Research and analysis

SPI-B: Social and behavioural impacts for lifting remaining restrictions, 10 February 2022

Published 11 February 2022

SPI-B note on social and behavioural impacts of lifting restrictions, including testing and self-isolation, February 2022.

Executive summary

In the event of remaining restrictions being lifted, policy makers and communicators should seek to mitigate potential economic and social harms to those identifying as clinically vulnerable and those from deprived socioeconomic and minority groups. They should consider unintended consequences of any changes to current provision of testing.

Removal of free access to testing will make it more difficult for people experiencing COVID-19 symptoms to confirm infection and take actions (including self-isolation) to reduce transmission to others. Especially in the short term, these changes may increase anxiety among some people and limit their social participation outside the home, particularly those who are, or who live with, someone who is clinically vulnerable [Medium confidence].

If the legal requirement to self-isolate upon testing positive is lifted and becomes an item of public health guidance, it is likely to lead to further ambiguity among the public about the need for strict adherence. This will disproportionately impact vulnerable sections of the population, for example those who face greater pressure to work outside the home when ill because of financial hardship, precarious employment, or caring responsibilities. [Medium to high confidence] Evidence from multiple rounds of the ONS Opinions and Lifestyles Survey shows that, throughout the pandemic, only a minority of the population report that they are able to work from home. The majority report travelling to work at all times.

Other countries’ efforts to reduce rates of infectious illness through improved sick pay have proved effective. There is scope to trial this in the UK and other ways to help people to stay at home when infectious.

Protective behaviours developed during the pandemic can easily reduce or cease if not promoted longer term [High confidence]. As perceptions of personal risk decline, messaging should continue to set out the importance of continued adherence to specific protective measures as well as the rationale for lifting restrictions. Messaging should emphasise voluntary adherence as a contribution to collective wellbeing, as well as the continuing risks for some groups.

Messaging on safe behaviours should stress recognition of the different risks, needs and risk appetites of others to help prevent abusive incidents, social tensions, and stigma towards minority groups. Some far-right and anti-vax groups have successfully tapped into these tensions (across traditional political boundaries) and will continue to do so over at least the next 2 months [High confidence].

Lifting remaining restrictions provides an opportunity to forge a new narrative about maintaining safe behaviours. The legitimacy of narratives may well be increased if the loss and trauma associated with the pandemic is acknowledged alongside messages about a return to normality.

Any communications should use a range of channels to increase their reach and accessibility. There is an important role for community champions in communicating public health advice.

Cross-national studies have shown that people have higher confidence in health advice from health professionals and scientists compared to politicians. Now may be an optimal time to shift responsibility for messaging from central government to public health and NHS agencies [High confidence]. However, it is important that Government departments remain consistent in their COVID-19-related communications to avoid undermining health-led messaging.

Policy makers need to recognise that adherence will be harder for some individuals as the legislative and normative environment changes.

Adherence can be promoted by ensuring institutions and environments are supportive. Organisations (such as workplaces) should be encouraged and enabled to decide and enact proportionate measures in consultation with local public health staff.

Paper

1. What are the potential social and behavioural impacts if Government ceases to require COVID-19 mitigation measures, such as testing and self-isolation?

Testing & isolation

Maintaining some protective behaviours will reduce transmission of COVID-19, benefiting individuals at risk and other citizens, such as people more at risk from infection or awaiting NHS treatment.

The use of diagnostic tests for COVID-19 has been reported as reassuring for people who have reason to believe that they may have been exposed to infection ^{[footnote 1]}. In the short-term, removing access to free testing may therefore increase anxiety among some people, particularly those who are, or who live with, someone who is clinically vulnerable [Medium confidence]. It will also have the unintended effect of making it more difficult for socioeconomically underrepresented and minority populations (who often have comorbidities) to take precautionary actions and seek medical treatment ^{[footnote 2]}. It is unclear what, if any, impact the withdrawal of free testing would have on anxiety levels more generally.

Throughout the pandemic, most people with COVID-19 symptoms have failed to take a test ^{[footnote 3]}. In part, this was initially driven by lack of availability of tests and later by public confusion as to whether their specific symptoms suggest the presence of COVID-19 or are more likely due to some other infectious or non-infectious cause ^{[footnote 4]}. If testing ceases to be encouraged or facilitated, then, for the public, COVID-19 symptoms will become ever more subsumed into the broader, ill-defined set of respiratory-illness symptoms that are common in the population and will be treated by the public in the same way as any other symptom [High confidence].

For many years, NHS advice on what people experiencing flu-like symptoms should do has been to stay off work or school until recovered ^{[footnote 5]}. Very often, this advice is not followed, increasing the risk of transmission ^{[footnote 6] [footnote 7]} [High confidence].

Any withdrawal of free testing for those experiencing possible COVID-19 symptoms or ending of requirements to isolate for those with COVID-19 may unintentionally communicate the message to some that it is acceptable to continue with social contacts regardless of infection or symptoms. This may have particularly adverse impacts on the ability of some employees to take sick leave when experiencing (possible) symptoms.

There is a growing body of evidence which explores the reasons why people who are ill attend work or school. These include issues such as the absence of sick pay, perceived pressure from employers, fear of increasing colleagues’ workload and cultural norms within an organisation. Risk factors such as the absence of sick pay have, in turn, been associated with a greater likelihood of disease outbreaks occurring within a workplace ^{[footnote 8] [footnote 9]}.

If COVID-19 becomes hidden among other ‘everyday’ infectious illnesses, reducing its impact on morbidity and mortality could be achieved if people with general symptoms of an infectious illness stay at home [High confidence]. Facilitating this would require the Government, employers, line managers and members of the public to address the broad range of factors set out in the referenced systematic reviews ^{[footnote 10] [footnote 11]}.

Previous attempts in other countries to reduce rates of infectious illness by providing improved sick pay have proved effective: as fewer sick staff attend work, less transmission occurs, leading to fewer staff absences overall. ^{[footnote 12] [footnote 13]} Unfortunately, trials of interventions that encourage and enable more people to stay at home when ill are lacking in the literature.

Social and community tensions

Advice on safe behaviours should acknowledge that different people view the risk of COVID-19 infection differently, often owing to morbidities which are invisible to others. Messaging should accordingly stress tolerance and recognition of the different needs and risk appetites of individuals. Stressing the need to respect others’ decisions is vital in order to prevent incidents of verbal abuse and physical assault, which have recently occurred in the UK and other countries. Social distancing, wearing face-coverings and other protective behaviours have become highly politicised and the potential for conflict is unlikely to diminish in the foreseeable future ^{[footnote 14]}.

Ending restrictions will produce greater uncertainty around how to act safely, generating more stigmatising and exclusionary behaviours [Medium confidence] ^{[footnote 15]}. This uncertainty should be mitigated as it will impact health-seeking behaviours, including potentially around vaccination.

Shifting responsibility for communicating the importance of protective behaviours to public health agencies may have a positive impact on adherence (public health agencies are more trusted than government [High confidence] – see also question 3). However, it is important that cross-government communications remain consistent to avoid undermining health-led messaging.

Inconsistent messaging may lead to confusion and uncertainty among the public, and may feed into existing social and political tensions which have evolved over the course of the pandemic in response to broader public frustration over restrictions ^{[footnote 16] [footnote 17]}. Some far-right and anti-vax groups have successfully tapped into these tensions (across traditional political boundaries) and will continue to do so over at least the next 2 months [High confidence].

Consistency of messaging is important to encourage protective behaviours; the Government’s intention to change the current policy mandating vaccination of NHS staff may cause tensions to fuel anti-vaccine sentiment. Public acceptability of vaccine mandates is mixed, and higher in some contexts (such as foreign travel) compared to others. If pursued, the need for vaccine mandates should be clearly communicated and consistently enacted ^{[footnote 18]}.

Previous SPI-B advice ^{[footnote 19]} on the security and policing implications of lifting restrictions should be considered.

Alongside the lifting of restrictions, consideration should be given to acknowledging and supporting the collective loss that has been experienced as a result of the pandemic. This can be done through communications, making practical support available and or symbolic commemoration ^{[footnote 20]}. The legitimacy of communications may be increased if experiences of loss and trauma are acknowledged in public discourse through local and national commemorations by neutral figures ^{[footnote 21]}.

Marginalised communities

Previous SPI-B advice has emphasised the need to consider the disproportionate economic, social and physical impacts of lifting restrictions on marginalised communities (such as migrant workers, people with disabilities and certain ethnic groups) ^{[footnote 22]}.

The lifting of restrictions may have a disproportionate impact on the health of marginalised and socio-economically deprived groups and areas. Factors influencing this include health inequities and barriers to accessing healthcare, occupation and household circumstances. Previous SPI-B advice on these impacts should be considered ^{[footnote 23]}.

To minimise the disproportionate economic and long-term social and mental health impacts on marginalised communities, financial aid and public communications to groups who have been most acutely affected should be considered ^{[footnote 24]}.

The clinically vulnerable

The lifting of remaining restrictions will affect the risk perceptions and ability to engage in society of those identifying as clinically vulnerable (which includes many from marginalised communities) particularly when levels of community transmission remain high [Medium confidence]. Any policy should consider and mitigate these harms through both policy measures and public communications.

2. What is the key advice for encouraging maintenance of safe behaviours in the absence of restrictions?

The SPI-B papers ‘Behavioural and social considerations when reducing restrictions’ ^{[footnote 25]} and ’Sustaining behaviours to reduce SARS-CoV-2 transmission’ ^{[footnote 26]} contain relevant advice on lifting restrictions, including the need for ongoing practical support to encourage public adherence to safe behaviours.

Public perceptions of risk

As perceptions of risk decline, messaging should continue to set out clearly why continued adherence to specific protective measures is important, as well as the scientific evidence and rationale for lifting restrictions ^{[footnote 27]}.

Behavioural routines developed during the pandemic can easily reduce and cease if not promoted over the long-term ^{[footnote 28]} [Medium to high confidence]. Reminder campaigns would be useful at key times of the year such as the return to school in September or as part of the transition to winter.

Responses to the important question of ’How safe is safe enough?’ are likely to differ between political leaders, experts and members of the public. Top-down designations of ‘safe enough’ will be less effective than co-created risk assessments and opportunities for collaborative, interactive monitoring and feedback. These collaborations should allow for quantitative measures and qualitative assessments to capture the unique challenges and successes of living and working in environments deemed ‘safe enough’ while the pandemic continues ^{[footnote 29]}.

A risk reduction framework may be a useful practical tool to help the public consider overall risk level in different situations rather than viewing risk as a binary decision (for example, indoor gatherings are ‘safe’ or ‘unsafe’), which could lead to an all-or-nothing approach [Low confidence].

Enabling public adherence

As stated in previous papers ^{[footnote 30]}, communications should emphasise voluntary adherence as a contribution to collective wellbeing, as well as the continuing risks for some groups.

Policy needs to recognise that adherence will be harder for some individuals as the legislative and normative environment changes and that their ability to make choices will depend on personal circumstances.

Government should consider how to encourage adherence to protective behaviours through broader social norms (as in many east Asian countries), particularly in a context where all restrictions may be lifted over a short time and COVID-19 becomes a longer-term public health concern.

Adherence can be promoted by ensuring institutions and environments are supportive, for example employers offer sufficient sick leave; transport operators promote mask use; and buildings provide effective ventilation, including the ability to open windows where this is part of the ventilation system [High confidence]. Where possible environments should be designed and managed to obviate the need for these kinds of behaviours (for example windows do not need to be opened if ventilation through a mechanical system is adequate without this).

Some organisations have demonstrated that they can implement a variety of preventive measures in locally appropriate ways through collaboration with local public health staff. Guidance should be created through collaboration and consultation, and adequate notice is needed when guidance changes ^{[footnote 31]}. Organisations should be encouraged and enabled to decide and enact proportionate measures in consultation with local public health staff.

Communications should avoid simply providing reassurance about safety. Messages should explain clearly the reasons for changes to advice around protective behaviours and identify the ways in which safety will be monitored. Regular updates should be made available [High confidence] ^{[footnote 32]}.

3. Are there implications if responsibility for communicating public health guidance shifts from central government to UKHSA or NHS?

Lifting remaining restrictions provides an opportunity to forge a new narrative around maintaining safe behaviours, emphasising that the public faces an environment in which risks are nuanced rather than binary (see above). Cross-national studies have shown that people have higher confidence in health advice from medical workers and other health and scientific experts ^{[footnote 33] [footnote 34]}. This is particularly the case when trust in government is low and where individuals report that government is less likely to follow scientific advice ^{[footnote 35]}. When trust in government is high regarding COVID-19 control measures (namely, these are perceived as well organised and clearly messaged), there is a higher adoption of protective health behaviours ^{[footnote 36]} [Medium to high confidence].

Given the above, it is advisable to build on the ongoing strong public trust in the NHS, which suggests that now may be a good time to shift responsibility for messaging from central government to public health agencies (NHS, UKHSA) [High confidence]. The profile of the NHS is obviously greater than the UKHSA, so that would be the preferred trusted source, though coherence and visibility of messaging remains important across a variety of sources.

Importance of consistent messaging from a variety of sources

The nationally funded Community Champions programme was a successful central government pandemic policy which resulted in coherence and alignment of messaging across national sources, local authorities, NHS, Clinical Commissioning Groups (CCGs) and community organisations ^{[footnote 37]}. A similar framework should be considered to increase coherence of messaging going forward.

The Community Champions programme has also demonstrated the importance of using trusted leaders and community members to improve communication strategies, as well as testing and vaccination rates during the pandemic, particularly for socioeconomically deprived groups. [High confidence]

Central government should ensure there is sufficient resourcing and support for devolved health systems, as well as giving a clear directive to local authorities to allocate sufficient resources to disadvantaged communities, where mainstream engagement efforts are less likely to be effective.

The public seeks and receives health guidance from a range of channels (beyond mainstream outlets such as press conferences and news media) [High confidence]. Any communication should use channels that the public engages with, including social media and messaging services, while taking care to correct misinformation and disinformation.

If the legal requirement to self-isolate when testing positive is lifted and becomes an item of public health guidance, it is also likely to lead to further ambiguity among the public about the need for strict adherence. This will disproportionately impact vulnerable sections of the population, for example those who face greater pressures to work outside the home when ill because of financial hardship, precarious employment or caring responsibilities [Medium to high confidence] ^{[footnote 38]}. Evidence from multiple rounds of the ONS Opinions and Lifestyles Survey show that, throughout the pandemic, only a minority of the population report that they are able to work from home. The majority report travelling to work at all times ^{[footnote 39]}.

Broader, long-term communications considerations

Public information needs can change over the course of extreme events. For example, high demand for information about the immediate health impacts during the ‘emergency’ portion of a longer-term extreme event can transition to a heavier focus on information about the longer-term health and social impacts ^{[footnote 40]}. Shifting responsibility for communication to health authorities creates an opportunity for new dialogue and recognition of the longer-term health impacts of COVID-19 (such as long COVID-19), as well as longer-term wider impacts (for example waiting lists, developmental and educational delays, mental health and wellbeing impacts, community tensions and more). Information about the longer-term health impacts of COVID-19 will need to be provided separately to information about current infections.

Previous research into extreme events shows that perceptions of personal costs vary in nature and extent at different stages of an emergency ^{[footnote 41] [footnote 42]}. For example, members of the public may experience personal costs associated with feelings of guilt if they survive an extreme event while others do not. Personal costs can also include secondary stressors that are more prevalent as an event runs on. For example, members of the public may experience ongoing economic and health consequences, difficulties with securing compensation, impacts on education and negative familial impacts as a result of the pandemic ^{[footnote 43]}. Health professionals and communicators will need to adapt their assessments to identify the impacts of pandemic-related secondary stressors, and potentially adapt the support offered.

1. Denford S, Martin AF, Love N, et al. Engagement with Daily Testing Instead of Self-Isolating in Contacts of Confirmed Cases of SARS-CoV-2: A Qualitative Analysis., ‘Front Public Health’, 2021;9:714041. Published 3 August 2021. doi:10.3389/fpubh.2021.714041. ↩

2. S1168_Ethnicity_Subgroup_Wave_1_and_2_qual_comparison (publishing.service.gov.uk ↩

3. Smith, LE, Potts HWW, Amlot R, Fear NT, Michie S, Rubin GJ. Do members of the public think they should use lateral flow tests or PCR tests when they have COVID-19-like symptoms? The COVID-19 Rapid Survey of Adherence to Interventions and Responses, CORSAIR, study, ‘Public Health’, 2021;198:260-262. DoI: 10.1016/j.puhe.2021.07.023. ↩

4. Mowbray F, Woodland L, Smith LE, Amlôt R, Rubin GJ. Is my cough a cold or covid? A qualitative study of COVID-19 symptom recognition and attitudes towards testing in the UK.. ‘Frontiers in Public Health’ 2021; 9:716421. Doi:10.3389/fpubh.2021.716421. ↩

5. NHS Flu page ↩

6. Rubin G. J., Amlȏt R., Fear N. T., Potts H. W. W., Michie S., Smith L. E. (Under review). Do people with symptoms of an infectious illness follow advice to stay at home? Evidence from a series of cross-sectional surveys in the UK. Pre-print: https://doi.org/ 10.17605/OSF.IO/KEC24. ↩

7. Fragaszy EB, Warren-Gash C, White PJ, Zambon M, Edmunds WJ, Nyguyen-Van-Tam JS, Haward AC. Effects of seasonal and pandemic influenxa on health-related quality of life, work and school absence in England: Results from the Flu Watch cohort study. Influence and Other Respiratory Viruses 2018;12(1):171-182. ↩

8. Webster RK, Liu R, Karimullina K, Hall I, Amlôt R, Rubin GJ. A systematic review of infectious illness Presenteeism: Prevalence, reasons and risk factors. ‘BMC Public Health’. 2019;19(1) doi:10.1186/s12889-019-7138-x. ↩

9. Shallcross L, Burke D, Abbott O, Donaldson A, Hallatt G, Hayward A, Hopkins S, Krutikov M, Sharp K, Wardman L, Thorne S. Factors associated with SARS-CoV-2 infection and outbreaks in long-term care facilities in England: a national cross-sectional survey. ‘Lancet Health Longevity’ 2021; 2: E129-E142. ↩

10. Webster RK, Liu R, Karimullina K, Hall I, Amlôt R, Rubin GJ. A systematic review of infectious illness Presenteeism: Prevalence, reasons and risk factors. ‘BMC Public Health’. 2019;19(1) doi:10.1186/s12889-019-7138-x. ↩

11. Daniels S, Wei H, Han Y, Catt H, Denning DW, Hall I, Regan M, Verma A, Whitfield CA, van Tongeren M. Risk factors associated with respiratory infectious disease-related presenteeism: a rapid review. BMC Public Health 2021; 21: 1955. ↩

12. Stearns J, White C. Can paid sick leave mandates reduce leave-taking? Labour Economics 2018;51: 227-246. ↩

13. Pichler S, Ziebarth NR. The pros and cons of sick pay schemes: testing for contagious presenteeism and noncontagious absenteeism behavior. ‘Journal of Public Economics’ 2017; 156: 14-33. ↩

14. Over the last 12 months, in the UK, the Far-Right has become increasingly involved in campaigns against mask-wearing as well as issues such as vaccine mandates. These issues feature regularly on the social media (such as Telegram) channels of Right-Wing influencers such as Tommy Robinson and in the literature of political parties such as the British Freedom Party and Patriotic Alternative. ↩

15. COVID-19 Ethnicity subgroup (2021) Interpreting differential health outcomes among minority ethnic groups in wave 1 and 2. ↩

16. BBC News: Covid: Mask row sparks fight on train. ↩

17. Welt: Rassistischer Angriff auf Jugendliche – Polizei gibt Fehler zu ↩

18. UKHSA Behavioural Science and Insights Unit, Impact of Vaccine Passports & Quasi-Mandatory Vaccination on COVID-19 Vaccine Uptake - Briefing Note, 17 September 2021. ↩

19. SPI-B (2021). Lifting restrictions – security and policing implications. ↩

20. Bear, L. et al (2020). ‘A Good Death’ During the Covid-19 Pandemic in the UK A Report of Key Findings and Recommendations ↩

21. ‘Good’ and ‘Bad’ deaths during the COVID-19 pandemic: insights from a rapid qualitative study, BMJ Global Health ↩

22. SPI-B: Sustaining behaviours to reduce SARS-CoV-2 transmission, 30 April 2021 ↩

23. S1168_Ethnicity_Subgroup_Wave_1_and_2_qual_comparison (publishing.service.gov.uk ↩

24. Simpson N, Angland M, Bhogal JK, et al ‘Good’ and ‘Bad’ deaths during the COVID-19 pandemic: insights from a rapid qualitative study.. ‘BMJ Global Health’, 2021;6:e00509 ↩

25. SPI-B: Behavioural and social considerations when reducing restrictions, 10 February 2021. ↩

26. SPI-B: Sustaining behaviours to reduce SARS-CoV-2 transmission, 22 April 2021 ↩

27. SPI- B, Behavioural and social considerations when reducing restrictions, 10 February 2021 ↩

28. SPI-B: Sustaining behaviours to reduce SARS-CoV-2 transmission, 22 April 2021 ↩

29. Rogers, M. B., Amlot, R., and Rubin, G. J. (2013). The Impact of Communication Materials on Public Responses to a Radiological Dispersal Device (RDD) Attack. Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science Volume 11, Number 1, 2013a Mary Ann Liebert, Inc. DOI: 10.1089/bsp.2012.0059 ↩

30. See, for example. SPI-B (2020) Increasing adherence to COVID-19 preventative behaviours among young people ↩

31. Neisha Sundaram, Chris Bonell, Shamez Ladhani, Sinéad M Langan, Frances Baawuah, Ifeanychukwu Okike, Shazaad Ahmad, Joanne Beckmann, Joanna Garstang, Bernadette E Brent, Andrew J Brent, Zahin Amin-Chowdhury, Felicity Aiano, James Hargreaves, Implementation of preventive measures to prevent COVID-19: a national study of English primary schools in summer 2020, ‘Health Education Research’, Volume 36, Issue 3, June 2021, Pages 272–285, https://doi.org/10.1093/her/cyab016. ↩

32. Krieger, K., Amlôt , R., and Rogers, M. B. (2014). Understanding public responses to chemical, biological, radiological and nuclear incidents — Driving factors, emerging themes and research gaps. Environment International 72 (2014) 66–74. ↩

33. Wellcome Global Monitor: How does the world feel about science and health? 2018. Page 72, Chart 3.14. ↩

34. Jennings, W.; Stoker, G.; Bunting, H.; Valgarðsson, V.O.; Gaskell, J.; Devine, D.; McKay, L.; Mills, M.C. Lack of Trust, Conspiracy Beliefs, and Social Media Use Predict COVID-19 Vaccine Hesitancy. ‘Vaccines’ 2021, 9, 593. https://doi.org/10.3390/vaccines9060593 ↩

35. Wellcome Global Monitor: How Covid-19 affected people’s lives and their views about science. 2020. Page 37, Chart 3.10. ↩

36. Han, Q., Zheng, B., Cristea, M., Agostini, M., Bélanger, J., Gützkow, B., Leander, N. (2021). Trust in government regarding COVID-19 and its associations with preventive health behaviour and prosocial behaviour during the pandemic: A cross-sectional and longitudinal study. ‘Psychological Medicine’, 1-11. doi:10.1017/S0033291721001306 ↩

37. SPI-B (2020), The role of Community Champion networks to increase engagement in the context of COVID-19: Evidence and best practice. ↩

38. SPI-B and EMG: MHCLG Housing Impacts Paper. ↩

39. ONS – Opinions and Lifestyle Survey. ↩

40. Rogers, M. B., Amlot, R., and Rubin, G. J. (2013). The Impact of Communication Materials on Public Responses to a Radiological Dispersal Device (RDD) Attack. Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science, Volume 11, Number 1, 2013a Mary Ann Liebert, Inc. DOI: 10.1089/bsp.2012.0059. ↩

41. Krieger, K., Amlôt , R., and Rogers, M. B. (2014). Understanding public responses to chemical, biological, radiological and nuclear incidents — Driving factors, emerging themes and research gaps. Environment International 72 (2014) 66–74. ↩

42. Rogers, M. B., Amlot, R., and Rubin, G. J. (2013). The Impact of Communication Materials on Public Responses to a Radiological Dispersal Device (RDD) Attack. Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science Volume 11, Number 1, 2013a Mary Ann Liebert, Inc. DOI: 10.1089/bsp.2012.0059. ↩

43. Lock S, Rubin GJ, Murray V, Rogers MB, Amlôt R, Williams R. Secondary stressors and extreme events and disasters: a systematic review of primary research from 2010-2011. ‘PLoS Curr.’ 2012;4:ecurrents.dis.a9b76fed1b2dd5c5bfcfc13c87a2f24f. Published 29 October 2012. doi:10.1371/currents.dis.a9b76fed1b2dd5c5bfcfc13c87a2f24f ↩