{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,31]],"date-time":"2026-07-31T19:28:13Z","timestamp":1785526093751,"version":"3.56.0"},"reference-count":60,"publisher":"Public Library of Science (PLoS)","issue":"7","license":[{"start":{"date-parts":[[2021,7,1]],"date-time":"2021-07-01T00:00:00Z","timestamp":1625097600000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["www.plosmedicine.org"],"crossmark-restriction":false},"short-container-title":["PLoS Med"],"abstract":"<jats:sec id=\"sec001\">\n<jats:title>Background<\/jats:title>\n<jats:p>We assessed the impact of the coronavirus disease 2019 (COVID-19) epidemic in India on the consumption of antibiotics and hydroxychloroquine (HCQ) in the private sector in 2020 compared to the expected level of use had the epidemic not occurred.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec002\">\n<jats:title>Methods and findings<\/jats:title>\n<jats:p>We performed interrupted time series (ITS) analyses of sales volumes reported in standard units (i.e., doses), collected at regular monthly intervals from January 2018 to December 2020 and obtained from IQVIA, India. As children are less prone to develop symptomatic severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, we hypothesized a predominant increase in non-child-appropriate formulation (non-CAF) sales. COVID-19-attributable changes in the level and trend of monthly sales of total antibiotics, azithromycin, and HCQ were estimated, accounting for seasonality and lockdown period where appropriate. A total of 16,290 million doses of antibiotics were sold in India in 2020, which is slightly less than the amount in 2018 and 2019. However, the proportion of non-CAF antibiotics increased from 72.5% (95% CI: 71.8% to 73.1%) in 2019 to 76.8% (95% CI: 76.2% to 77.5%) in 2020. Our ITS analyses estimated that COVID-19 likely contributed to 216.4 million (95% CI: 68.0 to 364.8 million; <jats:italic>P =<\/jats:italic> 0.008) excess doses of non-CAF antibiotics and 38.0 million (95% CI: 26.4 to 49.2 million; <jats:italic>P &lt;<\/jats:italic> 0.001) excess doses of non-CAF azithromycin (equivalent to a minimum of 6.2 million azithromycin treatment courses) between June and September 2020, i.e., until the peak of the first epidemic wave, after which a negative change in trend was identified. In March 2020, we estimated a COVID-19-attributable change in level of +11.1 million doses (95% CI: 9.2 to 13.0 million; <jats:italic>P &lt;<\/jats:italic> 0.001) for HCQ sales, whereas a weak negative change in monthly trend was found for this drug. Study limitations include the lack of coverage of the public healthcare sector, the inability to distinguish antibiotic and HCQ sales in inpatient versus outpatient care, and the suboptimal number of pre- and post-epidemic data points, which could have prevented an accurate adjustment for seasonal trends despite the robustness of our statistical approaches.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec003\">\n<jats:title>Conclusions<\/jats:title>\n<jats:p>A significant increase in non-CAF antibiotic sales, and particularly azithromycin, occurred during the peak phase of the first COVID-19 epidemic wave in India, indicating the need for urgent antibiotic stewardship measures.<\/jats:p>\n<\/jats:sec>","DOI":"10.1371\/journal.pmed.1003682","type":"journal-article","created":{"date-parts":[[2021,7,1]],"date-time":"2021-07-01T18:44:10Z","timestamp":1625165050000},"page":"e1003682","update-policy":"https:\/\/doi.org\/10.1371\/journal.pmed.corrections_policy","source":"Crossref","is-referenced-by-count":102,"title":["Sales of antibiotics and hydroxychloroquine in India during the COVID-19 epidemic: An interrupted time series analysis"],"prefix":"10.1371","volume":"18","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-6641-0094","authenticated-orcid":true,"given":"Giorgia","family":"Sulis","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5772-120X","authenticated-orcid":true,"given":"Brice","family":"Batomen","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Anita","family":"Kotwani","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3667-4536","authenticated-orcid":true,"given":"Madhukar","family":"Pai","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sumanth","family":"Gandra","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2021,7,1]]},"reference":[{"issue":"15","key":"pmed.1003682.ref001","doi-asserted-by":"crossref","first-page":"E3463","DOI":"10.1073\/pnas.1717295115","article-title":"Global increase and geographic convergence in antibiotic consumption between 2000 and 2015","volume":"115","author":"EY Klein","year":"2018","journal-title":"Proc Natl Acad Sci U S A"},{"issue":"9","key":"pmed.1003682.ref002","doi-asserted-by":"crossref","first-page":"e003393","DOI":"10.1136\/bmjgh-2020-003393","article-title":"Antibiotic overuse in the primary health care setting: a secondary data analysis of standardised patient studies from India, China and Kenya","volume":"5","author":"G Sulis","year":"2020","journal-title":"BMJ Glob Health"},{"issue":"11","key":"pmed.1003682.ref003","doi-asserted-by":"crossref","first-page":"e0224848","DOI":"10.1371\/journal.pone.0224848","article-title":"Outpatient antibiotic prescription rate and pattern in the private sector in India: evidence from medical audit data","volume":"14","author":"HH Farooqui","year":"2019","journal-title":"PLoS ONE"},{"issue":"9","key":"pmed.1003682.ref004","first-page":"1657","article-title":"COVID-19 and antimicrobial resistance: parallel and interacting health emergencies","volume":"72","author":"R Nieuwlaat","year":"2021","journal-title":"Clin Infect Dis"},{"key":"pmed.1003682.ref005","volume-title":"Treatment guidelines for antimicrobial use in common syndromes","author":"Indian Council of Medical Research","year":"2019"},{"issue":"5","key":"pmed.1003682.ref006","doi-asserted-by":"crossref","first-page":"479","DOI":"10.1007\/s00228-011-1161-x","article-title":"Macrolides: from in vitro anti-inflammatory and immunomodulatory properties to clinical practice in respiratory diseases","volume":"68","author":"P Zarogoulidis","year":"2012","journal-title":"Eur J Clin Pharmacol"},{"issue":"1","key":"pmed.1003682.ref007","doi-asserted-by":"crossref","first-page":"10","DOI":"10.1093\/jac\/dkh519","article-title":"Anti-inflammatory effects of macrolides\u2014an underappreciated benefit in the treatment of community-acquired respiratory tract infections and chronic inflammatory pulmonary conditions?","volume":"55","author":"GW Amsden","year":"2005","journal-title":"J Antimicrob Chemother"},{"issue":"3","key":"pmed.1003682.ref008","doi-asserted-by":"crossref","first-page":"590","DOI":"10.1128\/CMR.00078-09","article-title":"Mechanisms of action and clinical application of macrolides as immunomodulatory medications","volume":"23","author":"S Kanoh","year":"2010","journal-title":"Clin Microbiol Rev"},{"issue":"1","key":"pmed.1003682.ref009","doi-asserted-by":"crossref","first-page":"48","DOI":"10.4103\/injr.injr_1_17","article-title":"New treatments for systemic lupus erythematosus","volume":"12","author":"R Lahita","year":"2017","journal-title":"Indian J Rheumatol"},{"issue":"5","key":"pmed.1003682.ref010","doi-asserted-by":"crossref","first-page":"381","DOI":"10.7861\/clinmed.2019-0035","article-title":"Chikungunya arthritis","volume":"19","author":"H Pathak","year":"2019","journal-title":"Clin Med (Lond)"},{"key":"pmed.1003682.ref011","volume-title":"National drug policy on malaria","author":"Directorate of National Vector Borne Disease Control Programme","year":"2013"},{"issue":"9","key":"pmed.1003682.ref012","doi-asserted-by":"crossref","first-page":"2163","DOI":"10.1007\/s10067-016-3283-0","article-title":"Treatment of rheumatoid arthritis (RA) in India-how and by whom: results from a speciality clinic-use of low-dose methotrexate (MTX) was inexplicably suboptimal","volume":"35","author":"AN Malaviya","year":"2016","journal-title":"Clin Rheumatol"},{"issue":"3","key":"pmed.1003682.ref013","doi-asserted-by":"crossref","first-page":"269","DOI":"10.1038\/s41422-020-0282-0","article-title":"Remdesivir and chloroquine effectively inhibit the recently emerged novel coronavirus (2019-nCoV) in vitro","volume":"30","author":"M Wang","year":"2020","journal-title":"Cell Res"},{"issue":"5","key":"pmed.1003682.ref014","doi-asserted-by":"crossref","first-page":"105938","DOI":"10.1016\/j.ijantimicag.2020.105938","article-title":"New insights on the antiviral effects of chloroquine against coronavirus: what to expect for COVID-19?","volume":"55","author":"CA Devaux","year":"2020","journal-title":"Int J Antimicrob Agents"},{"issue":"6","key":"pmed.1003682.ref015","doi-asserted-by":"crossref","first-page":"517","DOI":"10.1056\/NEJMoa2016638","article-title":"A randomized trial of hydroxychloroquine as postexposure prophylaxis for Covid-19","volume":"383","author":"DR Boulware","year":"2020","journal-title":"N Engl J Med"},{"issue":"9","key":"pmed.1003682.ref016","doi-asserted-by":"crossref","first-page":"e0238681","DOI":"10.1371\/journal.pone.0238681","article-title":"Observational study of azithromycin in hospitalized patients with COVID-19","volume":"15","author":"A Rodr\u00edguez-Molinero","year":"2020","journal-title":"PLoS ONE"},{"issue":"21","key":"pmed.1003682.ref017","doi-asserted-by":"crossref","first-page":"2030","DOI":"10.1056\/NEJMoa2022926","article-title":"Effect of hydroxychloroquine in hospitalized patients with Covid-19","volume":"383","author":"P Horby","year":"2020","journal-title":"N Engl J Med"},{"issue":"5","key":"pmed.1003682.ref018","doi-asserted-by":"crossref","first-page":"417","DOI":"10.1056\/NEJMoa2021801","article-title":"A cluster-randomized trial of hydroxychloroquine for prevention of Covid-19","volume":"384","author":"O Mitj\u00e0","year":"2021","journal-title":"N Engl J Med"},{"issue":"10279","key":"pmed.1003682.ref019","doi-asserted-by":"crossref","first-page":"1063","DOI":"10.1016\/S0140-6736(21)00461-X","article-title":"Azithromycin for community treatment of suspected COVID-19 in people at increased risk of an adverse clinical course in the UK (PRINCIPLE): a randomised, controlled, open-label, adaptive platform trial","volume":"397","author":"PRINCIPLE Trial Collaborative Group","year":"2021","journal-title":"Lancet"},{"issue":"2","key":"pmed.1003682.ref020","doi-asserted-by":"crossref","first-page":"266","DOI":"10.1016\/j.jinf.2020.05.046","article-title":"Co-infections in people with COVID-19: a systematic review and meta-analysis","volume":"81","author":"L Lansbury","year":"2020","journal-title":"J Infect"},{"issue":"12","key":"pmed.1003682.ref021","doi-asserted-by":"crossref","first-page":"1622","DOI":"10.1016\/j.cmi.2020.07.016","article-title":"Bacterial co-infection and secondary infection in patients with COVID-19: a living rapid review and meta-analysis","volume":"26","author":"BJ Langford","year":"2020","journal-title":"Clin Microbiol Infect"},{"key":"pmed.1003682.ref022","volume-title":"Clinical management of COVID-19. Interim guidance\u201427 May 2020","author":"World Health Organization","year":"2020"},{"key":"pmed.1003682.ref023","unstructured":"Clinical Management Protocol: COVID-19. New Delhi, India: Government of India, Ministry of Health and Family Welfare - Directorate General of Health Services; 2020 Jun 27 [cited 2021 Mar 15]. Available from: https:\/\/www.mohfw.gov.in\/pdf\/ClinicalManagementProtocolforCOVID19dated27062020.pdf."},{"issue":"11","key":"pmed.1003682.ref024","doi-asserted-by":"crossref","first-page":"1371","DOI":"10.1017\/ice.2020.381","article-title":"Antibiotic prescription during the COVID-19 pandemic: a biphasic pattern","volume":"41","author":"G Abelenda-Alonso","year":"2020","journal-title":"Infect Control Hosp Epidemiol"},{"issue":"11","key":"pmed.1003682.ref025","doi-asserted-by":"crossref","first-page":"e01011","DOI":"10.1128\/AAC.01011-20","article-title":"Antibiotic consumption and stewardship at a hospital outside of an early coronavirus disease 2019 epicenter","volume":"64","author":"DJ Buehrle","year":"2020","journal-title":"Antimicrob Agents Chemother"},{"issue":"6","key":"pmed.1003682.ref026","doi-asserted-by":"crossref","first-page":"751","DOI":"10.1017\/ice.2020.1277","article-title":"Inpatient antibiotic utilization in the Veterans\u2019 Health Administration during the coronavirus disease 2019 (COVID-19) pandemic","volume":"42","author":"TD Dieringer","year":"2021","journal-title":"Infect Control Hosp Epidemiol"},{"issue":"4","key":"pmed.1003682.ref027","doi-asserted-by":"crossref","first-page":"646","DOI":"10.1016\/j.cmi.2020.09.055","article-title":"Antibiotic use in the COVID-19 crisis in Spain","volume":"27","author":"B Gonzalez-Zorn","year":"2021","journal-title":"Clin Microbiol Infect"},{"key":"pmed.1003682.ref028","article-title":"Impact of COVID-19 on pneumonia-focused antibiotic use at an academic medical center","author":"MJ Nestler","year":"2020","journal-title":"Infect Control Hosp Epidemiol"},{"key":"pmed.1003682.ref029","article-title":"Changes in antimicrobial utilization during the COVID-19 pandemic after implementation of a multispecialty clinical guidance team","author":"MB Staub","year":"2020","journal-title":"Infect Control Hosp Epidemiol"},{"issue":"5","key":"pmed.1003682.ref030","doi-asserted-by":"crossref","first-page":"642","DOI":"10.1017\/ice.2020.312","article-title":"Pediatric antimicrobial stewardship in the COVID-19 outbreak","volume":"42","author":"E Velasco-Arnaiz","year":"2021","journal-title":"Infect Control Hosp Epidemiol"},{"issue":"1","key":"pmed.1003682.ref031","doi-asserted-by":"crossref","first-page":"62","DOI":"10.1093\/jpids\/piaa124","article-title":"Impact of the COVID-19 pandemic on infectious diagnoses and antibiotic use in pediatric ambulatory practices","volume":"10","author":"SE Katz","year":"2021","journal-title":"J Pediatric Infect Dis Soc"},{"key":"pmed.1003682.ref032","volume-title":"COVID-19: details on cases","author":"PRS Legislative Research","year":"2020"},{"issue":"10044","key":"pmed.1003682.ref033","doi-asserted-by":"crossref","first-page":"596","DOI":"10.1016\/S0140-6736(16)00342-1","article-title":"What is the private sector? Understanding private provision in the health systems of low-income and middle-income countries","volume":"388","author":"M Mackintosh","year":"2016","journal-title":"Lancet"},{"issue":"9766","key":"pmed.1003682.ref034","doi-asserted-by":"crossref","first-page":"668","DOI":"10.1016\/S0140-6736(10)61884-3","article-title":"Financing health care for all: challenges and opportunities","volume":"377","author":"AK Kumar","year":"2011","journal-title":"Lancet"},{"key":"pmed.1003682.ref035","doi-asserted-by":"crossref","first-page":"82","DOI":"10.1016\/j.jclinepi.2018.05.026","article-title":"A methodological framework for model selection in interrupted time series studies","volume":"103","author":"J Lopez Bernal","year":"2018","journal-title":"J Clin Epidemiol"},{"key":"pmed.1003682.ref036","volume-title":"Coronavirus pandemic (COVID-19)","author":"Our World in Data","year":"2021"},{"key":"pmed.1003682.ref037","volume-title":"Population projections for India and States, 2011\u20132036: report of the Technical Group on population projections","author":"National Commission on Population","year":"2019"},{"issue":"1","key":"pmed.1003682.ref038","doi-asserted-by":"crossref","first-page":"67","DOI":"10.1016\/S1473-3099(18)30547-4","article-title":"Consumption of oral antibiotic formulations for young children according to the WHO Access, Watch, Reserve (AWaRe) antibiotic groups: an analysis of sales data from 70 middle-income and high-income countries","volume":"19","author":"Y Hsia","year":"2019","journal-title":"Lancet Infect Dis"},{"issue":"6","key":"pmed.1003682.ref039","doi-asserted-by":"crossref","first-page":"e001869","DOI":"10.1136\/bmjgh-2019-001869","article-title":"Over-the-counter antibiotic dispensing by pharmacies: a standardised patient study in Udupi district","volume":"4","author":"V Nafade","year":"2019","journal-title":"India. BMJ Glob Health"},{"key":"pmed.1003682.ref040","volume-title":"ATC\/DDD index 2021","author":"WHO Collaborating Centre for Drug Statistics Methodology","year":"2021"},{"issue":"12","key":"pmed.1003682.ref041","doi-asserted-by":"crossref","first-page":"1278","DOI":"10.1016\/S1473-3099(19)30532-8","article-title":"Encouraging AWaRe-ness and discouraging inappropriate antibiotic use-the new 2019 Essential Medicines List becomes a global antibiotic stewardship tool","volume":"19","author":"M Sharland","year":"2019","journal-title":"Lancet Infect Dis"},{"key":"pmed.1003682.ref042","article-title":"Reflection on modern methods: a common error in the segmented regression parameterization of interrupted time-series analyses","author":"H Xiao","year":"2020","journal-title":"Int J Epidemiol"},{"issue":"8","key":"pmed.1003682.ref043","doi-asserted-by":"crossref","first-page":"1205","DOI":"10.1038\/s41591-020-0962-9","article-title":"Age-dependent effects in the transmission and control of COVID-19 epidemics","volume":"26","author":"NG Davies","year":"2020","journal-title":"Nat Med"},{"key":"pmed.1003682.ref044","volume-title":"COVID data tracker: demographic trends of COVID-19 cases and deaths in the US reported to CDC","author":"Centers for Disease Control and Prevention","year":"2020"},{"issue":"4","key":"pmed.1003682.ref045","doi-asserted-by":"crossref","first-page":"e2020006460","DOI":"10.1542\/peds.2020-006460","article-title":"Social distancing for COVID-19 and diagnoses of other infectious diseases in children","volume":"146","author":"J Hatoun","year":"2020","journal-title":"Pediatrics"},{"key":"pmed.1003682.ref046","first-page":"727","article-title":"Time series analysis for psychological research: examining and forecasting change","volume":"6","author":"AT Jebb","year":"2015","journal-title":"Front Psychol"},{"key":"pmed.1003682.ref047","author":"Ministry of Health and Family Welfare","year":"2020"},{"issue":"Suppl 1","key":"pmed.1003682.ref048","doi-asserted-by":"crossref","first-page":"225","DOI":"10.1007\/s12070-011-0437-x","article-title":"Azithromycin in acute bacterial upper respiratory tract infections: an Indian non-interventional study","volume":"66","author":"S Donde","year":"2014","journal-title":"Indian J Otolaryngol Head Neck Surg"},{"issue":"20","key":"pmed.1003682.ref049","doi-asserted-by":"crossref","first-page":"1941","DOI":"10.1056\/NEJMoa2002606","article-title":"Macrolide and nonmacrolide resistance with mass azithromycin distribution","volume":"383","author":"T Doan","year":"2020","journal-title":"N Engl J Med"},{"key":"pmed.1003682.ref050","doi-asserted-by":"crossref","first-page":"150","DOI":"10.1016\/j.jgar.2016.05.007","article-title":"Faecal carriage rate of extended-spectrum \u03b2-lactamase-producing Enterobacteriaceae in hospitalised patients and healthy asymptomatic individuals coming for health check-up","volume":"6","author":"R Babu","year":"2016","journal-title":"J Glob Antimicrob Resist"},{"issue":"6","key":"pmed.1003682.ref051","doi-asserted-by":"crossref","first-page":"e002446","DOI":"10.1136\/bmjgh-2020-002446","article-title":"Mass azithromycin administration: considerations in an increasingly resistant world","volume":"5","author":"Y Hooda","year":"2020","journal-title":"BMJ Glob Health."},{"issue":"4","key":"pmed.1003682.ref052","doi-asserted-by":"crossref","first-page":"e0004616","DOI":"10.1371\/journal.pntd.0004616","article-title":"The burden of typhoid and paratyphoid in India: systematic review and meta-analysis","volume":"10","author":"J John","year":"2016","journal-title":"PLoS Negl Trop Dis"},{"issue":"5","key":"pmed.1003682.ref053","doi-asserted-by":"crossref","first-page":"e120","DOI":"10.1093\/cid\/ciaa1773","article-title":"spontaneous emergence of azithromycin resistance in independent lineages of Salmonella Typhi in northern India","volume":"72","author":"ME Carey","year":"2021","journal-title":"Clin Infect Dis"},{"key":"pmed.1003682.ref054","volume-title":"CDC yellow book 2020: health information for international travel","author":"GW Brunette","year":"2019"},{"issue":"3","key":"pmed.1003682.ref055","doi-asserted-by":"crossref","first-page":"105902","DOI":"10.1016\/j.ijantimicag.2020.105902","article-title":"Faropenem resistance causes in vitro cross-resistance to carbapenems in ESBL-producing Escherichia coli","volume":"55","author":"S Gandra","year":"2020","journal-title":"Int J Antimicrob Agents"},{"key":"pmed.1003682.ref056","volume-title":"Clinical management protocol: COVID-19","author":"Directorate General of Health Services","year":"2020"},{"key":"pmed.1003682.ref057","volume-title":"Notification. The Gazette of India: extraordinary","author":"Department of Health and Family Welfare","year":"2020"},{"issue":"8","key":"pmed.1003682.ref058","doi-asserted-by":"crossref","first-page":"742","DOI":"10.1016\/S1473-3099(14)70780-7","article-title":"Global antibiotic consumption 2000 to 2010: an analysis of national pharmaceutical sales data","volume":"14","author":"TP Van Boeckel","year":"2014","journal-title":"Lancet Infect Dis"},{"issue":"6","key":"pmed.1003682.ref059","doi-asserted-by":"crossref","first-page":"e1003139","DOI":"10.1371\/journal.pmed.1003139","article-title":"Antibiotic prescription practices in primary care in low- and middle-income countries: a systematic review and meta-analysis","volume":"17","author":"G Sulis","year":"2020","journal-title":"PLoS Med"},{"issue":"12","key":"pmed.1003682.ref060","doi-asserted-by":"crossref","first-page":"1368","DOI":"10.1016\/S1473-3099(18)30483-3","article-title":"Outbreak investigation of ceftriaxone-resistant Salmonella enterica serotype Typhi and its risk factors among the general population in Hyderabad, Pakistan: a matched case-control study","volume":"18","author":"FN Qamar","year":"2018","journal-title":"Lancet Infect Dis"}],"container-title":["PLOS Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pmed.1003682","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2021,7,1]],"date-time":"2021-07-01T18:45:16Z","timestamp":1625165116000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pmed.1003682"}},"subtitle":[],"editor":[{"given":"Gwenan M.","family":"Knight","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"editor"}]}],"short-title":[],"issued":{"date-parts":[[2021,7,1]]},"references-count":60,"journal-issue":{"issue":"7","published-online":{"date-parts":[[2021,7,1]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pmed.1003682","relation":{},"ISSN":["1549-1676"],"issn-type":[{"value":"1549-1676","type":"electronic"}],"subject":[],"published":{"date-parts":[[2021,7,1]]}}}