"Connecting Communities for COVID19 News" 20th Jan 2021

Isolation Tips
Six practical ways to stop the ‘working from home burnout'
There are plenty of good things about working from home. Our hair has enjoyed a break from dry shampoo abuse, we’ve been able to live perpetually in pyjama bottoms and setting an alarm for five minutes before we log on has meant more time snuggled under the sheets. But while commutes might be a thing of the past for many of us, sometimes the journey from bed to desk is a tough challenge in and of itself. So how can you stop the burnout and keep your work/life balance in order? Video conference call provider PowWowNow has five practical ways to change things up
Hygiene Helpers
Wearing face masks DOES stop spread of Covid-19 and reduces R rate
US researchers gave a questionnaire to more than 300,000 people in 50 states Increase of 10% in people wearing masks makes it 3x more likely R is less than 1 Experts add that wearing a mask does not mean social distancing is not needed
US needs national COVID 'smart testing' strategy, APHL says
As the United States starts off 2021 with COVID-19 vaccines as well as variants, the Association of Public Health Laboratories (APHL) reasserts the importance of strategic COVID-19 testing strategies with a report published late last week. In the report, "Smart Testing for Optimizing Pandemic Response," the group recommends a coordinated national approach, supply chain management, and a focus on using test results as a means to improve public health surveillance.
How to reduce the risk of catching Covid-19 when travelling by car
Experts outline the best way to prevent coronavirus infection when sharing a car Sanitising high touch-points and sticking to essential travel only are also advised Government currently prohibits travel with other people with some exceptions
International arrivals to New Zealand must return negative Covid test before flight
New Zealand has imposed a blanket testing regime for all flights arriving internationally, with passengers now required to return a negative Covid test result before departure. The Covid-19 response minister, Chris Hipkins, said while New Zealand already had tight border controls in place, the rising number of cases around the globe meant further protections were called for. Australia, Antarctica and most Pacific Islands will be exempt from the new requirement. “As we signalled last week, given the high rates of infection in many countries, most global air routes are of critical concern for the foreseeable future,” Hipkins said.
New Zealand women taking leap into entrepreneurship during Covid-19 era
Many women are starting their own small businesses after a wave of Covid-19-related redundancies, according to Chooice NZ founder Sarah Colcord. More than 5000 new businesses registered with the companies office in 2020, the only rise in the number of companies in New Zealand in the past five years. The novel coronavirus has changed how many people work and live, with side-hustles often transformed into a main income source - a trend that is tipped to grow. Small businesses have long been the backbone of New Zealand. There are 546,732 small enterprises in Aotearoa - making up over 97 percent of all companies. Sarah Colcord founded New Zealand's largest Facebook Group, Chooice (formerly NZ Made Products) and co-founded its e-commerce partner Chooice.co.nz.
Community Activities
Bells and candlelight to honor 400,000 COVID-19 dead on eve of Trump's White House departure
President-elect Joe Biden on Tuesday led a national memorial observance on the eve of his inauguration to honor the 400,000 Americans who have perished from COVID-19 during the 11 months since the novel coronavirus claimed its first U.S. life. The sundown commemoration came hours before President Donald Trump was due to depart the White House for the last time and hand over a country wracked by the greatest public health crisis in a century, economic devastation and violent political upheaval. Ceremonies spearheaded by Biden and Vice President-elect Kamala Harris from the base of the Lincoln Memorial marked the federal government’s first official nod to the staggering death toll from the pandemic.
Campaign launched to help children have access to a laptop in Doncaster
Laptops for Kids was an idea created by David Richards - founder and chief executive of WANdisco - who launched the campaign in Sheffield with The Star and Learn Sheffield in September 2020. Individuals and businesses donate unused computers, which are recycled and cleaned, ready to be distributed to a young person who is currently unable to learn at home. A spokesperson for Laptops for Kids Doncaster, said: “The unfortunate reality is that for many young people, virtual learning = digital isolation. Something that many of us assume is a basic necessity - access to digital tech - is a very real challenge for lots of young people...right now.”
Fang Fang: Author vilified for Wuhan Diary speaks out a year on
She has faced a nationalist backlash for her diaries documenting life in Wuhan in the early days of the coronavirus outbreak, but Chinese author Fang Fang she says she will not be silenced. "When facing a catastrophe, it's vital to voice your opinion and give your advice," she told BBC Chinese in a rare email interview with international media. In late January, when Wuhan became the first place in the world to enter a state of complete lockdown, many of the city's 11 million residents found solace in reading Fang Fang's online diaries. They also provided a revealing glimpse into the city where the virus first emerged.
As Chinese cities face new Covid-19 lockdowns, have 2020 lessons been learned?
Echoes in Hebei of measures a year ago in Wuhan, with students stranded in icy conditions and some people unable to get routine medical treatment. Residents complain of mistakes being repeated, as countries continue to struggle to balance a speedy response with the public’s wider needs
Most Americans want vaccine as nation tops 400,000 COVID deaths
One day before Joe Biden is sworn in as the 46th president of the United States, a new poll from Washington Post-ABC News shows that 52% of Americans think the coronavirus outbreak is out of control, and 62% say trying to control the pandemic is more important than restarting the economy. The numbers come as a national vaccine campaign has rolled out in fits and starts across the country. Though the new poll still shows a political divide, most Americans said they will (40%) or probably will (23%) get a COVID-19 vaccine when one is made available to them. Half of Democrats polled said they would definitely get a vaccine, while only 25% of Republicans said the same.
GP couple give covid vaccine to housebound patients on their day off
In England, newlywed doctors spent their day off going door-to-door to get the coronavirus vaccine to housebound patients. GP duo Dominique Thompson and Simon Bradley volunteered their spare time to vaccinate 36 vulnerable people in the Little Stoke area of South Gloucestershire. They spent most of Friday driving and wheeling around vials of the Oxford-AstraZeneca vaccine in a special trolley, and administering it to patients in their own homes. All patients were eligible to get the vaccine at Concord Medical Centre, where Dr Bradley works, but were unable to get there. He said: "We just wanted to get out and vaccinate our housebound."
Unwanted tech helps bridge 'digital divide' in lockdown Britain
Nearly one in 10 British families - including up to 1.8 million children - had no computer or tablet at home at the start of the pandemic, according to estimates from the country’s Ofcom media regulator. The government has pledged more than a million laptops to help children get online, and has said that those without computers at home can attend school if necessary. But education experts and charities have warned that many poorer families are still struggling with a “digital divide” that risks widening existing education gaps. Dozens of business and community-led computer donation schemes have sprung up around the country to help plug gaps, an offshoot of “mutual aid” community groups established in many neighbourhoods to help the vulnerable during the pandemic.
Working Remotely
Working from home 'battle' looms between managers, employees
A disconnect between employers and employees on working from home has been revealed as managers signal concerns staff are slacking off in a new survey, while workers say their performance has improved out of the office. As Victorian offices begin to welcome back staff this week, many companies are embracing a new hybrid working model where workers split their time between home and the office. However, the survey of more than 600 workers and 300 employers across Australia found there was a divide on expectations of the new arrangements. Workers listed isolation as their number one challenge when working from home, whereas for employers oversight of staff and managing productivity was their biggest concern.
First lockdown, then Storm Filomena: Why Spanish families are struggling to maintain work-life balance
“I’m feeling really down today,” tweeted Silvia Nanclares last week when it was still unclear whether the Madrid region would open its schools the following Monday due to Storm Filomena. “I can’t face another round of childcare and remote working. Even if it’s for a short period. I have no energy left.” Nanclares and her partner are just one of many couples in Spain struggling to juggle working from home with their responsibilities as parents who are overwhelmed by the difficulty of separating their private and professional lives. Different social psychology studies indicate that the home is not the best place to carry out intellectual tasks if there is no room with a door and no rules to regulate access
Irish Examiner view: Permanent remote working option could be transformative — if it's done properly
In Ireland, wearing his trade-enterprise-and-employment-minister hat, Tánaiste Leo Varadkar last week announced a plan to have 20% of public servants working remotely on a more permanent basis this year. He suggested private sector workers would also be able to request the opportunity to work from home and that this right would be contained in a new Workplace Relations Commission code. Working from home, if — a big “if” — domestic circumstances allow, can be a wonderful, freeing experience for workers and, consequently, a boon for employers, whose staff are not half-exhausted by the daily, sometimes hours-long commute.
Virtual Classrooms
Chester academies trust in mission to ensure all Cheshire school pupils have access to laptops
In England, a Chester-based academies trust is spearheading a campaign to help ensure children across Cheshire have access to a laptop for home-schooling. North West Academies Trust decided to act when, despite distributing all school-owned laptops to pupils, an audit revealed there was still a substantial number of children without the necessary equipment to join the virtual classroom. NWAT appealed to fellow schools, businesses and individuals asking them to donate devices which could make a huge difference to families in the area. Now NWAT have extended the campaign with the aim of helping pupils at other local schools across Cheshire and Shropshire. They have offered to pay for used laptops to be reconditioned, and act as a distribution centre.
Māori-medium education thrived during lockdown, leading the education sector by example
In New Zealand, a new report from the Education Review Office found that while schools will feel the impact of the Covid-19 lockdown into 2021, one group in particular thrived: Māori-medium education. The report found some students had lost a term in learning as a result of the lockdown, and the impact would be felt into the 2021 academic year. But the review into Māori-medium education – where students are taught all or some curriculum subjects in the Māori language for at least 51 per cent of the time – found staying connected and using resources creatively, allowed students to succeed. One student who was interviewed for the report said they were able to plan their own learning programme, and their kaiako (teacher), encouraged them to be adventurous.
Public Policies
China's capital steps up COVID-19 measures as outbreak persists
China’s capital Beijing said on Wednesday it will investigate all individuals who entered the city from abroad from Dec. 10 and shut down a subway station after reporting the biggest daily jump in new COVID-19 cases in more than three weeks. The measures come amid what has become the country’s most severe COVID-19 outbreak since March 2020 ahead of the key Chinese Lunar New Year holiday season, when hundreds of millions travel, raising fears of another major COVID-19 wave that could bring the country back into a debilitating standstill. The National Health Commission said on Wednesday that a total of 103 new COVID-19 cases were reported on Jan. 19, down from 118 a day earlier. Northeastern Jilin province reported 46 new cases, however, setting another record in daily cases, while Hebei province surrounding Beijing reported 19 new cases.
Covid-19 in Scotland: Nicola Sturgeon extends lockdown to at least mid-February
Schools will remain closed to most pupils for at least another month after Nicola Sturgeon extended lockdown in Scotland. Cases of Covid-19 are stabilising but the first minister warned that any relaxation risks sending “the situation into reverse”. The first minister said that ministers had agreed to extend the current curbs — which came into force on December 26 and have since been tightened — until at least the middle of February.
Germany extends lockdown to Feb. 14 on fears of COVID variants, sources say
German Chancellor Angela Merkel warned that Germany may need to consider border crossing curbs if other European countries do not act to halt the spread of the coronavirus, particularly its new, more transmissible variants. “We can do anything we like, but we will not succeed if others are not working in parallel,” Merkel told journalists on Tuesday, two days ahead of a videoconference of European leaders. “We need to make sure that everyone around us is doing the same. Otherwise we have to look at measures such as entry restrictions.”
Outcry in Italy at call for more vaccines for rich regions
The idea that richer areas should get a bigger share of coronavirus vaccines sparked an outcry on Tuesday (19 January) in Italy, one of the countries worst hit by the pandemic. The proposal came from Letizia Moratti, the aristocrat wife of a late oil baron, who this month was appointed health chief of the northern Lombardy region, which includes Milan. Writing to the government coronavirus crisis commissioner, she said vaccines should be allocated to regions based not only on population density, but also on gross domestic product (GDP), local impact of the pandemic and levels of mobility. “It is not about giving more vaccines to richer regions… but in helping Lombardy’s recovery you would automatically help the recovery of the whole country,” she said in the letter, parts of which media published.
Third wave hits Spain in record rise
Joe Biden’s team announced that he plans to extend travel restrictions barring people from much of Europe and Brazil from travelling to the US, shortly after President Trump said he would lift the restrictions on January 26. Mr Trump signed an order yesterday ending the ban, which he imposed early last year in response to the pandemic, after securing support from his coronavirus task force and public health officials.
Spain to extend COVID furlough scheme until May, PM says
Spain will extend its scheme supporting hundreds of thousands of workers furloughed due to COVID-19 until May, Prime Minister Pedro Sanchez said on Tuesday after the government, unions and business groups reached an agreement on the issue. The ERTE furlough scheme, which has benefitted millions of workers since the beginning of the pandemic, had been due to expire on Jan. 31 under a previous such agreement. As most of business restrictions were lifted during the past months following a nationwide lockdown, many furloughed workers returned to work though 755,000 were still on the state-supported furlough scheme in December.
France sticks to Covid plans in race between vaccines and contagious variant
France’s government said Tuesday it would avoid the strictest lockdown measures despite gradually increasing Covid-19 cases and hospital admissions, preferring to bank on vaccinations. The spread of a more contagious variant of the new coronavirus seems to have prompted many to get the jab and there are now concerns over delays in delivery. Despite laboratory delays and reports of shortages and logistical problems in its vaccine campaign, France’s government said it would avoid toughening health restrictions even as case numbers and hospital admissions continued to increase. “We already took a tough decision last week to impose a 6pm curfew on the country as a whole,” health minister Olivier Véran told France Inter radio. “I cannot say we will impose a confinement but the circulation of the virus remains worrying.”
Portugal tightens Covid-19 lockdown amid record numbers of new cases, deaths
Stricter lockdown rules are being enacted in Portugal, the government announced Monday, as a surging Covid-19 pandemic sets grim records and pushes hospitals to the limit of their capacity. Prime Minister António Costa said too many people had taken advantage of exceptions included in the lockdown that began last Friday, with authorities reporting 70% of normal movement over the weekend. “We are going through the most serious phase of the pandemic” so far, Costa said, urging people to comply with the rules. “This is no time for finding loopholes in the law.”
China defends COVID-19 response after criticism by experts
China has defended its actions as “prompt and decisive” in containing the coronavirus outbreak during its early days, rebuking criticism made by an independent panel of experts over Beijing’s handling of the outbreak. “As the first country to sound the alarm against the pandemic, we took prompt and decisive measures even though we had incomplete information at the time,” the Chinese foreign ministry spokeswoman, Hua Chunying, said on Tuesday. Hua said Beijing imposed early measures – including the announcement of a hard lockdown on Wuhan weeks after the virus was detected – that “reduced infections and deaths”. Her comments came after the release of the Independent Panel for Pandemic Preparedness and Response’s interim report that highlighted how China could have acted “more rapidly” against a virus that has now killed more than two million people worldwide. The panel was formed last year following a request by member countries of the Geneva-based World Health Organization (WHO) to identify new information on the spread of COVID-19.
Rwanda re-imposes strict lockdown in capital after COVID-19 cases surge
Rwanda has re-introduced tough lockdown measures in its capital Kigali after a surge in coronavirus cases. The government has also banned movement into and out of the city, except for essential services and for tourists, it said, citing a jump in the number of cases found in a given sample of tests, known as the positivity rate. “All employees, public and private, shall work from home, except for those providing essential services,” the government said in a statement.
Malaysia expands lockdown measures to most states as virus spreads
Malaysia on Tuesday said it would extend lockdown restrictions across most of the country as it grappled with a rise in coronavirus infections. Last week, capital Kuala Lumpur and six states went into a two-week lockdown. Essential sectors including manufacturing, plantations and construction were allowed to stay open, but a nationwide travel ban was implemented. Security minister Ismail Sabri Yaakob on Tuesday said the lockdown will also be imposed on six other states from Friday for two weeks. Only the eastern state of Sarawak will not see a full lockdown, though some restrictions are in place. Prime Minister Muhyiddin Yassin has said the lockdown measures were necessary as the healthcare system was at a breaking point.
UK still looking at mid-Feb for COVID lockdown review: minister
Britain’s government is still aiming to review COVID-19 lockdown restrictions in mid-February, Northern Ireland minister Brandon Lewis said on Tuesday. “When we put these current restrictions in place we said we would do a review in mid-February ... and that’s still the case,” Lewis told Sky News.
Africa's fears over Covid-19 vaccine shortage
One of Africa's top public health officials, virologist Dr John Nkengasong has spoken of his concern that countries in the continent will not be getting the vaccines they need. The director of the Africa Centre for Disease Control and Prevention told BBC World News: "We are truly headed towards a moral catastrophe if this situation isn't addressed." When the pandemic first hit the world it was agreed everyone needed equitable and timely access to vaccines, Dr Nkengasong said. Now that the vaccines are here it was time to translate those words into action he said, explaining that the second wave of the virus in the continent was much more aggressive and devastating.
Coronavirus: Why South Africa has yet to roll out vaccines
More than a third of all Covid-19 cases in Africa have been in South Africa and numbers are surging with the emergence of a new variant of the virus. But unlike some other badly hit countries in the world, South Africa is yet to start its vaccination programme.
Maintaining Services
Moderna says possible allergic reactions to COVID-19 vaccine under investigation
Moderna Inc said on Tuesday it had received a report from California’s health department that several people at a center in San Diego were treated for possible allergic reactions to its COVID-19 vaccine from a particular batch. The company’s comments come after California’s top epidemiologist on Sunday issued a statement recommending providers pause vaccination from lot no. 41L20A due to possible allergic reactions that are under investigation. "A higher-than-usual number of possible allergic reactions were reported with a specific lot of Moderna vaccine administered at one community vaccination clinic. Fewer than 10 individuals required medical attention over the span of 24 hours," the epidemiologist said in a statement here. The vaccine maker said it was unaware of comparable cases of adverse events from other vaccination centers which may have administered vaccines from the same lot or from other lots of its vaccine.
Ireland’s first Covid-19 vaccine recipient receives second dose
The first person in Ireland to receive the Covid-19 vaccine has been given her second dose today. Dublin woman Annie Lynch (79) received the first round of the Pfizer/BioNTech vaccine in St James’s Hospital on December 29, making her the first person in the country to be given the Covid-19 jab outside of clinical trials. The mother of three, who has 10 grandchildren, returned to St James Hospital to receive her second round of the vaccine.
Coronavirus: India to provide vaccines to six countries from Wednesday
India will provide coronavirus vaccines made in the country to six nations - Bhutan, Maldives, Bangladesh, Nepal, Myanmar and Seychelles - from Wednesday, the Ministry of External Affairs said in a statement. Vaccines will be sent to Sri Lanka, Afghanistan and Mauritius as well, once necessary regulatory clearances are received, the ministry added. Meanwhile, Prime Minister Narendra Modi said it was a matter of honour and that vaccines will be sent to more countries. “India is deeply honoured to be a long-trusted partner in meeting the healthcare needs of the global community,” he tweeted. “Supplies of Covid vaccines to several countries will commence tomorrow, and more will follow in the days ahead.”
More than 45,000 people in Florida are overdue for their second coronavirus vaccine dose
Of the 1.03 million people in Florida who have received at least one shot of the coronavirus vaccine, 45,056 are overdue for their second dose. Florida's Department of Health has refused to answer questions about whether officials are concerned and reasons for why people have missed their second jab. Health experts say some might be worried about the side effects of getting the second dose, which is known to be stronger than the first. In a statement on Thursday, Gov Ron DeSantis urged Floridians being vaccinated to not forego their second shot
Covid in Scotland: Concerns about vaccine supply amid GP frustration
Opposition parties have voiced concerns about vaccine supplies after "frustrated" GPs said they were still waiting for deliveries. At Holyrood on Tuesday, the first minister was pressed on why the rollout was going "so slowly" and on whether there was a problem with distribution. Dr Andrew Buist, of BMA Scotland, told the BBC that patients were getting anxious and practices could not plan. Nicola Sturgeon said there were ongoing challenges but targets would be met. Dr Buist claimed that as of Monday, the Scottish government had taken receipt of more than 700,000 vaccines - but only used 264,991.
Covid vaccine: New York to run out of doses by Thursday, warns mayor
New York City could run out of Covid-19 vaccine doses by Thursday, warned Mayor Bill de Blasio, which could force the city to cancel vaccination appointments. “We will have literally nothing left to give as of Friday,” Mr de Blasio said. “What does that mean? It means that if we do not get more vaccine quickly, a new supply of vaccine, we will have to cancel appointments and no longer give shots after Thursday for the reminder of the week at a lot of our sites.” The warning came during the mayor’s coronavirus press briefing on Tuesday morning.
Hospitals in Japan close to collapse as serious Covid cases soar
Hospitals in Covid-hit regions of Japan are on the brink of collapse, medical experts have warned, as the country battles a third wave of infections that has caused record numbers of people to fall seriously ill. Japan reported more than 4,900 coronavirus infections on Monday, with serious cases rising to a record high of 973, local media reported. Although Japan has avoided the huge caseloads and death tolls seen in some other countries, infections have doubled over the past six weeks to about 338,000, according to the public broadcaster NHK, with 4,623 deaths. The increase, coupled with the discovery of the first recorded community transmissions of a fast-spreading strain of Covid-19 initially identified in Britain, is adding to pressure on the prime minister, Yoshihide Suga, to move quickly to protect stretched medical services.
COVID-19: Schools might not all reopen at the same time across England, suggests Dr Jenny Harries
Schools might not all reopen at the same time across England as lockdown restrictions are eased, MPs have been told. Dr Jenny Harries, one of England's deputy chief medical officers, said there was "likely" to be regional differences in COVID measures once the national shutdown ends.
Hospitals in Americas, Europe under growing strain of COVID-19
The world added more than 2 million new COVID-19 cases in the past 3 days, with health systems coming under pressure in the Americas and in more European countries and China reporting another pocket of local spread, triggering more strong measures. Over the past week, the World Health Organization (WHO) Americas region reported 2.5 million cases, making up more than half of the global total, Carissa Etienne, MBBS, MSc, who directs the Pan American Health Organization (PAHO), said today at a briefing. She added that over the past week, 42,000 more people in the region died from their infections.
Healthcare Innovations
SAGE papers reveal three key fears experts have about Covid vaccine rollout
Many Brits will "probably no longer follow the rules" once vaccinated and this may outweigh the benefits of the jabs, the Government's scientific advisers fear. Minutes from a Scientific Advisory Group for Emergencies (SAGE) meeting reveal three key fears experts have about Covid vaccine rollout, the Telegraph reports. They are an increase in social mixing, the country being divided into a two tier system and black and ethnic minority group members refusing to get inoculated. There are growing concerns people will ignore distancing and begin meeting up with those outside their households, including non-vaccinated family members visiting elderly relatives who have had the inoculation, assuming they are safe.
A New COVID-19 Challenge: Mutations Rise Along With Cases
The race against the virus that causes COVID-19 has taken a new turn: Mutations are rapidly popping up, and the longer it takes to vaccinate people, the more likely it is that a variant that can elude current tests, treatments and vaccines could emerge. The coronavirus is becoming more genetically diverse, and health officials say the high rate of new cases is the main reason. Each new infection gives the virus a chance to mutate as it makes copies of itself, threatening to undo the progress made so far to control the pandemic.
Pfizer's Covid vaccine COULD stop people spreading the virus as well as preventing serious illness, Israeli doctor claims after finding antibody levels surged after second dose
Patients who received the Pfizer vaccine may prevent transmission of Covid-19 The Israeli study found only two subjects developed low amounts of antibodies Elderly people have been the priority since the vaccine programme started
COVID-19: 'Real-world' analysis of vaccine in Israel raises questions about UK strategy
The first real-world analysis of the Pfizer/BioNTech coronavirus vaccine suggests it is matching its performance in clinical trials, but raises serious questions about the UK's decision to delay the second dose. Scientists in Israel - which is leading the COVID-19 vaccination race - have told Sky News that they are "very hopeful" having studied preliminary data from 200,000 vaccinated people. But crucially they say their results do not show efficacy at a level close to that used by the UK to justify delaying the second dose of the Pfizer/BioNtech jab.
What we now know — and don’t know — about the coronavirus variants
The coronavirus variants are, in a word, confusing. By now, you have likely heard about different variants that first raised trouble in the United Kingdom, South Africa, Brazil, and now maybe California — though the jury is very much out on whether that last one is cause for concern. To make a messy alphabet soup even more jumbled, these variants have unwieldy names, and they each contain mutations with unwieldy names of their own. The result is that people are left trying to differentiate among B.1.1.7 and N501Y and E484K and C-3PO.
Almost 30% of Covid patients in England readmitted to hospital after discharge – study
Nearly a third of people who were discharged from hospitals in England after being treated for Covid-19 were readmitted within five months – and almost one in eight died, a study suggests. The research, which is still to be peer-reviewed, also found a higher risk of problems developing in a range of organs after hospital discharge in those younger than 70 and ethnic minority individuals. “There’s been so much talk about all these people dying from Covid … but death is not the only outcome that matters,” said Dr Charlotte Summers, a lecturer in intensive care medicine at the University of Cambridge who was not involved in this study.