
freedoms and assert patient autonomy in a socially responsible manner, while educating the population about
the positive eects of health surveillance47.
An important limitation of wearable technology is the loss of signal of GPS tracking, especially in indoor
environments, which introduces the challenge of how to treat missing values. As a response, automated micro-
environment classication algorithms that include spatial and temporal buering have been developed and
validated, especially for air pollution exposure studies48 and provide an eective way to account for missing
location data. Our ndings should be interpreted with caution and not be generalized directly to all children
or to the general population, because soon aer the appearance of the COVID-19 pandemic it became widely
known that asthmatic patients may be at increased risk for severe disease49. Furthermore, asthmatic patients
were more likely accustomed to protective behavioural changes even before the pandemic, as they were aware
of the negative health eects of poor air quality50,51 and the potential of atmospheric pollutants to further impair
the respiratory system and facilitate viral infection, as it has been suggested for SARS-CoV-252. ese factors
may have led to increased compliance to public health intervention measures for COVID-19, as compared to
the general population. Further studies, focusing on the general population are needed to better assess the full
extent of population compliance to public health intervention measures for COVID-19. Finally, our cohort lacks
information about family characteristics during the pandemic, such as parents’ employment status and time spent
working from home, which may aect the outcomes of our study.
Conclusion
In conclusion, we implemented novel wearable technology methods to assess personal compliance to public
health interventions aiming to contain the spread of a novel, highly contagious virus such as SARS-CoV-2. e
successful implementation of public health interventions in Cyprus and Greece, which minimized COVID-19
related mortality in both countries, was reected in the sharp mobility reductions recorded in the participants
of our study early in the course of the outbreak. Wearable devices provide objective, continuous, real-time data
that may timely inform public health ocials on compliance to various tiers of public health interventions and
ensure informed decision-making and strategic planning in the containment of epidemics, both at national and
cross-national levels.
Materials and methods
Study setting. Asthmatic children were recruited from primary schools in Cyprus and Greece (Heraklion
district, Crete) and were enrolled in the ongoing LIFE-MEDEA public health intervention project (Clinical.
Trials.gov Identier: NCT03503812). e LIFE-MEDEA project aims to evaluate the ecacy of behavioral rec-
ommendations to reduce exposure to particulate matter during desert dust storm (DDS) events and thus miti-
gate disease-specic adverse health eects in vulnerable groups of patients. Details of the study protocol and
methods are presented in Supplementary File 1. In order to assess adherence to recommendations, participants
are equipped with a wearable device (smartwatch) with several sensors. Participants are instructed to wear the
smartwatch throughout the study period, during both DDS and non-DDS days. During non-DDS days, all par-
ticipants carry out their usual daily activities. e rst MEDEA study period took place during February-June
2019, the second study period during February-June 2020.
Study populations and recruitment. In the asthma panel study the target population were children aged
from 6 to 11years with mild to moderate persistent asthma. e eligibility criteria included a physician’s diagno-
sis of asthma and at least one of the following: daily preventative asthma medication, wheezing episodes and/or
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unscheduled medical visits for asthma during the past 12months. Basic demographic and clinical information
from all participants was collected during the recruitment process. e number of eligibility criteria applying for
each participant were used to categorize participants into asthma severity groups. e groups were dened as
follows: Asthma Severity 1 (Physician diagnosis plus one other eligibility criterion), Asthma Severity 2 (Physi-
cian diagnosis plus two other eligibility criteria) and Asthma Severity 3 (Physician diagnosis plus three or more
other eligibility criteria). In Cyprus, study approvals were obtained from the Cyprus National Bioethics Commit-
tee (EEBK EΠ 2017.01.141), the Data Protection Commissioner (No. 3.28.223) and the Ministry of Education
(No 7.15.01.23.5). In Greece, approvals were obtained from the Scientic Committee (25/04/2018, No: 1748)
and the Governing Board of the University General Hospital of Heraklion (25/22/08/2018). Guardians of all
participants provided written informed consent and all methods described below were performed in accordance
with the relevant guidelines and regulations.
Physical activity and GPS tracking. Physical activity and global positioning system (GPS) data were
recorded between February 3 and April 26, for both study years (2019 and 2020) in Cyprus and Greece using
the smartwatch. Data from study year 2020 were extracted to assess the participants’ mobility before and during
the enforcement of COVID-19 lockdown measures while data from study year 2019 that represent a completely
restrictions-free mobility period were also used for comparison. e EMBRACE™ smartwatch (Embrace Tech
LTD, Cyprus) was used for data collection. e smartwatch works as a stand-alone device and is equipped with
multiple sensors such as pedometer, GPS and heart rate as well as an embedded sim-card for Wi-Fi data trans-
fer. e soware is capable of synchronizing the sensors, so the data are transferred to the cloud with the same
timestamp. Data on GPS coordinates and steps/time unit, and heart rate are collected per 5-min intervals. Data
synchronization with a cloud-based database is performed automatically when the smartwatch contacts the
Wi-Fi network inside the participants’ home. For each participant we recorded the total number of steps per day
(24-h period). In addition, we dened the fraction of time spent at home as the ratio of time with GPS signal
within a 100m radius around the participant’s residence divided by 24h. e 100m radius was dened as the
maximum barrier to account for the accuracy of GPS signal in commercially available GPS receivers53. As signal
accuracy in urban and especially indoor environments is further blocked or bounced repeatedly o buildings
prior to being received54, we also classied 5-min intervals with no GPS signal as either “at-home” or “out-home,
depending on the signal of the most recent valid GPS recording. Lastly, the days that participants did not wear
the smartwatch were identied by absence of heart rate measurements, and were excluded from subsequent
analysis. We also excluded from the analysis GPS and pedometer data for DDS days in Cyprus (5days during
February-April 2020 and 4days during February-April 2019) and Crete-Greece (1day during February-April
2020 and 2days during February-April 2019) that may had further inuenced the mobility of the participants.
Public health (non‑pharmaceutical) interventions in Cyprus and Greece. Data collection period
spans for 12weeks from February 3 to April 26, 2020 and was divided into four levels based on the implemented
public health interventions in each country. In Cyprus, the rst COVID-19 cases were identied on March 9,
2020 and the study period is divided to: i) level 0 (baseline)—no public health interventions (Weeks 1–5: Febru-
ary 3, 2020–March 12, 2020), ii) level 1—social distancing measures, ban of public events with > 75 people, bars,
restaurants and schools closed (Weeks 6–7: March 13, 2020–March 24, 2020), iii) level 2—all retail shops and
worship places were closed, and mobility restrictions were implemented, except for subsistence and health needs
(3 permissions per person per day) (Week 8: March 25, 2020–March 31, 2020), iv) level 3—stringent lockdown
Figure3. Timeline of public health interventions in Cyprus and Greece. Timeline of the study recordings in
relation to introduction of public health interventions in Cyprus (A) and Greece (B) during March–April 2020.
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with only one mobility permission per person per day (Weeks 9–12: April 01, 2020–April 26, 2020) (Fig.3). In
Greece, the rst COVID-19 case was identied on February 26, 2020 and the study period is divided to: i) level
0 (baseline)— no public health interventions (Weeks 1–5: February 03, 2020–March 10, 2020), ii) level 1—social
distancing measures, ban of all public events, bars, restaurants and schools closed (Week 6: March 11, 2020–
March 15, 2020), iii) level 2—all retail shops and worship places closed, ban of gatherings of > 10 people (Week 7:
March 16, 2020–March 22, 2020), iv) level 3—mobility restrictions except for subsistence and health needs (no
daily limit) (Weeks 8–12: March 23, 2020-April 26, 2020) (Fig.3).
Statistical analysis. Basic demographics and clinical characteristics of the asthmatic children were sum-
marized using mean (standard deviation) for continuous variables and percentages for categorical variables.
In an unadjusted analysis, the mean fraction time spent at home and mean total steps per day were compared
between the dierent periods of public health interventions using ANOVA, while graphs were constructed in
order to demonstrate the weekly variation in mobility before and during the implementation of public health
interventions in Cyprus and Greece. Furthermore, the course of fraction time spent at home and total steps per
day in asthmatic children participating in the second MEDEA study period during February–April 2020 and
the same parameters’ course in asthmatic children participating in the rst MEDEA study period during Febru-
ary–April 2019 are displayed in separate graphs for Cyprus and Greece.
e changes in the daily levels of fraction time spent at home and total steps were further explored in a
mixed eect model, which included a xed eect term for the level of public health interventions and a random
intercept for each participant. e mixed eect model was adjusted for the eect of age, gender, temperature,
humidity, year, and weekend on mobility. In addition, sine and cosine functions were included to control for
monthly variability in our data. Finally, for each parameter, we used an interaction term to test for dierential
change of mobility across the levels of interventions measures.
All statistical comparisons were performed using STATA 12 (StataCorp, TX) and a p value lower than 0.05
was considered as statistically signicant.
Data availability
A preprint of the manuscript is available under https ://www.resea rchsq uare .co m/a rtic le/rs-37518 /v1. e original
data are available under https ://zenod o.org/recor d/39064 45#.XvUBh G5uI2 w (https ://doi.org/10.5281/zenod
o.39064 45).
Received: 1 July 2020; Accepted: 18 February 2021
References
1. Cui, J., Li, F. & Shi, Z. Origin and evolution of pathogenic coronaviruses. Nat. Rev. Microbiol. 17, 181–192 (2019).
2. Wu, Z. & McGoogan, J. M. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in
China: Summary of a report of 72 314 cases from the Chinese Center for Disease Control and Prevention. JAMA 323, 1239–1242
(2020).
3. h ttps ://www.who.int/dg/speec hes/detai l/who-direc tor-gener al-s-openi ng-remar ks-at-the-media -brie ng-on-covid -19-11-march
-2020.
4. Amanat, F. & Krammer, F. SARS-CoV-2 vaccines: status report. Immunity 52, 583–589 (2020).
5. Wilder-Smith, A., Chiew, C. J. & Lee, V. J. Can we contain the COVID-19 outbreak with the same measures as for SARS?. Lancet
Infect. Dis. 20, e102–e107 (2020).
6. Wilder-Smith, A. & Freedman, D. Isolation, quarantine, social distancing and community containment: pivotal role for old-style
public health measures in the novel coronavirus (2019-nCoV) outbreak. J. Travel Med. 27, taaa020 (2020).
7. NussbaumerStreit, B. et al. Quarantine alone or in combination with other public health measures to control COVID19: A rapid
review. Cochrane Database Syst. Rev. (2020).
8. Ní Ghráinne, B. Covid-19, Border closures, and international law. Border Closures, and International Law (July 28, 2020) (2020).
9. Kandel, N., Chungong, S., Omaar, A. & Xing, J. Health security capacities in the context of COVID-19 outbreak: An analysis of
International Health Regulations annual report data from 182 countries. e Lancet (2020).
10. Bedford, J. et al. COVID-19: Towards controlling of a pandemic. Lancet 395, 1015–1018 (2020).
11. Saez, M., Tobias, A., Varga, D. & Barceló, M. A. Eectiveness of the measures to atten the epidemic curve of COVID-19. e case
of Spain. Sci. Total Environ. 138761 (2020).
12. Paital, B., Das, K. & Parida, S. K. Inter nation social lockdown versus medical care against COVID-19, a mild environmental insight
with special reference to India. Sci. Total Environ. 138914 (2020).
13. Ebrahim, S. H., Ahmed, Q. A., Gozzer, E., Schlagenhauf, P. & Memish, Z. A. Covid-19 and community mitigation strategies in a
pandemic (2020).
14. Tian, H. et al. Early evaluation of Wuhan City travel restrictions in response to the 2019 novel coronavirus outbreak. Medrxiv
(2020).
15. Markel, H., Gostin, L. O. & Fidler, D. P. Extensively drug-resistant tuberculosis: an isolation order, public health powers, and a
global crisis. JAMA 298, 83–86 (2007).
16. Anderson, R. M., Heesterbeek, H., Klinkenberg, D. & Hollingsworth, T. D. How will country-based mitigation measures inuence
the course of the COVID-19 epidemic?. Lancet 395, 931–934 (2020).
17. Blendon, R. J. et al. Public response to community mitigation measures for pandemic inuenza. Emerg. Infect. Dis. 14, 778–786
(2008).
18. Taylor, M. et al. Public health measures during an anticipated inuenza pandemic: Factors inuencing willingness to comply. Risk
Manag. Healthc. Policy. 2, 9–20 (2009).
19. Eastwood, K. et al. Knowledge about pandemic inuenza and compliance with containment measures among Australians. Bull.
World Health Organ. 87, 588–594 (2009).
20. Collivignarelli, M. C. et al. Lockdown for CoViD-2019 in Milan: What are the eects on air quality?. Sci. Total Environ. 732, 139280
(2020).
21. Bashir, M. F., Benjiang, M. & Shahzad, L. A brief review of socio-economic and environmental impact of Covid-19. Air Qual.
Atmos. Health 13, 1403–1409 (2020).
Content courtesy of Springer Nature, terms of use apply. Rights reserved

Vol:.(1234567890)
Scientic Reports | (2021) 11:5895 | 
www.nature.com/scientificreports/
22. Saladié, Ò., Bustamante, E. & Gutiérrez, A. COVID-19 lockdown and reduction of trac accidents in Tarragona province, Spain.
Transp. Res. Interdiscip. Perspect. 8, 100218 (2020).
23. Lecocq, T. et al. Global quieting of high-frequency seismic noise due to COVID-19 pandemic lockdown measures. Science 369,
1338–1343 (2020).
24. CDC COVID-19 Response Team. Coronavirus Disease 2019 in Children United States, February 12-April 2, 2020. MMWR Morb.
Mortal. Wkly. Rep. 69, 422–426 (2020).
25. Lee, S. C., Son, K. J., Han, C. H., Jung, J. Y. & Park, S. C. Impact of comorbid asthma on severity of coronavirus disease (COVID-
19). Scientic reports 10, 1–9 (2020).
26. Bousquet, J., Bousquet, P. J., Godard, P. & Daures, J. e public health implications of asthma. Bull. World Health Organ. 83, 548–554
(2005).
27. Pisano, L., Galimi, D. & Cerniglia, L. A qualitative report on exploratory data on the possible emotional/behavioral correlates of
Covid-19 lockdown in 4–10 years children in Italy (2020).
28. https ://mrc-ide.githu b.io/covid 19est imate s/#/inter venti ons.
29. Gatto, M. et al. Spread and dynamics of the COVID-19 epidemic in Italy: Eects of emergency containment measures. Proc. Natl.
Acad. Sci. U. S. A. 117, 10484–10491 (2020).
30. https ://www.ecdc.europ a.eu/en/cases -2019-ncov-eueea .
31. Castro-Rodriguez, J. A. & Forno, E. Asthma and COVID-19 in children: A systematic review and call for data. Pediatr. Pulmonol.
55, 2412–2418 (2020).
32. Kenyon, C. C., Hill, D. A., Henrickson, S. E., Bryant-Stephens, T. C. & Zorc, J. J. Initial eects of the COVID-19 pandemic on
pediatric asthma emergency department utilization. J. Allergy Clin. Immunol. Pract. 8, 2774–2776 (2020).
33. Taquechel, K. et al. Pediatric asthma health care utilization, viral testing, and air pollution changes during the COVID-19 pandemic.
J. Allergy Clin. Immunol. Pract. 8, 3378–3387 (2020).
34. Abe, K., Miyawaki, A., Nakamura, M., Ninomiya, H. & Kobayashi, Y. Trends in hospitalizations for asthma during the COVID-19
outbreak in Japan. J. Allergy Clin. Immunol. Pract. 9, 494–496 (2020).
35. Kim, J., Campbell, A. S., de Ávila, B. E. & Wang, J. Wearable biosensors for healthcare monitoring. Nat. Biotechnol. 37, 389–406
(2019).
36. Reynolds, D. et al. Understanding, compliance and psychological impact of the SARS quarantine experience. Epidemiol. Infect.
136, 997–1007 (2008).
37. Yiallouros, P. K. et al. Gender dierences in objectively assessed physical activity in asthmatic and non-asthmatic children. Ped iatr.
Pulmonol. 50, 317–326 (2015).
38. Reznik, M., Islamovic, F., Choi, J., Leu, C. & Rowlands, A. V. Factors associated with in-school physical activity among urban
children with asthma. J. Asthma 55, 492–501 (2018).
39. Ting, D. S. W., Carin, L., Dzau, V. & Wong, T. Y. Digital technology and COVID-19. Nat. Med. 26, 459–461 (2020).
40. Budd, J. et al. Digital technologies in the public-health response to COVID-19. Nat. Med. 26, 1183–1192 (2020).
41. Amit, M. et al. Mass-surveillance technologies to ght coronavirus spread: e case of Israel. Nat. Med. 26, 1167–1169 (2020).
42. Pepe, E. et al. COVID-19 outbreak response, a dataset to assess mobility changes in Italy following national lockdown. Sci. Data
7, 1–7 (2020).
43. Anaya, L. S., Alsadoon, A., Costadopoulos, N. & Prasad, P. Ethical implications of user perceptions of wearable devices. Sci. Eng.
Ethics 24, 1–28 (2018).
44. Hayry, M. Public health and human values. J. Med. Ethics 32, 519–521 (2006).
45. Van Bavel, J. J. et al. Using social and behavioural science to support COVID-19 pandemic response. Nat. Hum. Behav. 4, 460–471
(2020).
46. Kokkoris, M. D. & Kamleitner, B. Would you sacrice your privacy to protect public health? Prosocial responsibility in a pandemic
paves the way for digital surveillance. Front. Psychol. 11, 2362 (2020).
47. Calvo, R. A., Deterding, S. & Ryan, R. M. Health surveillance during covid-19 pandemic (2020).
48. Breen, M. S. et al. GPS-based microenvironment tracker (MicroTrac) model to estimate time–location of individuals for air pol-
lution exposure assessments: Model evaluation in central North Carolina. J. Eposure Sci. Environ. Epidemiol. 24, 412–420 (2014).
49. Hartmann-Boyce, J. et al. Asthma and COVID-19: review of evidence on risks and management considerations (BMJ Evid Based,
2020).
50. Edginton, S., O’Sullivan, D. E., King, W. D. & Lougheed, M. D. e eect of acute outdoor air pollution on peak expiratory ow
in individuals with asthma: A systematic review and meta-analysis. Environ. Res. 192, 110296 (2020).
51. Watanabe, M. et al. Inuence of Asian desert dust on lower respiratory tract symptoms in patients with asthma over 4 years. Yon ago
Acta Med. 55, 41–48 (2012).
52. Fattorini, D. & Regoli, F. Role of the chronic air pollution levels in the Covid-19 outbreak risk in Italy. Environ. Pollut. 264, 114732
(2020).
53. Duncan, M. J., Badland, H. M. & Mummery, W. K. Applying GPS to enhance understanding of transport-related physical activity.
J. Sci. Med. Sport 12, 549–556 (2009).
54. Wu, J. et al. Performances of dierent global positioning system devices for time-location tracking in air pollution epidemiological
studies. Environ. Health Insights 4, S6246 (2010).
Acknowledgements
We are grateful to all LIFE-MEDEA participants, their families and school teachers for their cooperation.
Author contributions
PK: Conceptualization, Project administration, Methodology, Soware, Data curation, Visualisation, Formal
analysis ,Writing-Original dra preparation; AM: Methodology, Data curation, Visualisation, Formal analysis,
Writing-Original dra preparation; PA: Data curation, Visualisation, Writing-Original dra preparation; EG:
Data curation, Visualisation, Writing—Review & Editing; EM: Data curation, Writing—Review & Editing; HD:
Project administration, Data curation, Writing—Review & Editing; AM: Data curation, Visualisation, Writing—
Review & Editing; PK: Data curation, Visualisation, Writing—Review & Editing; SA: Data curation, Visualisation,
Writing—Review & Editing; HZ: Soware, Writing—Review & Editing; SIP: Conceptualization, Methodology,
Writing—Review & Editing; PK: Conceptualization, Methodology, Soware, Writing—Review & Editing; GKN:
Conceptualization, Methodology; Soware, Formal analysis, Writing—Review & Editing; PKY: Conceptualiza-
tion, Methodology; Writing—Review & Editing, Funding acquisition, Supervision.
Funding
is study was supported by the European Union LIFE Project MEDEA (LIFE16 CCA/CY/000041).
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... Most publications (19 out of 25, or 76% of publications) included in descriptive synthesis (Table 1), semi-structured synthesis (mmc1), and structured, machine-searchable synthesis (mmc2) utilized mHealth apps, or apps in conjunction with various online platforms or web portals. The remaining publications [31][32][33][34][35][36] utilized combinations of different standalone digital sensors (that is, without integration by an app) or a single digital sensor. ...
... Another publication [33] utilized a standalone device that permitted monitoring adherence to therapy nebulization in pre-school children (mmc1). A third publication [36] applied a standalone device to monitor the physical activity of asthmatic children and their whereabouts during the pandemic restrictions. These standalone devices connected with and transmitted the data to the telemonitoring team via WiFi access (i.e., in the Internet-of-Things manner), once the child returned home. ...
... Interestingly, the latter publication [36] was the only one in the final pool of 25 included publications that specifically addressed asthma management during the COVID-19 pandemic. This publication [36] used standalone devices for monitoring of physical activity of asthmatic children, as well as for ensuring proper compliance with lockdown regulations. ...
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Mobile (m) Health technology is well-suited for Remote Patient Monitoring (RPM) in a patient’s habitual environment. In recent years there have been fast-paced developments in mHealth-enabled pediatric RPM, especially during the COVID-19 pandemic, necessitating evidence synthesis. To this end, we conducted a scoping review of clinical trials that had utilized mHealth-enabled RPM of pediatric asthma. MEDLINE, Embase and Web of Science were searched from September 1, 2016 through August 31, 2021. Our scoping review identified 25 publications that utilized synchronous and asynchronous mHealth-enabled RPM in pediatric asthma, either involving mobile applications or via individual devices. The last three years has seen the development of evidence-based, multidisciplinary, and participatory mHealth interventions. The quality of the studies has been improving, such that 40% of included studies reported were randomized controlled trials. In conclusion, there exists high-quality evidence on mHealth-enabled RPM in pediatric asthma, warranting future systematic reviews and/or meta-analyses of the benefits of such RPM.
... Heterogeneity in the study types was observed as follows: cross-sectional (n = 9; 53%), longitudinal (n = 4; 24%), retrospective (n = 1; 6%), narrative review (n = 1; 6%) and pilot non-randomized studies (n = 2; 12%). Similar heterogeneity was found in participants too in the included studies: pregnant women [27], elderly [24,26], office workers [21], diabetes [18] and children [25]. All the studies were from high-income countries. ...
... Seven studies administered smartphone-based physical activity measurement through inbuilt accelerometers from which the captured data were transferred to the cloud server and visualized in smartphone applications [16-19, 21, 24, 31]. Majority of studies (n = 9; 53%) employed wrist bands and wristwatches of multiple technology firms (Apple, Samsung, Xiaomi) and wearable research-based accelerometers [20,23,25,26,[28][29][30]32]. A few studies (n = 4; 24%) reported the psychometrics of the wearables, and lowto-moderate validity was found [21,22,27]. ...
... Further reduction in step count and sleep time was found to be positively associated with body mass [19], depression [26] and workplace stress [32]. Various behavior change techniques such as self-efficacy, goal setting, prompt/cues, information and social networking were associated with the compliance of wearable use [24,25,31]. ...
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Background Wearables are intriguing way to promote physical activity and reduce sedentary behavior in populations with and without chronic diseases. However, the contemporary evidence demonstrating the effectiveness of wearables on physical health during the COVID-19 pandemic has yet to be explored. Aim The present review aims to provide the readers with a broader knowledge of the impact of wearables on physical health during the pandemic. Methods Five electronic databases (Web of Science, Scopus, Ovid Medline, Cumulative Index to Nursing and Allied Health Literature and Embase) were searched. The eligibility criteria of the studies to be included were based on PICOT criteria: population (adults, children and elderly), intervention (wearable, smartphones), comparison (any behavioral intervention), outcome (physical activity or sedentary behavior levels) and time frame (between December 1st, 2019 and November 19th, 2021). The present scoping review was framed as per the guidelines of the Arksey and O’Malley framework. Results Of 469 citations initially screened, 17 articles were deemed eligible for inclusion and potential scoping was done. Smartphone-based applications with inbuilt accelerometers were commonly used, while a few studies employed smart bands, smartwatches for physical health monitoring. Most of the studies observed the increased use of wearables in healthy adults followed by elderly, children and pregnant women. Considerable reduction (almost—50%) in physical activity during the pandemic: daily step count (− 2812 steps/min), standing (− 32.7%) and walking (− 52.2%) time was found. Conclusion Wearables appears to be impending means of improving physical activity and reducing sedentary behavior remotely during the COVID-19 pandemic.
... Results also show that wearable sensors can be biosensors connected to the body for assessing different biological elements; therefore, the healthcare system is one of the essential applications [52,90,91]. In fact, the embedding of wearable sensor systems in health treatment procedures reduces the cost of hospitals' daily expenditures. ...
... These high-frequency words' similarity regarding their co-occurrence matrix have been considered in topic creations. Results also show that wearable sensors can be biosensors connected to the body for assessing different biological elements; therefore, the healthcare system is one of the essential applications [52,90,91]. In fact, the embedding of wearable sensor systems in health treatment procedures reduces the cost of hospitals' daily expenditures. ...
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Scientific developments and new technological trajectories in sensors play an important role in understanding technological and social change. The goal of this study is to develop a scientometric analysis (using scientific documents and patents) to explain the evolution of sensor research and new sensor technologies that are critical to science and society. Results suggest that new directions in sensor research are driving technological trajectories of wireless sensor networks, biosensors and wearable sensors. These findings can help scholars to clarify new paths of technological change in sensors and policymakers to allocate research funds towards research fields and sensor technologies that have a high potential of growth for generating a positive societal impact.
... In the period of the COVID-19 pandemic, an objective decrease in PA levels has been observed in children with asthma. Using wearable sensors to continuously track personal location and PA, Kouis et al. assessed changes in mobility of asthmatic children in Cyprus and Greece, reporting an overall increase of time spent at home and a decrease of PA level (27). In Israel, a study using an electronic questionnaire submitted during lockdown (March-May 2020) to caregivers of children and adolescents with asthma and other chronic respiratory disorders demonstrated that patients aged >5 years had increased screen time, and decreased PA compared to their younger counterparts (p = 0.008 and p < 0.001, respectively) (28). ...
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Physical activity (PA) has been seen to improve asthma symptoms, lung function, and quality of life, as well as to reduce airway inflammation and bronchial responsiveness. As a consequence of the COVID-19 pandemic, the minimal amount of PA recommended by the World Health Organization—i.e., about 60 min/day of moderate-to-high intensity—is difficult to achieve for many children, particularly those living in urban areas. Short-term changes in PA because of the COVID-19 pandemic may become habitual, increasing the risk of adverse asthma outcomes in children. Indeed, prolonged home confinement during the COVID-19 pandemic reduces PA levels and increases sedentary behaviors, possibly impairing immune system function and increasing susceptibility to inflammatory diseases. However, there is limited evidence regarding the effects of lockdown due to COVID-19 on PA and sedentary behaviors in asthmatic children. Given that children stay longer indoors, indoor air pollution represents a major issue to consider during home confinement. This narrative review aims to summarize the available evidence about the impact of decreased PA and increased sedentary behaviors on children with asthma during the COVID-19 pandemic. In addition, strategies for supporting PA in children with asthma during the COVID-19 pandemic are suggested, also looking at the issue of indoor air quality.
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Objectives: To prospectively quantify at the community level changes in asthma symptom control and other morbidity indices, among asthmatic schoolchildren in response to coronavirus disease 2019 (COVID-19) lockdown measures. Methods: In Spring 2019 and Spring 2020, we prospectively assessed monthly changes in pediatric asthma control test (c-ACT), asthma medication usage, infections and unscheduled visits for asthma among schoolchildren with active asthma in Cyprus and Greece. We compared asthma symptom control and other morbidity indices before and during lockdown measures, while participants' time spent at home was objectively assessed by wearable sensors. Results: A total of 119 asthmatic children participated in the study during Spring 2020. Compared to a mean baseline (pre-COVID-19 lockdown) c-ACT score of 22.70, adjusted mean increases of 2.58 (95% confidence interval [CI]: 1.91, 3.26, p < 0.001) and 3.57 (95% CI: 2.88, 4.27, p < 0.001) in the 2nd and 3rd monthly assessments were observed after implementation of lockdown measures. A mean increase in c-ACT score of 0.32 (95% CI: 0.17, 0.47, p < 0.001) was noted per 10% increase in the time spent at home. Improvement was more profound in children with severe asthma, while significant reductions in infections, asthma medication usage and unscheduled visits for asthma were also observed. During Spring 2019, 39 children participated in the study in the absence of lockdown measures and no changes in c-ACT or other indices of disease severity were observed. Conclusions: Clinically meaningful improvements in asthma symptom control, among asthmatic schoolchildren were observed during the COVID-19 lockdown measures in Spring 2020. Improvements were independently associated with time spent at home and were more profound in the children with severe asthma.
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This paper analyses the impact that the lockdown decreed by the Spanish Government to combat the spread of COVID-19 has had on traffic accidents in Tarragona province (Spain). During the studied period of the lockdown (March 16 - April 26 2020) the number of accidents per day fell by 74,3% in coparison with those in February 14-20 (reference week) and 76% in respect to the equivalent period in 2018-2019. This reduction of accidents has been higher than the decrease of mobility during the same reference period (62.9%). This suggests a multiplicative positive effect of traffic reduction on roads safety. Our findings provide new evidences of the disruptive effect of the COVID-19 pandemic on transportation and of how it could be used as a catalyst to promote more sustainable and secure transport systems.
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The severity of the coronavirus disease (COVID-19) is associated with various comorbidities. However, no studies have yet demonstrated the potential risk of respiratory failure and mortality in COVID-19 patients with pre-existing asthma. We selected 7272 adult COVID-19 patients from the Korean Health Insurance Review and Assessment COVID-19 database for this nationwide retrospective cohort study. Among these, 686 patients with asthma were assessed by their severities and evaluated by the clinical outcome of COVID-19 compared to patients without asthma. Of 7272 adult COVID-19 patients, 686 with asthma and 6586 without asthma were compared. Asthma was not a significant risk factor for respiratory failure or mortality among all COVID-19 patients (odds ratio [OR] = 0.99, P = 0.997 and OR = 1.06, P = 0.759) after adjusting for age, sex, and the Charlson comorbidity score. However, a history of acute exacerbation (OR = 2.63, P = 0.043) was significant risk factors for death among COVID-19 patients with asthma. Asthma is not a risk factor for poor prognosis of COVID-19. However, asthma patients who had any experience of acute exacerbation in the previous year before COVID-19 showed higher COVID-19-related mortality, especially in case of old age and male sex.
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Digital surveillance methods, such as location tracking apps on smartphones, have been implemented in many countries during the COVID-19 pandemic, but not much is known about predictors of their acceptance. Could it be that prosocial responsibility, to which authorities appealed in order to enhance compliance with quarantine measures, also increases acceptance of digital surveillance and restrictions of privacy? In their fight against the COVID-19 pandemic, governments around the world communicated that self-isolation and social distancing measures are every citizen’s duty in order to protect the health not only of oneself but also of vulnerable others. We suggest that prosocial responsibility besides motivating people to comply with anti-pandemic measures also undermines people’s valuation of privacy. In an online research conducted with US participants, we examined correlates of people’s willingness to sacrifice individual rights and succumb to surveillance with a particular focus on prosocial responsibility. First, replicating prior research, we found that perceived prosocial responsibility was a powerful predictor of compliance with self-isolation and social distancing measures. Second, going beyond prior research, we found that perceived prosocial responsibility also predicted willingness to accept restrictions of individual rights and privacy, as well as to accept digital surveillance for the sake of public health. While we identify a range of additional predictors, the effects of prosocial responsibility hold after controlling for alternative processes, such as perceived self-risk, impact of the pandemic on oneself, or personal value of freedom. These findings suggest that prosocial responsibility may act as a Trojan horse for privacy compromises.
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Nationwide preventive measures for COVID-19 in Japan was associated with a sharp drop in hospitalizations for asthma as a secondary effect. Health professionals may reappraise the importance of patients’ behavior and physical environment to improve the regulation of their asthma.
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Digital technologies are being harnessed to support the public-health response to COVID-19 worldwide, including population surveillance, case identification, contact tracing and evaluation of interventions on the basis of mobility data and communication with the public. These rapid responses leverage billions of mobile phones, large online datasets, connected devices, relatively low-cost computing resources and advances in machine learning and natural language processing. This Review aims to capture the breadth of digital innovations for the public-health response to COVID-19 worldwide and their limitations, and barriers to their implementation, including legal, ethical and privacy barriers, as well as organizational and workforce barriers. The future of public health is likely to become increasingly digital, and we review the need for the alignment of international strategies for the regulation, evaluation and use of digital technologies to strengthen pandemic management, and future preparedness for COVID-19 and other infectious diseases. The COVID-19 pandemic has resulted in an accelerated development of applications for digital health, including symptom monitoring and contact tracing. Their potential is wide ranging and must be integrated into conventional approaches to public health for best effect.
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In recent months, Covid-19 has caused significant global social and economic distress. Governments and health officials around the world have introduced mandatory preventive measures to combat Covid-19, i.e., hand sanitizers, gloves, and masks, which have contributed to large quantities of medical wastes. Social distancing and mandatory lockdown have also been put in place to protect people from Covid-19. This epidemic has caused severe demographic changes and unemployment, and economic activities have been shut down to save human lives. Transportation and travel industries are most severely hit as global tourism has fallen to almost zero in recent months; as a solution, economic institutes have introduced stimulus packages worth more than $6 trillion. However, restricted economic activities have also contributed towards a cleaner environment. However, environmental changes are not permanent, and the pollution level may rise again in the future. As a result, current research suggests that policymakers must introduce stringent environmental policies to promote clean energy.
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Objectives Acute exposures to outdoor air pollution have been shown to reduce lung function in children with asthma, but the effect on adults with asthma has not been established in a meta-analysis. The objective of this study was to conduct a systematic literature review and meta-analysis of studies that assessed the relationship of outdoor air pollution and peak expiratory flow (PEF) in adults with asthma. Methods Studies that contained data on outdoor air pollution levels (PM10, PM2.5, or NO2) and PEF in adults with asthma were eligible for inclusion. Effect estimates were quantified for each air pollution measure using random effects models. Heterogeneity was investigated with the Q-test and I² statistics. Meta-regression and subgroup analyses were conducted to determine differences in effect by air pollution measures and the inclusion of smokers. Results A total of 22 effect estimates from 15 studies were included in this review. A 10 μg/m³ increase in acute PM10 exposure was associated with a −0.19 L/min (95% CI: 0.30, −0.09) change in PEF. For both PM10 and PM2.5, the inclusion of current smokers was a significant source of heterogeneity among studies (meta-regression: p = 0.04 and p = 0.03). Among studies that only included non-smokers, a 10 μg/m³ increase in acute exposure to PM10 and PM2.5 was associated with changes in PEF of −0.25 L/min (95% CI: 0.38, −0.13) and −1.02 L/min (95% CI: 1.79, −0.24), respectively. Conclusions This study provides evidence that acute increases in PM10 and PM2.5 levels are associated with decreases in PEF in adults with asthma, particularly among non-smokers.
Article
Background: Coronavirus disease 2019 (COVID-19) is a rapidly emerging disease classified as a pandemic by the World Health Organization (WHO). To support the WHO with their recommendations on quarantine, we conducted a rapid review on the effectiveness of quarantine during severe coronavirus outbreaks. Objectives: To assess the effects of quarantine (alone or in combination with other measures) of individuals who had contact with confirmed or suspected cases of COVID-19, who travelled from countries with a declared outbreak, or who live in regions with high disease transmission. Search methods: An information specialist searched the Cochrane COVID-19 Study Register, and updated the search in PubMed, Ovid MEDLINE, WHO Global Index Medicus, Embase, and CINAHL on 23 June 2020. Selection criteria: Cohort studies, case-control studies, time series, interrupted time series, case series, and mathematical modelling studies that assessed the effect of any type of quarantine to control COVID-19. We also included studies on SARS (severe acute respiratory syndrome) and MERS (Middle East respiratory syndrome) as indirect evidence for the current coronavirus outbreak. Data collection and analysis: Two review authors independently screened abstracts and titles in duplicate. Two review authors then independently screened all potentially relevant full-text publications. One review author extracted data, assessed the risk of bias and assessed the certainty of evidence with GRADE and a second review author checked the assessment. We used three different tools to assess risk of bias, depending on the study design: ROBINS-I for non-randomised studies of interventions, a tool provided by Cochrane Childhood Cancer for non-randomised, non-controlled studies, and recommendations from the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) for modelling studies. We rated the certainty of evidence for the four primary outcomes: incidence, onward transmission, mortality, and costs. Main results: We included 51 studies; 4 observational studies and 28 modelling studies on COVID-19, one observational and one modelling study on MERS, three observational and 11 modelling studies on SARS, and three modelling studies on SARS and other infectious diseases. Because of the diverse methods of measurement and analysis across the outcomes of interest, we could not conduct a meta-analysis and undertook a narrative synthesis. We judged risk of bias to be moderate for 2/3 non-randomized studies of interventions (NRSIs) and serious for 1/3 NRSI. We rated risk of bias moderate for 4/5 non-controlled cohort studies, and serious for 1/5. We rated modelling studies as having no concerns for 13 studies, moderate concerns for 17 studies and major concerns for 13 studies. Quarantine for individuals who were in contact with a confirmed/suspected COVID-19 case in comparison to no quarantine Modelling studies consistently reported a benefit of the simulated quarantine measures, for example, quarantine of people exposed to confirmed or suspected cases may have averted 44% to 96% of incident cases and 31% to 76% of deaths compared to no measures based on different scenarios (incident cases: 6 modelling studies on COVID-19, 1 on SARS; mortality: 2 modelling studies on COVID-19, 1 on SARS, low-certainty evidence). Studies also indicated that there may be a reduction in the basic reproduction number ranging from 37% to 88% due to the implementation of quarantine (5 modelling studies on COVID-19, low-certainty evidence). Very low-certainty evidence suggests that the earlier quarantine measures are implemented, the greater the cost savings may be (2 modelling studies on SARS). Quarantine in combination with other measures to contain COVID-19 in comparison to other measures without quarantine or no measures When the models combined quarantine with other prevention and control measures, such as school closures, travel restrictions and social distancing, the models demonstrated that there may be a larger effect on the reduction of new cases, transmissions and deaths than measures without quarantine or no interventions (incident cases: 9 modelling studies on COVID-19; onward transmission: 5 modelling studies on COVID-19; mortality: 5 modelling studies on COVID-19, low-certainty evidence). Studies on SARS and MERS were consistent with findings from the studies on COVID-19. Quarantine for individuals travelling from a country with a declared COVID-19 outbreak compared to no quarantine Very low-certainty evidence indicated that the effect of quarantine of travellers from a country with a declared outbreak on reducing incidence and deaths may be small for SARS, but might be larger for COVID-19 (2 observational studies on COVID-19 and 2 observational studies on SARS). Authors' conclusions: The current evidence is limited because most studies on COVID-19 are mathematical modelling studies that make different assumptions on important model parameters. Findings consistently indicate that quarantine is important in reducing incidence and mortality during the COVID-19 pandemic, although there is uncertainty over the magnitude of the effect. Early implementation of quarantine and combining quarantine with other public health measures is important to ensure effectiveness. In order to maintain the best possible balance of measures, decision makers must constantly monitor the outbreak and the impact of the measures implemented. This review was originally commissioned by the WHO and supported by Danube-University-Krems. The update was self-initiated by the review authors.
Article
Background: Respiratory illnesses typically present increased risks to people with asthma (PWA). However, data on the risks of COVID-19 to PWA have presented contradictory findings, with implications for asthma management. Objective: To assess the risks and management considerations of COVID-19 in people with asthma (PWA). Method: We conducted a rapid literature review. We searched PubMed, medRxiv, LitCovid, TRIP, Google and Google Scholar for terms relating to asthma and COVID-19, and for systematic reviews related to specific management questions within our review, in April 2020. References were screened and data were extracted by one reviewer. Results: We extracted data from 139 references. The evidence available is limited, with some sources suggesting an under-representation of PWA in hospitalised cases and others showing an increased risk of worse outcomes in PWA, which may be associated with disease severity. Consensus broadly holds that asthma medications should be continued as usual. Almost all aspects of asthma care will be disrupted during the pandemic due not only to limits in face-to-face care but also to the fact that many of the diagnostic tools used in asthma are considered aerosol-generating procedures. Self-management and remote interventions may be of benefit for asthma care during this time but have not been tested in this context. Conclusions: Evidence on COVID-19 and asthma is limited and continuing to emerge. More research is needed on the possible associations between asthma and COVID-19 infection and severity, as well as on interventions to support asthma care in light of constraints and disruptions to healthcare systems. We found no evidence regarding health inequalities, and this urgently needs to be addressed in the literature as the burdens of asthma and of COVID-19 are not equally distributed across the population.
Article
Background The COVID-19 pandemic caused dramatic changes in daily routines and healthcare utilization and delivery patterns in the United States. Understanding the influence of these changes and associated public health interventions on asthma care is important to determine effects on patient outcomes and identify measures that will ensure optimal future healthcare delivery. Objective We sought to identify changes in pediatric asthma-related healthcare utilization, respiratory viral testing, and air pollution during the COVID-19 pandemic. Methods For the time period Jan 17-May 17, 2015-2020, asthma-related encounters and weekly summaries of respiratory viral testing data were extracted from Children’s Hospital of Philadelphia (CHOP) electronic health records, and pollution data for four criteria air pollutants were extracted from AirNow. Changes in encounter characteristics, viral testing patterns, and air pollution before and after Mar 17, 2020, the date public health interventions to limit viral transmission were enacted in Philadelphia, were assessed and compared to data from 2015-2019 as a historical reference. Results After Mar 17, 2020, in-person asthma encounters decreased by 87% (outpatient) and 84% (emergency + inpatient). Video telemedicine, which was not previously available, became the most highly utilized asthma encounter modality (61% of all visits), and telephone encounters increased by 19%. Concurrently, asthma-related systemic steroid prescriptions and frequency of rhinovirus test positivity decreased, while air pollution levels did not substantially change, compared to historical trends. Conclusion The COVID-19 pandemic in Philadelphia was accompanied by changes in pediatric asthma healthcare delivery patterns, including reduced admissions and systemic steroid prescriptions. Reduced rhinovirus infections may have contributed to these patterns.