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Excess Deaths from COVID-19 and Other Causes, March-April 2020
... (5) The elderly population is at a higher risk of death (5,6) , but this might be attributed to their pre-existing medical conditions such as cardiovascular diseases, diabetes, respiratory diseases, or cancer independently associated with increased risk of death related to COVID-19. (5)(6)(7) Obesity has also been shown to contribute to disease severity (8,9) . ...
... (10) It has been suggested that the mortality rate due to COVID-19 could be under or overestimated depending on reporting mechanism and definition of COVID-19 direct cause of mortality. (7,11) Excess mortality estimates the degree to which currently measured mortality exceeds baseline levels estimated using historical data. Rapid mortality surveillance (RMS), "a system that generates daily or weekly counts of total mortality by age, sex, date of death, place of death" was proposed to inform decision-makers about the trajectory and magnitude of the pandemic, with excess mortality being the main focal point. ...
... Death from non-respiratory causes had a significant proportional increase in 5 US states with the highest excess deaths related to COVID-19. (7) Deaths in individuals with diabetes are increasing by 96% and having the most significant increase in New York City by 356%. Heart diseases related deaths increased by 89% and 398% in New York City. ...
Background: Coronavirus disease of 2019 (COVID-19) created a major public health emergency and an international concern. It is an infectious respiratory illness caused by acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The international mortality rates due to COVID-19 reached 2,748,763 on March 24, 2021. We describe the prevalence, case fatality rate, and epidemiological trends of COVID-19 mortality in Saudi Arabia in this paper.
Method: A systematic approach of evaluating COVID-19 related mortalities was established in Saudi Arabia. A scientific committee that evaluated all reported cases with suspicious or confirmed COVID-19 disease using a standardized electronic form. A data registry of all deaths with all clinical parameters was built based on active reporting from all healthcare facilities in Saudi Arabia. Analysis of data using national and regional crude case fatality rate (cCFR) and death per 100,000 population was carried. Descriptive analysis of age, gender, nationality, and comorbidities. Mortality trend was plotted per week and compared to international figures.
Results: The total reported number of deaths between March 23rd until April 9, 2021 was 6,737. cCFR was reported as 1.70%, and death per 100,000 population was reported as 19.24 which compared favourably to figures reported by several developed countries. Highest percentages of deaths were among individuals aged between 60-69 years, males (74%), individuals with diabetes (60%), and Hypertension (50%).
Conclusion: Case fatality rate and death per 100,000 population in Saudi Arabia is among the lowest in the world due to multiple factors. Several comorbidities have been identified namely diabetes, hypertension, obesity, and cardiac arrhythmias.
... In contrast, the estimation of excess deaths takes account of the pandemic's negative (mortality-increasing) and positive (mortality-decreasing) direct and indirect effects. 12,13 We hypothesized that the overall impact of the first wave of the COVID-19 pandemic on NH residents in France could be assessed by leveraging the national NH administrative database (RESID-EHPAD, part of the French National Health Data System). 14 A recent similar, but at a regional level, was conducted in Wales. ...
... The six-year reference period was used to smooth out annual variations in mortality. 12,16 Residents can contribute follow-up time for each year in which they were registered in the NH between Jan 1st and 28/29 Feb ie. residents who entered the care ...
Background: The objectives were to assess the excess deaths among Nursing Home (NH) residents during the first wave of the COVID-19 pandemic, to determine their part in the total excess deaths and whether there was a mortality displacement.
Methods: We studied a cohort of 494,753 adults in 6,515 NHs in France exposed to COVID-19 pandemic (from March 1st to May 31st, 2020) and compared with the 2014–2019 cohorts using data from the French National Health Data System. The main outcome was death. Excess deaths and standardized mortality ratios (SMRs) were estimated.
Result: There were 13,505 excess deaths. Mortality increased by 43% (SMR: 1.43). The mortality excess was higher among males than females (SMR: 1.51 and 1.38) and decreased with increasing age (SMRs in females: 1.61 in the 60–74 age group, 1.58 for 75–84, 1.41 for 85–94, and 1.31 for 95 or over; Males: SMRs: 1.59 for 60–74, 1.69 for 75–84, 1.47 for 85–94, and 1.41 for 95 or over). No mortality displacement effect was observed up until August 30th,2020. By extrapolating to all NH residents nationally (N = 570,003), we estimated that they accounted for 51% of the general population excess deaths (N = 15,114 out of 29,563).
Conclusion: NH residents accounted for half of the total excess deaths in France during the first wave of the COVID-19 pandemic. The excess death rate was higher among males than females and among younger than older residents.
... 12 Moreover, states with higher rates of COVID-19 also reported increased deaths attributed to heart disease, diabetes, and other conditions. 13 To better understand these potential indirect effects, this study used data from a large, multistate health care system to examine changes in hospital volume and its relationship to in-hospital mortality for patients without COVID-19 during the first 10 months of the pandemic. ...
... Recent work examining national surveillance data suggest that up to one-third of excess deaths (deaths higher than those expected for season) early in the pandemic have occurred among patients without known COVID-19. 13,[18][19][20] Specifically, these studies estimate that mortality rates in the United States increased by 15% to 19% in the spring of 2020; of the identified excess deaths, only 38% to 77% could be attributed to COVID-19, with the remainder attributed to cardiovascular disease, diabetes, and Alzheimer's disease, among others. In addition, reports from several European countries and China examining population death data have found similar trends, 21-25 as well as a recent study examining excess deaths in nursing homes. ...
Background:
The extent to which the COVID-19 pandemic has affected outcomes for patients with unplanned hospitalizations is unclear.
Objective:
To examine changes in in-hospital mortality for patients without COVID-19 during the first 10 months of the pandemic (March 4, 2020 to December 31, 2020).
Design, setting, and participants:
Observational study of adults with unplanned hospitalizations at 51 hospitals across 6 Western states.
Exposures:
Unplanned hospitalizations occurring during the spring COVID-19 surge (March 4 to May 13, 2020; Period 1), an intervening period (May 14 to October 19, 2020; Period 2), and the fall COVID-19 surge (October 20 to December 31, 2020; Period 3) were compared with a pre-COVID-19 baseline period from January 1, 2019, to March 3, 2020.
Main outcomes and measures:
We examined daily hospital admissions and in-hospital mortality overall and in 30 conditions.
Results:
Unplanned hospitalizations declined steeply during Periods 1 and 3 (by 47.5% and 25% compared with baseline, respectively). Although volumes declined, adjusted in-hospital mortality rose from 2.9% in the pre-pandemic period to 3.5% in Period 1 (20.7% relative increase), returning to baseline in Period 2, and rose again to 3.4% in Period 3. Elevated mortality was seen for nearly all conditions studied during the pandemic surge periods.
Conclusion:
Pandemic COVID-19 surges were associated with higher rates of in-hospital mortality among patients without COVID-19, suggesting disruptions in care patterns for patients with many common acute and chronic illnesses.
... [2][3][4][5][6][7][8][9][10][11] However, the impact of the COVID-19 pandemic on mortality is not completely captured by the analysis of the reported COVID-19 deaths and cases due to limited testing capacity, disruption of health services and a possible reduction in other causes of death as a consequence of restrictive control measures. Indeed, many studies have highlighted that COVID-19 deaths represent only a small proportion of the excess mortality observed since the start of the pandemic in several countries, 5,6,12,13 indicating that indirect excess deaths may also contribute to the overall mortality burden. This is particularly true in countries heavily affected by the pandemic such as Italy, 5,6 France, 6 Brazil, 14,15 the UK 6 and the USA. ...
... This is particularly true in countries heavily affected by the pandemic such as Italy, 5,6 France, 6 Brazil, 14,15 the UK 6 and the USA. 12,13 Thus, analysis of overall excess mortality represents an important complementary tool to investigate the influence of the SARS-CoV-2 pandemic on mortality. Importantly, in the case of COVID-19, during the initial weeks of the pandemic, most countries lacked adequate testing and healthcare systems were overwhelmed with patients displaying symptoms of COVID-19; therefore, many cases and deaths that should have been attributed to COVID-19 were not tested and identified. ...
Background: This study aimed to investigate overall and sex-specific excess all-cause mor
... They present a range of values for excess deaths based on different historical thresholds, including the average expected count or upper boundary of the uncertainty interval, and apply weights to the 2020 provisional death data to account for incomplete data. In contrast, Weinberger and colleagues and Woolf and colleagues use multivariable Poisson regression models to evaluate increases in the occurrence of deaths due to any cause across the US [21,22]. Weinberger and colleagues adjust for influenza activity [21]. ...
... These data suggest that between 1% and 28% of excess deaths were not directly assigned to COVID-19. An analysis by Woolf and colleagues, based on data from March 1 through April 25, 2020, yielded a higher estimate, finding that of 87,001 excess deaths, 30,755 excess deaths or 35% were not assigned to COVID-19 [22]. A subsequent analysis by Woolf and colleagues using data from March 1 through August 1 found that of 225,530 excess deaths, 150,541 were directly assigned to COVID-19, suggesting that 33% of excess deaths were not assigned to COVID-19 [38]. ...
Background
Coronavirus Disease 2019 (COVID-19) excess deaths refer to increases in mortality over what would normally have been expected in the absence of the COVID-19 pandemic. Several prior studies have calculated excess deaths in the United States but were limited to the national or state level, precluding an examination of area-level variation in excess mortality and excess deaths not assigned to COVID-19. In this study, we take advantage of county-level variation in COVID-19 mortality to estimate excess deaths associated with the pandemic and examine how the extent of excess mortality not assigned to COVID-19 varies across subsets of counties defined by sociodemographic and health characteristics.
Methods and findings
In this ecological, cross-sectional study, we made use of provisional National Center for Health Statistics (NCHS) data on direct COVID-19 and all-cause mortality occurring in US counties from January 1 to December 31, 2020 and reported before March 12, 2021. We used data with a 10-week time lag between the final day that deaths occurred and the last day that deaths could be reported to improve the completeness of data. Our sample included 2,096 counties with 20 or more COVID-19 deaths. The total number of residents living in these counties was 319.1 million. On average, the counties were 18.7% Hispanic, 12.7% non-Hispanic Black, and 59.6% non-Hispanic White. A total of 15.9% of the population was older than 65 years. We first modeled the relationship between 2020 all-cause mortality and COVID-19 mortality across all counties and then produced fully stratified models to explore differences in this relationship among strata of sociodemographic and health factors. Overall, we found that for every 100 deaths assigned to COVID-19, 120 all-cause deaths occurred (95% CI, 116 to 124), implying that 17% (95% CI, 14% to 19%) of excess deaths were ascribed to causes of death other than COVID-19 itself. Our stratified models revealed that the percentage of excess deaths not assigned to COVID-19 was substantially higher among counties with lower median household incomes and less formal education, counties with poorer health and more diabetes, and counties in the South and West. Counties with more non-Hispanic Black residents, who were already at high risk of COVID-19 death based on direct counts, also reported higher percentages of excess deaths not assigned to COVID-19. Study limitations include the use of provisional data that may be incomplete and the lack of disaggregated data on county-level mortality by age, sex, race/ethnicity, and sociodemographic and health characteristics.
Conclusions
In this study, we found that direct COVID-19 death counts in the US in 2020 substantially underestimated total excess mortality attributable to COVID-19. Racial and socioeconomic inequities in COVID-19 mortality also increased when excess deaths not assigned to COVID-19 were considered. Our results highlight the importance of considering health equity in the policy response to the pandemic.
... In the USA, between March and April 2020, CVDrelated deaths increased by 89% in the five states with the highest number of COVID-19 related deaths. 26 Similarly, according to death registers in England and Wales, 2085 more deaths were caused by acute CVD between 2 March and 30 June 2020, compared with the same period of the previous 6 years. 25 In the present study, we expanded Figure 2 SMRs with 95% CI for CVD-related mortality and SIRS with 95% CI for CVD-related hospitalisation. ...
Objective
To assess the impact of the COVID-19 outbreak on cardiovascular disease (CVD) related mortality and hospitalisation.
Design
Community-based prospective cohort study.
Setting
The UK Biobank.
Participants
421 372 UK Biobank participants who were registered in England and alive as of 1 January 2020.
Primary and secondary outcome measures
The primary outcome of interest was CVD-related death, which was defined as death with CVD as a cause in the death register. We retrieved information on hospitalisations with CVD as the primary diagnosis from the UK Biobank hospital inpatient data. The study period was 1 January 2020 to June 30 2020, and we used the same calendar period of the three preceding years as the reference period. In order to control for seasonal variations and ageing of the study population, standardised mortality/incidence ratios (SMRs/SIRs) with 95% CIs were used to estimate the relative risk of CVD outcomes during the study period, compared with the reference period.
Results
We observed a distinct increase in CVD-related deaths in March and April 2020, compared with the corresponding months of the three preceding years. The observed number of CVD-related deaths (n=218) was almost double in April, compared with the expected number (n=120) (SMR=1.82, 95% CI 1.58 to 2.07). In addition, we observed a significant decline in CVD-related hospitalisations from March onwards, with the lowest SIR observed in April (0.45, 95% CI 0.41 to 0.49).
Conclusions
There was a distinct increase in the number of CVD-related deaths in the UK Biobank population at the beginning of the COVID-19 outbreak. The shortage of medical resources for hospital care and stress reactions to the pandemic might have partially contributed to the excess CVD-related mortality, underscoring the need of sufficient healthcare resources and improved instructions to the public about seeking healthcare in a timely way.
... Montana, Oregon, and Washington), few excess deaths were identified over the entire observation period. The observation of fewer excess deaths per 1,000 ESRD patients in regions affected later in the pandemic is consistent with studies of excess deaths in the overall U.S. population (9). ...
End-stage renal disease (ESRD) is a condition in which kidney function has permanently declined such that renal replacement therapy* is required to sustain life (1). The mortality rate for patients with ESRD in the United States has been declining since 2001 (2). However, during the COVID-19 pandemic, ESRD patients are at high risk for COVID-19-associated morbidity and mortality, which is due, in part, to weakened immune systems and presence of multiple comorbidities (3-5). The ESRD National Coordinating Center (ESRD NCC) supports the Centers for Medicare & Medicaid Services (CMS) and the ESRD Networks†,§ through analysis of data, dissemination of best practices, and creation of educational materials. ESRD NCC analyzed deaths reported to the Consolidated Renal Operations in a Web-Enabled Network (CROWNWeb), a system that facilitates the collection of data and maintenance of information about ESRD patients on chronic dialysis or receiving a kidney transplant who are treated in Medicare-certified dialysis facilities and kidney transplant centers in the United States. Excess death estimates were obtained by comparing observed and predicted monthly numbers of deaths during February 1-August 31, 2020; predicted deaths were modeled based on data from January 1, 2016, through December 31, 2019. The analysis estimated 8.7-12.9 excess deaths per 1,000 ESRD patients, or a total of 6,953-10,316 excess deaths in a population of 798,611 ESRD patients during February 1-August 31, 2020. These findings suggest that deaths among ESRD patients during the early phase of the pandemic exceeded those that would have been expected based on previous years' data. Geographic and temporal patterns of excess mortality, including those among persons with ESRD, should be considered during planning and implementation of interventions, such as COVID-19 vaccination, infection control guidance, and patient education. These findings underscore the importance of data-driven technical assistance and further analyses of the causes and patterns of excess deaths in ESRD patients.
... Monitoring the excess deaths has emerged as an important approach to assess the magnitude of the impact of COVID-19, [2][3][4][5] and tracking these numbers in near to real time provides an invaluable bird's eye view of how the pandemic is unfolding. Leon et al. [6] suggested that real-time weekly excess deaths could provide the most objective and comparable way of assessing the scale of the pandemic and formulating lessons to be learned. ...
... On a national level, almost 15% of inpatient beds are currently estimated to be occupied by a COVID-19 patient. Moreover, since the beginning of the pandemic, studies have shown a significant increase in mortality related to non-COVID-related illnesses [3]. ese facts highlight the pandemic's wide-reaching impact that extends beyond the direct mortality related to SARS-CoV-2 itself. ...
As SARS-CoV-2 continues to spread across the globe and significantly impacts health-care systems and strains resources, identifying prognostic factors to predict clinical outcome remains essential. We conducted a retrospective cohort study to further explore the prognostic value of serum hypoalbuminemia and other factors in hospitalized COVID-19 patients. The primary endpoint was defined as the risk of in-hospital mortality. 300 patients were included in the analysis, with 56% being male and a mean (±SD) age of 61.5 ± 15.3 years. The mean (±SD) albumin was 2.86 ± 0.5 g/dL. Our analysis showed that patients with in-hospital mortality had lower albumin levels than patients without in-hospital mortality (2.6 ± 0.49 vs. 2.9 ± 0.48 g/dL, respectively, with P value = <0.001). A multivariant logistic regression analysis was subsequently conducted, and after adjustment, the serum albumin level remained a strong predictor of the primary outcome. Based on the data gathered, we were able to create a model predictive of mortality in this patient group based on the serum albumin level and other pertinent factors. In this model, with all other variables remaining constant, each one-unit increase in albumin is estimated to reduce the odds of mortality by 73%. Our results strengthen the current available data on the prognostic value of serum albumin in COVID-19 patients and provide a model to predict in-hospital mortality.
... Patients with acute coronary syndromes may have avoided emergent medical care and thus died at home (which is consistent with reports that deaths at home have increased in areas with the hardest hit by . 17 There is a potential link of the observed increased deaths of ischemic heart disease to the decreased nuclear cardiac studies performed during the same time period, as reflected in our institution results (Fig. 2). Although the data are not sufficient to show a direct causal link between the increased ischemic cardiac deaths and the decreased nuclear cardiac scans, it clearly suggests that the latter could be a factor that contributes to the cardiac death. ...
The pandemic of coronavirus 2019 disease (COVID-19) not only directly causes high morbidity and mortality of the disease, but also indirectly affects patients with pre-existing medical conditions, particularly cardiovascular diseases, with delayed or deferred outpatient care and procedure including nuclear medicine studies because of concerns about exposure to the virus. In this article, the impact of COVID-19 on hospital operation and nuclear medicine practice in the United States along with recommendations and guidance from major academic organizations are presented. Safe operation of specific nuclear medicine scans, such as lung scintigraphy and nuclear cardiac imaging, are reviewed in the context of balancing benefits to patients against the risk of exacerbating the spread of the virus. Thoughtful reintroduction of nuclear medicine services are discussed based on ethical considerations that maximize benefits to those who are likely to benefit most, taking into consideration baseline health inequities, and ensuring that all decisions reflect best available evidence with transparent communication. Finally, potential correlation between decreased volume of nuclear cardiac studies performed during the pandemic and corresponding increased deaths from ischemic and hypertensive cardiac disease is discussed.
... Attribution of deaths to COVID-19 may have led to bias for certain age groups if countries defined COVID-19 deaths differently. Current policies and pandemic restrictions can also indirectly affect the fatality rate through delayed emergency care, on-going health issues, or affected social determinants to health (i.e., socioeconomic status) [39,60,61]. Differences in healthcare systems, as well as the effectiveness and accuracy of a country's COVID-19 testing approaches may also affect the reported data and case fatality rates between age groups. ...
Since the beginning of 2020, COVID-19 has been the biggest public health crisis in the world. To help develop appropriate public health measures and deploy corresponding resources, many governments have been actively tracking COVID-19 in real time within their jurisdictions. However, one of the key unresolved issues is whether COVID-19 was distributed differently among different age groups and between the two sexes in the ongoing pandemic. The objectives of this study were to use publicly available data to investigate the relative distributions of COVID-19 cases, hospitalizations, and deaths among age groups and between the sexes throughout 2020; and to analyze temporal changes in the relative frequencies of COVID-19 for each age group and each sex. Fifteen countries reported age group and/or sex data of patients with COVID-19. Our analyses revealed that different age groups and sexes were distributed differently in COVID-19 cases, hospitalizations, and deaths. However, there were differences among countries in both their age group and sex distributions. Though there was no consistent temporal change across all countries for any age group or either sex in COVID-19 cases, hospitalizations, and deaths, several countries showed statistically significant patterns. We discuss the potential mechanisms for these observations, the limitations of this study, and the implications of our results on the management of this ongoing pandemic.
... 3,6,10,30,50 Sub-optimal management of pre-existing conditions due to limited access to healthcare resources and social distancing orders during the pandemic is also associated with excess health risks in vulnerable patients. 4,46,47 Excess mortality from non-COVID-19 related causes has been documented during the COVID-19 pandemic. 21,36 COVID-19 pandemic has also caused a global crisis of mental health problems. ...
Background
Patients with pre-existing conditions and poor health status are vulnerable for adverse health sequalae during the COVID-19 pandemic. We investigated the association of pre-existing medical conditions and self-perceived health status with the risk of mental health complications during the COVID-19 pandemic.
Methods
In October—December, 2020, 1036 respondents completed online survey that included assessment of pre-existing conditions, self-perceived health status, depressive (Patient Health Questionnaire-8 score ≥ 10), anxiety (Generalized Anxiety Disorders-7 score ≥ 10) and post-traumatic stress (Impact of Events Scale Revised) symptoms, alcohol use (AUDIT), and COVID-19 fear (COVID-19 Fears Questionnaires for Chronic Medical Conditions).
Results
Study participants were predominantly women (83%), younger than 61 years of age (94%). Thirty-six percent of respondents had a pre-existing condition and 5% considered their health status as bad or very bad. Pre-existing conditions and poor perceived health status were associated with increased risk for moderate to severe depressive and anxiety symptoms, fear of COVID-19 and post-traumatic stress symptoms, independently from respondents’ age, gender, living area, smoking status, exercise, alcohol consumption and diet.
Conclusions
Pre-existing medical conditions and poor perceived health status are associated with increased risk of poor mental health status during the COVID-19 pandemic.
... That intuition would, however, prove wrong if prepandemic mortality sex ratios do not generalize to the intra-pandemic ratio of non-COVID-19 deaths. And, indeed, they may not because behavior-constraining interventions intended to reduce the spread of infection likely change sex-specific exposures to lethal hazards other than SARS-CoV-2 [4]. Social distancing, for example, has reportedly increased non-COVID-19 deaths by inducing economic hardship and impeding access to medical care and social support [5], but decreased deaths attributable to transportation accidents and other hazards presented by human mobility [6,7]. ...
Aims
To determine whether differences between Norway’s and Sweden’s attempts to contain SARS-CoV-2 infection coincided with detectably different changes in their all-cause mortality sex ratios. Measuring temporal variation in the all-cause mortality sex ratio before and during the pandemic in populations exposed to different constraints on risky behavior would allow us to better anticipate changes in the ratio and to better understand its association with infection control strategies.
Methods
I apply time Box–Jenkins modeling to 262 months of pre-pandemic mortality sex ratios to arrive at counterfactual values of 10 intra-pandemic ratios. I compare counterfactual to observed values to determine if intra-pandemic ratios differed detectably from those expected as well as whether the Norwegian and Swedish differences varied from each other.
Results
The male to female mortality sex ratio in both Norway and Sweden increased during the pandemic. I, however, find no evidence that the increase differed between the two countries despite their different COVID-19 containment strategies.
Conclusion
Societal expectations of who will die during the COVID-19 pandemic will likely be wrong if they assume pre-pandemic mortality sex ratios because the intra-pandemic ratios appear, at least in Norway and Sweden, detectably higher. The contribution of differences in policies to reduce risky behavior to those higher ratios appears, however, small.
... Furthermore, Nsp4 affects ER membranes and thus influences viral replication, and nonstructural protein 6 initiates the formation of autophagosomes from the endoplasmic reticulum. Nsp7 is an RNA-dependent RNA polymerase having a major effect on virus replication, similar to non-structural proteins 8,9,12,13. Nsp10 is involved in the activation of virus transcription and, like Nsp16, has methyltransferase-like activity. Nsp14 and Nsp15 are nucleases that act within the genetic material of the virus. ...
The effect of BCG vaccination against tuberculosis on the reduction in COVID-19 infection is related to the effect of the BCG vaccine on the immunomodulation of non-specific immunity. In the early stages of the pandemic, countries with universal BCG vaccination programs registered a low number of new cases of COVID-19, with the situation now reversed, as exemplified by India. The high genetic variability of SARS-CoV-2, a known characteristic of RNA viruses, causing the occurrence of SARS-CoV-2 variants may have led to the virus adapting to overcome the initial immune protection. The strains from the United Kingdom (B1.1.7), Brazil (B1.1.28 and B1.1.33), South Africa (B.1.351), and India (B.1.617) are characterized by a greater ability to spread in the environment, in comparison with the original infectious agent of SARS-CoV-2. It should be remembered that the large variation in the genetic makeup of SARS-CoV-2 may result in future changes in its pathogenicity, immunogenicity and antigenicity, and therefore it is necessary to carefully study the mutations occurring within the virus to determine whether the current vaccines will remain effective. However, most studies show that monoclonal antibodies produced after vaccination against COVID-19 are effective against the newly developed variants.
... Some of this early research showed increases in: stress, anxiety, and depression (Ettman et al., 2020;Salari et al., 2020), certain types of criminal activity such as domestic violence and aggravated assault and homicide (Rosenfeld et al., 2021), alcohol use (Pollard et al., 2020), and even reports of a large CrimRxiv A COVID-19 Public Health Silver Lining? Reductions in Driving Under the In uence Events and Accidents In Miami-Dade County 3 number of excess deaths that were indirectly tied to COVID-19 but not a direct result of the virus itself (Woolf et al., 2020). In short, and unsurprisingly, the virus and some policy efforts have had a wide range of adverse effects on people and society more generally. ...
... "Presumed COVID-related deaths" are counted by some municipalities in an attempt to capture more deaths for which no test was done but for which circumstances suggested the cause was likely COVID-19; of course this categorization requires a subjective decision. 40 "Excess deaths" analyses relative to all-cause mortality from previous years [41][42][43][44][45] can provide a valuable measure of the impact of the virus, although differentiating deaths caused by the virus vs those related to but not directly caused by the virus is often not straightforward. The case fatality rate can be considered a measure of the danger of COVID-19 relative to other viral diseases, or can be used to compare outcomes across countries. ...
The world has experienced three global pandemics over the last half‐century: HIV/AIDS, H1N1, and COVID‐19. HIV/AIDS and COVID‐19 are still with us and have wrought extensive havoc worldwide. There are many differences between these two infections and their global impacts, but one thing they have in common is the mobilization of scientific resources to both understand the infection and develop ways to combat it. As was the case with HIV, statisticians have been in the forefront of scientists working to understand transmission dynamics and the natural history of infection, determine prognostic factors for severe disease, and develop optimal study designs to assess therapeutics and vaccines.
... 88 (2) 75 (3) 84 (8) 100 (5) 58 (7) 83 (9) 67 (10) 96 (8) 70 (2) 84 (8) 80 ( (10) 85 (10) 82 (10) 97 (6) 69 (10) 84 (9) 80 (9) 98 (6) 79 (10) 89 (7) 84 (87) Provider (10) 86 (9) 82 (10) 100 (6) 57 (7) 86 (10) 94 (9) 97 (7) 79 (9) 89 (7) 86 (84) Provider, % 32 For example, limited screening, referral and diagnosis for cancer services during the pandemic could lead to a 20% increase in cancer deaths in the next 12 months. 33,34 Obesity is a chronic, progressive and relapsing disease that requires long-term treatment. ...
Obesity is a risk factor for severe complications from coronavirus disease 2019 (COVID-19). During the COVID-19 pandemic in Spring 2020, many clinics and obesity centers across Europe were required to close. This study aimed to determine the impact of COVID-19 on the provision of obesity services across 10 European countries via a survey of physicians (n = 102) specializing in treating persons with obesity (PwO). In total, 62–95 out of 102 physicians reported that COVID-19 affected obesity-related services, with cancellations/suspensions ranging from 50% to 100% across the 10 countries. Approximately 75% of cancellations/suspensions were provider- rather than patient-initiated. A median increase of 20%–25% in waiting times was reported for most services across the countries. When services resume, 87 out of 100 physicians consider factors influencing down-stream patient outcomes as the most relevant factors for prioritizing interventional treatment. Responses showed that 65 out of 102 and 36 out of 102 physicians believed it (highly) likely that a change in treatment guidance will occur to prioritize earlier interventional treatment for the management of PwO, by either using bariatric surgery or pharmacotherapy, respectively. Results from this study provide important learnings, such as opportunities for, and discrepancies in, the provision of alternative care in light of services cancellations or delays, which may be important for the future management of obesity, especially during future waves of COVID-19 or other infectious pandemics.
... However, official COVID-19 death tallies underestimate full impact of COVID-19-related mortality. 16,17 Previous work found >30% higher death rates during winter months compared with summer months, suggesting that OHCAs would be expected to decline as the year progresses rather than plateau as occurred in 2020. 18,19 Thus, the increase in PI-OHCA during 2020 is out of proportion and noted before reduction in PI-STEMI occurred; this in conjunction with a lower proportion of field defibrillation may be associated with prevalent but undiagnosed COVID-19. ...
Background
Public health emergencies may significantly impact emergency medical services responses to cardiovascular emergencies. We compared emergency medical services responses to out‐of‐hospital cardiac arrest (OHCA) and ST‐segment‒elevation myocardial infarction (STEMI) during the 2020 COVID‐19 pandemic to 2018 to 2019 and evaluated the impact of California's March 19, 2020 stay‐at‐home order.
Methods and Results
We conducted a population‐based cross‐sectional study using Los Angeles County emergency medical services registry data for adult patients with paramedic provider impression (PI) of OHCA or STEMI from February through May in 2018 to 2020. After March 19, 2020, weekly counts for PI‐OHCA were higher (173 versus 135; incidence rate ratios, 1.28; 95% CI, 1.19‒1.37; P <0.001) while PI‐STEMI were lower (57 versus 65; incidence rate ratios, 0.87; 95% CI, 0.78‒0.97; P =0.02) compared with 2018 and 2019. After adjusting for seasonal variation in PI‐OHCA and decreased PI‐STEMI, the increase in PI‐OHCA observed after March 19, 2020 remained significant ( P =0.02). The proportion of PI‐OHCA who received defibrillation (16% versus 23%; risk difference [RD], −6.91%; 95% CI, −9.55% to −4.26%; P <0.001) and had return of spontaneous circulation (17% versus 29%; RD, −11.98%; 95% CI, −14.76% to −9.18%; P <0.001) were lower after March 19 in 2020 compared with 2018 and 2019. There was also a significant increase in dead on arrival emergency medical services responses in 2020 compared with 2018 and 2019, starting around the time of the stay‐at‐home order ( P <0.001).
Conclusions
Paramedics in Los Angeles County, CA responded to increased PI‐OHCA and decreased PI‐STEMI following the stay‐at‐home order. The increased PI‐OHCA was not fully explained by the reduction in PI‐STEMI. Field defibrillation and return of spontaneous circulation were lower. It is critical that public health messaging stress that emergency care should not be delayed.
Background
How SARS-CoV-2 infectivity varies with viral load is incompletely understood. Whether rapid point-of-care antigen lateral flow devices (LFDs) detect most potential transmission sources despite imperfect clinical sensitivity is unknown.
Methods
We combined SARS-CoV-2 testing and contact tracing data from England between 01-September-2020 and 28-February-2021. We used multivariable logistic regression to investigate relationships between PCR-confirmed infection in contacts of community-diagnosed cases and index case viral load, S gene target failure (proxy for B.1.1.7 infection), demographics, SARS-CoV-2 incidence, social deprivation, and contact event type. We used LFD performance to simulate the proportion of cases with a PCR-positive contact expected to be detected using one of four LFDs.
Results
231,498/2,474,066(9%) contacts of 1,064,004 index cases tested PCR-positive. PCR-positive results in contacts independently increased with higher case viral loads (lower Ct values) e.g., 11.7%(95%CI 11.5-12.0%) at Ct=15 and 4.5%(4.4-4.6%) at Ct=30. B.1.1.7 infection increased PCR-positive results by ~50%, (e.g. 1.55-fold, 95%CI 1.49-1.61, at Ct=20). PCR-positive results were most common in household contacts (at Ct=20.1, 8.7%[95%CI 8.6-8.9%]), followed by household visitors (7.1%[6.8-7.3%]), contacts at events/activities (5.2%[4.9-5.4%]), work/education (4.6%[4.4-4.8%]), and least common after outdoor contact (2.9%[2.3-3.8%]). Contacts of children were the least likely to test positive, particularly following contact outdoors or at work/education. The most and least sensitive LFDs would detect 89.5%(89.4-89.6%) and 83.0%(82.8-83.1%) of cases with PCR-positive contacts respectively.
Conclusions
SARS-CoV-2 infectivity varies by case viral load, contact event type, and age. Those with high viral loads are the most infectious. B.1.1.7 increased transmission by ~50%. The best performing LFDs detect most infectious cases.
Factors such as varied definitions of mortality, uncertainty in disease prevalence, and biased sampling complicate the quantification of fatality during an epidemic. Regardless of the employed fatality measure, the infected population and the number of infection-caused deaths need to be consistently estimated for comparing mortality across regions. We combine historical and current mortality data, a statistical testing model, and an SIR epidemic model, to improve estimation of mortality. We find that the average excess death across the entire US from January 2020 until February 2021 is 9 $$\%$$ % higher than the number of reported COVID-19 deaths. In some areas, such as New York City, the number of weekly deaths is about eight times higher than in previous years. Other countries such as Peru, Ecuador, Mexico, and Spain exhibit excess deaths significantly higher than their reported COVID-19 deaths. Conversely, we find statistically insignificant or even negative excess deaths for at least most of 2020 in places such as Germany, Denmark, and Norway.
Long-term care facilities (LTCF) were and are particularly affected by the COVID-19 pandemic. The dimensions of the outbreaks and the high mortality among residents led to massive restrictions in LTCFs, especially in the area of social contacts and activities but also in areas of medical care. With the start of vaccinations and the improved testing options, the situation has now changed and existing restrictions must be evaluated to determine whether they are still appropriate. In an interprofessional and interdisciplinary group of experts, considerations have been formulated on how a way back to normality could look like in LTCFs.
Males are at higher risk relative to females of severe outcomes following COVID-19 infection. Focusing on COVID-19-attributable mortality in the United States (U.S.), we quantify and contrast years of potential life lost (YPLL) attributable to COVID-19 by sex based on data from the U.S. National Center for Health Statistics as of 31 March 2021, specifically by contrasting male and female percentages of total YPLL with their respective percent population shares and calculating age-adjusted male-to-female YPLL rate ratios both nationally and for each of the 50 states and the District of Columbia. Using YPLL before age 75 to anchor comparisons between males and females and a novel Monte Carlo simulation procedure to perform estimation and uncertainty quantification, our results reveal a near-universal pattern across states of higher COVID-19-attributable YPLL among males compared to females. Furthermore, the disproportionately high COVID-19 mortality burden among males is generally more pronounced when measuring mortality in terms of YPLL compared to age-irrespective death counts, reflecting dual phenomena of males dying from COVID-19 at higher rates and at systematically younger ages relative to females. The U.S. COVID-19 epidemic also offers lessons underscoring the importance of a public health environment that recognizes sex-specific needs as well as different patterns in risk factors, health behaviors, and responses to interventions between men and women. Public health strategies incorporating focused efforts to increase COVID-19 vaccinations among men are particularly urged.
In this manuscript, we describe how efforts to increase access to buprenorphine for Opioid Use Disorder (OUD) through a telemedicine hub before and since the COVID-19 pandemic have played out in the Veterans Healthcare Administration (VHA) in New England. We look at how the COVID-19 pandemic and subsequent spike in opioid overdoses tilted the risk: benefit calculation for tele-prescribing a controlled substance such as buprenorphine toward expanding access to tele-buprenorphine. We conclude that there is a need for tele-buprenorphine hubs that can fill gaps in geographically dispersed healthcare systems.
COVID-19 outbreaks have had high mortality in low- and medium-income countries such as Ecuador. Human mobility is an important factor influencing the spread of diseases possibly leading to a high burden of disease at the country level. Drastic control measures, such as complete lockdown are effective epidemic controls, yet in practice, one hopes that a partial shutdown would suffice. It is an open problem to determine how much mobility can be allowed while controlling an outbreak. In this paper, we use statistical models to relate human mobility to the excess death in Ecuador while controlling for demographic factors. The mobility index provided by GRANDATA, based on mobile phone users, represents the change of number of out-of-home events with respect to a benchmark date (March 2nd, the first date the data is available). The study confirms the global trend that more men are dying than expected compared to women, and that people under 30 show less deaths than expected. Specifically, individuals in the age groups younger than 20, we found have their death rate reduced during the pandemic between 22% and 27% of the expected deaths in the absence of COVID-19. The weekly median mobility time series shows a sharp decrease in human mobility immediately after a national lockdown was declared on March 17, 2020 and a progressive increase towards the pre-lockdown level within two months. Relating median mobility to excess death shows a lag in its effect: first, a decrease in mobility in the previous two to three weeks decreases the excess death and more novel, we found that an increase of mobility variability four weeks prior, increases the number of excess deaths.
Little research has been conducted to explore the functional status of community‐dwelling older adults in sub‐Saharan Africa, including Ghana, especially during the COVID‐19 pandemic. This study investigated the functional status and the health‐seeking behaviour of older adults during the COVID‐19 pandemic in Ghana. Utilising a descriptive qualitative approach, semi‐structured interviews were used to collect data from 12 eligible older adults from southern Ghana. With the use of NVivo (v12), descriptive and focused coding techniques were employed to analyse the data. The following five themes were identified after the data analysis: (a) older adults' health status during COVID‐19 pandemic, (b) feeling limited, (c) feeling of unhappiness for being inactive, (d) striving to be active and (e) seeking healthcare during COVID‐19 pandemic. This study revealed the unique health and social‐related needs of Ghanaian older adults during the COVID‐19 pandemic. This study's findings draw attention to the urgent need for the state to devise practical health and social‐related initiatives to support older adults during and after the COVID‐19 pandemic.
Coronavirus disease 2019 (COVID‐19) is caused by the new severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2), which binds to ectoenzyme angiotensin‐converting enzyme 2. It is very contagious and is spreading rapidly around the world. Until now, coronaviruses have mainly been associated with the aerodigestive tract due to the presence of a monobasic cleavage site for the resident transmembrane serine protease 2. Notably, SARS‐CoV‐2 is equipped with a second, polybasic cleavage site for the ubiquitous furin protease, which may determine the widespread tissue tropism. Furthermore, the terminal sequence of the furin‐cleaved spike protein also binds to neuropilin receptors. Clinically, there is enormous variability in the severity of the disease. Severe consequences are seen in a relatively small number of patients, most show moderate symptoms, but asymptomatic cases, especially among young people, drive disease spread. Unfortunately, the number of local infections can quickly build up, causing disease outbreaks suddenly exhausting health services’ capacity. Therefore, COVID‐19 is dangerous and unpredictable and has become the most serious threat for generations. Here, the latest research on COVID‐19 is summarized, including its spread, testing methods, organ‐specific complications, the role of comorbidities, long‐term consequences, mortality, as well as a new hope for immunity, drugs, and vaccines. The enormously contagious severe acute respiratory syndrome coronavirus 2 has rapidly spread worldwide. The virus has acquired a new proteolytic site for a ubiquitous furin protease, as well as new binding site for an adhesion molecule in the brain and immune cells. In this way, the virus has a broad firepower across all organs.
Background
: Social determinants of health (SDOH) may limit the practice of COVID-19 risk mitigation guidelines with health implications for individuals with underlying cardiovascular disease (CVD). Population-based evidence of the association between SDOH and practicing such mitigation strategies in adults with CVD is lacking. We used the National Opinion Research Center's COVID-19 Household Impact Survey conducted between April and June 2020 to evaluate sociodemographic disparities in adherence to COVID-19 risk mitigation measures in a sample of respondents with underlying CVD representing 18 geographic areas of the United States (US).
Methods
: CVD status was ascertained by self-reported history of receiving heart disease, heart attack, or stroke diagnosis. We built de novo, a cumulative index of SDOH burden using education, insurance, economic stability, 30-day food security, urbanicity, neighborhood quality, and integration. We described the practice of measures under the broad strategies of personal protection (mask, hand hygiene, physical distancing), social distancing (avoiding crowds, restaurants, social activities, and high-risk contact), and work flexibility (work-from-home, canceling/postponing work). We reported prevalence ratios (PR) and 95% confidence intervals (CIs) for the association between SDOH burden (quartiles of cumulative indices) and practicing these measures adjusting for age, sex, race/ethnicity, comorbidity, and interview wave.
Results
: 2036/25269 (7.0%) adults, representing 8.69 million in 18 geographic areas of the US, reported underlying CVD. Compared to the least SDOH burden, fewer individuals with the greatest SDOH burden practiced all personal protection (75.6% vs 89.0%) and social distancing measures (41.9% vs 58.9%) and had any flexible work schedule (26.2% vs 41.4%). These associations remained statistically significant after full adjustment: personal protection, (PR = 0.83; 95% CI [0.73-0.96]; P = 0.009); social distancing (PR = 0.69; 95% CI [0.51-0.94]; P = 0.018); and work flexibility (PR = 0.53; 95% CI [0.36-0.79]; P = 0.002).
Conclusions
: SDOH burden is associated with lower COVID-19 risk mitigation practices in the CVD population. Identifying and prioritizing individuals whose medical vulnerability is compounded by social adversity may optimize emerging preventive efforts, including vaccination guidelines.
Coronavirus disease 2019 (COVID-19) often results in pneumonia and can lead to acute respiratory distress syndrome (ARDS). ARDS is one of the most significant causes of death in patients with COVID-19. The development of a “cytokine storm” in patients with COVID-19 causes progression to ARDS. In this scoping review, we investigated the effect of pro-inflammatory cytokines in inducing moderate and severe ARDS outcomes. A comprehensive search was performed using PubMed and Google Scholar to implement a broad query that captured all the relevant studies published between December 2019 and September 2020.We identified seven studies that evaluated the immune response in COVID-19 patients with ARDS. The white blood cell counts (WBCs), CRP, and IL-6 were higher in the moderately presenting ARDS patients, critically ill patients, and those with more severe ARDS. This study may contribute to better patient management and outcomes if tailored immune marker interventions are implemented in the near future.
Background
The impact of COVID-19 on the diagnosis and management of tuberculosis (TB) patients remains unknown.
Methods
Participant centres completed a structured web-based survey regarding changes in the management of TB patients during the COVID-19 pandemic. In addition, investigators included all patients ≥ 18 years with a TB diagnosis in two different periods: from March 15th to June 30th of 2020 and March 15th to June 30th, 2019. Clinical variables and information about household contacts were retrospectively collected.
Results
Seven (70%) TB Units reported changes in the TB team usual operation. A total of 169 patients were diagnosed with active TB in both periods of study (90 in 2019 and 79 in 2020). Patients diagnosed in 2020 showed more frequently bilateral lesions in CXR compared with patients diagnosed in 2019 (p = 0·004). A higher percentage of LTBI and active TB among children household contacts of patients diagnosed in 2020 compared to patients diagnosed in 2019 (p = 0·001) was observed.
Conclusions
COVID-19 pandemic has caused substantial changes in TB care. TB patients diagnosed during COVID pandemic showed more extended pulmonary forms. The increase in LTBI infection and active TB in household children could reflect an expanded household transmission derived from antiCOVID19 measures.
This article describes an estimated 6953–10 316 excess deaths among individuals with end-stage renal disease during the early months of the COVID-19 pandemic in February 2020–August 2020 (compared to death rates prior to the pandemic). Notably, the estimated number of excess deaths was reported as 10.8–16.6 per 1000 individuals on dialysis and 2.6–5.5 per 1000 individuals with a prior kidney transplantation. Although not adjusted for confounders, these data suggest that the immunosuppression associated with kidney transplantation is not a dominant determinant of outcomes associated with COVID-19 in this population.
Background
Excess deaths during the COVID-19 pandemic compared with those expected from historical trends have been unequally distributed, both geographically and socioeconomically. Not all excess deaths have been directly related to COVID-19 infection. We investigated geographical and socioeconomic patterns in excess deaths for major groups of underlying causes during the pandemic.
Methods
Weekly mortality data from 27/12/2014 to 2/10/2020 for England and Wales were obtained from the Office of National Statistics. Negative binomial regressions were used to model death counts based on pre-pandemic trends for deaths caused directly by COVID-19 (and other respiratory causes) and those caused indirectly by it (cardiovascular disease or diabetes, cancers, and all other indirect causes) over the first 30 weeks of the pandemic (7/3/2020–2/10/2020).
Findings
There were 62,321 (95% CI: 58,849 to 65,793) excess deaths in England and Wales in the first 30 weeks of the pandemic. Of these, 46,221 (95% CI: 45,439 to 47,003) were attributable to respiratory causes, including COVID-19, and 16,100 (95% CI: 13,410 to 18,790) to other causes. Rates of all-cause excess mortality ranged from 78 per 100,000 in the South West of England and in Wales to 130 per 100,000 in the West Midlands; and from 93 per 100,000 in the most affluent fifth of areas to 124 per 100,000 in the most deprived. The most deprived areas had the highest rates of death attributable to COVID-19 and other indirect deaths, but there was no socioeconomic gradient for excess deaths from cardiovascular disease/diabetes and cancer.
Interpretation
During the first 30 weeks of the COVID-19 pandemic there was significant geographic and socioeconomic variation in excess deaths for respiratory causes, but not for cardiovascular disease, diabetes and cancer. Pandemic recovery plans, including vaccination programmes, should take account of individual characteristics including health, socioeconomic status and place of residence.
Funding
None.
Background
The rates of in-hospital mortality following percutaneous interventional procedures (PIP) during the COVID-19 pandemic period compared to the non-pandemic period has not been reported so far.
Methods
We retrospectively enrolled all consecutive patients admitted for PIP across five centers from February 2020 to May 2020.
Results
A total of 4092 PIP were performed during the reference periods. The total number of procedures dropped from 2380 to 1712 (28.0% reduction). Overall in-hospital mortality increased from 1.1% in 2019, to 2.6% in 2020 (63% relative increase).
Conclusion
During the COVID-19 pandemic, in-hospital all-cause mortality significantly increased in patients admitted for cardiological PIP.
Importance
Heterogeneous evidence exists for the association between COVID-19 and the clinical outcomes of patients with mental health disorders. It remains unknown whether patients with COVID-19 and mental health disorders are at increased risk of mortality and should thus be targeted as a high-risk population for severe forms of COVID-19.
Objective
To determine whether patients with mental health disorders were at increased risk of COVID-19 mortality compared with patients without mental health disorders.
Data Sources
For this systematic review and meta-analysis, MEDLINE, Web of Science, and Google Scholar were searched from inception to February 12, 2021. Bibliographies were also searched, and the corresponding authors were directly contacted. The search paradigm was based on the following combination: (mental, major[MeSH terms]) AND (COVID-19 mortality[MeSH terms]). To ensure exhaustivity, the term mental was replaced by psychiatric, schizophrenia, psychotic, bipolar disorder, mood disorders, major depressive disorder, anxiety disorder, personality disorder, eating disorder, alcohol abuse, alcohol misuse, substance abuse, and substance misuse.
Study Selection
Eligible studies were population-based cohort studies of all patients with identified COVID-19 exploring the association between mental health disorders and mortality.
Data Extraction and Synthesis
Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline was used for abstracting data and assessing data quality and validity. This systematic review is registered with PROSPERO.
Main Outcomes and Measures
Pooled crude and adjusted odds ratios (ORs) for the association of mental health disorders with mortality were calculated using a 3-level random-effects (study/country) approach with a hierarchical structure to assess effect size dependency.
Results
In total, 16 population-based cohort studies (data from medico-administrative health or electronic/medical records databases) across 7 countries (1 from Denmark, 2 from France, 1 from Israel, 3 from South Korea, 1 from Spain, 1 from the UK, and 7 from the US) and 19 086 patients with mental health disorders were included. The studies covered December 2019 to July 2020, were of good quality, and no publication bias was identified. COVID-19 mortality was associated with an increased risk among patients with mental health disorders compared with patients without mental health disorders according to both pooled crude OR (1.75 [95% CI, 1.40-2.20]; P < .05) and adjusted OR (1.38 [95% CI, 1.15-1.65]; P < .05). The patients with severe mental health disorders had the highest ORs for risk of mortality (crude OR: 2.26 [95% CI, 1.18-4.31]; adjusted OR: 1.67 [95% CI, 1.02-2.73]).
Conclusions and Relevance
In this systematic review and meta-analysis of 16 observational studies in 7 countries, mental health disorders were associated with increased COVID-19–related mortality. Thus, patients with mental health disorders should have been targeted as a high-risk population for severe forms of COVID-19, requiring enhanced preventive and disease management strategies. Future studies should more accurately evaluate the risk for patients with each mental health disorder. However, the highest risk seemed to be found in studies including individuals with schizophrenia and/or bipolar disorders.
Much attention on the spread and impact of the ongoing pandemic has focused on institutional factors such as government capacity along with population-level characteristics such as race, income, and age. This paper draws on a growing body of evidence that bonding, bridging, and linking social capital - the horizontal and vertical ties that bind societies together - impact public health to explain why some U.S. counties have seen higher (or lower) excess deaths during the COVID19 pandemic than others. Drawing on county-level reports from the Centers for Disease Control and Prevention (CDC) since February 2020, we calculated the number of excess deaths per county compared to 2018. Starting with a panel dataset of county observations over time, we used coarsened exact matching to create smaller but more similar sets of communities that differ primarily in social capital. Controlling for several factors, including politics and governance, health care quality, and demographic characteristics, we find that bonding and linking social capital reduce the toll of COVID-19 on communities. Public health officials and community organizations should prioritize building and maintaining strong social ties and trust in government to help combat the pandemic.
Background
In the United States, Coronavirus Disease 2019 (COVID-19) deaths are captured through the National Notifiable Disease Surveillance System and death certificates reported to the National Vital Statistics System (NVSS). However, not all COVID-19 deaths are recognized and reported because of limitations in testing, exacerbation of chronic health conditions that are listed as the cause of death, or delays in reporting. Estimating deaths may provide a more comprehensive understanding of total COVID-19–attributable deaths.
Methods
We estimated COVID-19 unrecognized attributable deaths, from March 2020—April 2021, using all-cause deaths reported to NVSS by week and six age groups (0–17, 18–49, 50–64, 65–74, 75–84, and ≥85 years) for 50 states, New York City, and the District of Columbia using a linear time series regression model. Reported COVID-19 deaths were subtracted from all-cause deaths before applying the model. Weekly expected deaths, assuming no SARS-CoV-2 circulation and predicted all-cause deaths using SARS-CoV-2 weekly percent positive as a covariate were modelled by age group and including state as a random intercept. COVID-19–attributable unrecognized deaths were calculated for each state and age group by subtracting the expected all-cause deaths from the predicted deaths.
Findings
We estimated that 766,611 deaths attributable to COVID-19 occurred in the United States from March 8, 2020—May 29, 2021. Of these, 184,477 (24%) deaths were not documented on death certificates. Eighty-two percent of unrecognized deaths were among persons aged ≥65 years; the proportion of unrecognized deaths were 0•24–0•31 times lower among those 0–17 years relative to all other age groups. More COVID-19–attributable deaths were not captured during the early months of the pandemic (March–May 2020) and during increases in SARS-CoV-2 activity (July 2020, November 2020—February 2021).
Discussion
Estimating COVID-19–attributable unrecognized deaths provides a better understanding of the COVID-19 mortality burden and may better quantify the severity of the COVID-19 pandemic.
Funding
None
In response to the Covid-19 outbreak, the Italian Government imposed an economic lockdown on March 22, 2020, and ordered the closing of all non-essential economic activities. This paper estimates the causal effects of this measure on mortality by Covid-19 and on mobility patterns. The identification of the causal effects exploits the variation in the active population across municipalities induced by the economic lockdown. The difference-in-differences empirical design compares outcomes in municipalities above and below the median variation in the share of active population before and after the lockdown within a province, also controlling for municipality-specific dynamics, daily shocks at the provincial level, and municipal unobserved characteristics. Our results show that the intensity of the economic lockdown is associated with a statistically significant reduction in mortality by Covid-19 and, in particular, for age groups between 40 and 64 and older (with larger and more significant effects for individuals above 50). Back of the envelope calculations indicate that 4793 deaths were avoided, in the 26 days between April 5 and April 30, in the 3518 municipalities which experienced a more intense lockdown. Several robustness checks corroborate our empirical findings.
In a prospective observational study (pre-AndroCoV Trial), the use of nitazoxanide, ivermectin and hydroxychloroquine demonstrated unexpected improvements in COVID-19 outcomes, when compared to untreated patients. The apparent yet likely positive results raised ethical concerns on the employment of further full placebo84 controlled studies in early stage COVID-19. The present analysis aimed to elucidate whether full placebo-control randomized clinical trials (RCTs) on early-stage COVID-19 are still ethically acceptable, through a comparative analysis with two control87 groups. Active group (AG) consisted of patients enrolled in the Pre AndroCoV-Trial (n = 585). Control Group 1 (CG1) consisted of a retrospectively obtained group of untreated patients of the same population (n = 137), and Control Group 2 (CG2) resulted from a precise prediction of clinical outcomes based on a thorough and structured review of indexed articles and official statements. Patients were matched for sex, age, comorbidities and disease severity at baseline. Compared to CG1 and CG2 AG showed reduction of 31.5-36.5% in viral shedding (p < 0.0001), 70-85% in disease duration (p < 0.0001), and 100% in respiratory complications, hospitalization, mechanical ventilations, and deaths (p < 0.0001 for all). For every 1,000 confirmed cases for COVID-19, at least 70 hospitalizations, 50 mechanical ventilations and five deaths were prevented. Benefits from the combination of early COVID-19 detection and early pharmacological approaches were consistent and overwhelming when compared to untreated groups, which, together with and well-established safety profile of the drug combinations tested in the Pre-AndroCoV Trial, precluded our study to continue employing full placebo in early COVID-19.
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) is identified as the cause of coronavirus disease 2019 (COVID-19), and is often linked to extreme inflammatory responses by over activation of neutrophil extracellular traps (NETs), cytokine storm, and sepsis. These are robust causes for multi-organ damage. In particular, potential routes of SARS-CoV2 entry, such as angiotensin-converting enzyme 2 (ACE2), have been linked to central nervous system (CNS) involvement. CNS has been recognized as one of the most susceptible compartments to cytokine storm, which can be affected by neuropilin-1 (NRP-1). ACE2 is widely-recognized as a SARS-CoV2 entry pathway; However, NRP-1 has been recently introduced as a novel path of viral entry. Apoptosis of cells invaded by this virus involves Fas receptor–Fas ligand (FasL) signaling; moreover, Fas receptor may function as a controller of inflammation. Furthermore, NRP-1 may influence FasL and modulate cytokine profile. The neuroimmunological insult by SARS-CoV2 infection may be inhibited by therapeutic approaches targeting soluble Fas ligand (sFasL), cytokine storm elements, or related viral entry pathways. In the current review, we explain pivotal players behind the activation of cytokine storm that are associated with vast CNS injury. We also hypothesize that sFasL may affect neuroinflammatory processes and trigger the cytokine storm in COVID-19.
During the first months of the coronavirus disease 2019 (COVID-19) pandemic in early 2020, Google Trends data in the United States showed a strong increase in search query frequency for chest pain symptoms despite a concurrent decrease in search interest for myocardial infarction. This suggests a reduced attention to acute coronary syndrome (ACS) and chest pain as its main symptom during this time period. These observations could help explain why cardiovascular mortality rose dramatically despite a strong decrease in hospitalisation rates for ACS.
Comparing the impact of the COVID-19 pandemic between countries or across time is difficult because the reported numbers of cases and deaths can be strongly affected by testing capacity and reporting policy. Excess mortality, defined as the increase in all-cause mortality relative to the expected mortality, is widely considered as a more objective indicator of the COVID-19 death toll. However, there has been no global, frequently-updated repository of the all-cause mortality data across countries. To fill this gap, we have collected weekly, monthly, or quarterly all-cause mortality data from 94 countries and territories, openly available as the regularly-updated World Mortality Dataset. We used this dataset to compute the excess mortality in each country during the COVID-19 pandemic. We found that in several worst-affected countries (Peru, Ecuador, Bolivia, Mexico) the excess mortality was above 50% of the expected annual mortality. At the same time, in several other countries (Australia, New Zealand) mortality during the pandemic was below the usual level, presumably due to social distancing measures decreasing the non-COVID infectious mortality. Furthermore, we found that while many countries have been reporting the COVID-19 deaths very accurately, some countries have been substantially underreporting their COVID-19 deaths (e.g. Nicaragua, Russia, Uzbekistan), sometimes by two orders of magnitude (Tajikistan). Our results highlight the importance of open and rapid all-cause mortality reporting for pandemic monitoring.
Delirium, a form of acute brain dysfunction, is very common in the critically ill adult patient population. Although its pathophysiology is poorly understood, multiple factors associated with delirium have been identified, many of which are coincident with critical illness. To date, no drug or non-drug treatments have been shown to improve outcomes in patients with delirium. Clinical trials have provided a limited understanding of the contributions of multiple triggers and processes of intensive care unit (ICU) acquired delirium, making identification of therapies difficult. Delirium is independently associated with poor long term outcomes, including persistent cognitive impairment. A longer duration of delirium is associated with worse long term cognition after adjustment for age, education, pre-existing cognitive function, severity of illness, and exposure to sedatives. Interestingly, differences in prevalence are seen between ICU survivor populations, with survivors of acute respiratory distress syndrome experiencing higher rates of cognitive impairment at early follow-up compared with mixed ICU survivor populations. Although cognitive performance improves over time for some ICU survivors, impairment is persistent in others. Studies have so far been unable to identify patients at higher risk of long term cognitive impairment; this is an active area of scientific investigation.
Brazil has been heavily affected by coronavirus disease 2019 (COVID-19). In this study, we used data on reported total deaths in 2020 and in January–April 2021 to measure and compare the death toll across states. We estimate a decline in 2020 life expectancy at birth (e0) of 1.3 years, a mortality level not seen since 2014. The reduction in life expectancy at age 65 (e65) in 2020 was 0.9 years, setting Brazil back to 2012 levels. The decline was larger for males, widening by 9.1% the female–male gap in e0. Among states, Amazonas lost 60.4% of the improvements in e0 since 2000. In the first 4 months of 2021, COVID-19 deaths represented 107% of the total 2020 figures. Assuming that death rates would have been equal to 2019 all-cause rates in the absence of COVID-19, COVID-19 deaths in 2021 have already reduced e0 in 2021 by 1.8 years, which is slightly larger than the reduction estimated for 2020 under similar assumptions. New estimates of life expectancy at birth and at age 65 years in Brazil reveal substantial declines as a result of COVID-19, bringing mortality back to levels observed 20 or more years ago.
Background
Improving accuracy of identification of COVID-19-related deaths is essential to public health surveillance and research. The verbal autopsy, an established strategy involving an interview with a decedent’s caregiver or witness using a semi-structured questionnaire, may improve accurate counting of COVID-19-related deaths.Objective
To develop and pilot-test the Verbal Autopsy Instrument for COVID-19 (VAIC) and a death adjudication protocol using it.Methods/Key ResultsWe used a multi-step process to design the VAIC and a protocol for its use. We developed a preliminary version of a verbal autopsy instrument specifically for COVID. We then pilot-tested this instrument by interviewing respondents about the deaths of 15 adults aged ≥65 during the initial COVID-19 surge in New York City. We modified it after the first 5 interviews. We then reviewed the VAIC and clinical information for the 15 deaths and developed a death adjudication process/algorithm to determine whether the underlying cause of death was definitely (40% of these pilot cases), probably (33%), possibly (13%), or unlikely/definitely not (13%) COVID-19-related. We noted differences between the adjudicated cause of death and a death certificate.Conclusions
The VAIC and a death adjudication protocol using it may improve accuracy in identifying COVID-19-related deaths.
Introduction
The coronavirus disease 2019 (COVID-19) pandemic’s impact on vascular procedural volumes and outcomes has not been fully characterized.
Methods
Volume and outcome data before (1/2019 – 2/2020), during (3/2020 – 4/2020), and following (5/2020 – 6/2020) the initial pandemic surge were obtained from the Vascular Quality Initiative ® . Volume changes were determined using interrupted Poisson time series regression. Adjusted mortality was estimated using multivariable logistic regression.
Results
The final cohort comprised 57,181 patients from 147 US and Canadian sites. Overall procedure volumes fell 35.2% (95% CI 31.9%, 38.4%, p < 0.001) during and 19.8% (95% CI 16.8%, 22.9%, p < 0.001) following the surge, compared with presurge months. Procedure volumes fell 71.1% for claudication (95% CI 55.6%, 86.4%, p < 0.001) and 15.9% for chronic limb-threatening ischemia (CLTI) (95% CI 11.9%, 19.8%, p < 0.001) but remained unchanged for acute limb ischemia (ALI) when comparing surge to presurge months. Adjusted mortality was significantly higher among those with claudication (0.5% vs 0.1%; OR 4.38 [95% CI 1.42, 13.5], p = 0.01) and ALI (6.4% vs 4.4%; OR 2.63 [95% CI 1.39, 4.98], p = 0.003) when comparing postsurge with presurge periods.
Conclusion
The first North American COVID-19 pandemic surge was associated with a significant and sustained decline in both elective and nonelective lower-extremity vascular procedural volumes. When compared with presurge patients, in-hospital mortality increased for those with claudication and ALI following the surge.
Objective
To estimate changes in life expectancy in 2010-18 and during the covid-19 pandemic in 2020 across population groups in the United States and to compare outcomes with peer nations.
Design
Simulations of provisional mortality data.
Setting
US and 16 other high income countries in 2010-18 and 2020, by sex, including an analysis of US outcomes by race and ethnicity.
Population
Data for the US and for 16 other high income countries from the National Center for Health Statistics and the Human Mortality Database, respectively.
Main outcome measures
Life expectancy at birth, and at ages 25 and 65, by sex, and, in the US only, by race and ethnicity. Analysis excluded 2019 because life table data were not available for many peer countries. Life expectancy in 2020 was estimated by simulating life tables from estimated age specific mortality rates in 2020 and allowing for 10% random error. Estimates for 2020 are reported as medians with fifth and 95th centiles.
Results
Between 2010 and 2018, the gap in life expectancy between the US and the peer country average increased from 1.88 years (78.66 v 80.54 years, respectively) to 3.05 years (78.74 v 81.78 years). Between 2018 and 2020, life expectancy in the US decreased by 1.87 years (to 76.87 years), 8.5 times the average decrease in peer countries (0.22 years), widening the gap to 4.69 years. Life expectancy in the US decreased disproportionately among racial and ethnic minority groups between 2018 and 2020, declining by 3.88, 3.25, and 1.36 years in Hispanic, non-Hispanic Black, and non-Hispanic White populations, respectively. In Hispanic and non-Hispanic Black populations, reductions in life expectancy were 18 and 15 times the average in peer countries, respectively. Progress since 2010 in reducing the gap in life expectancy in the US between Black and White people was erased in 2018-20; life expectancy in Black men reached its lowest level since 1998 (67.73 years), and the longstanding Hispanic life expectancy advantage almost disappeared.
Conclusions
The US had a much larger decrease in life expectancy between 2018 and 2020 than other high income nations, with pronounced losses among the Hispanic and non-Hispanic Black populations. A longstanding and widening US health disadvantage, high death rates in 2020, and continued inequitable effects on racial and ethnic minority groups are likely the products of longstanding policy choices and systemic racism.
Risk factors for increased risk of death from COVID-19 have been identified, but less is known on characteristics that make communities resilient or vulnerable to the mortality impacts of the pandemic. We applied a two-stage Bayesian spatial model to quantify inequalities in excess mortality in people aged 40 years and older at the community level during the first wave of the pandemic in England, March-May 2020 compared with 2015–2019. Here we show that communities with an increased risk of excess mortality had a high density of care homes, and/or high proportion of residents on income support, living in overcrowded homes and/or with a non-white ethnicity. We found no association between population density or air pollution and excess mortality. Effective and timely public health and healthcare measures that target the communities at greatest risk are urgently needed to avoid further widening of inequalities in mortality patterns as the pandemic progresses.
Background
Older adults often have atypical presentations of common diseases and COVID-19 is no exception. Presentations range from asymptomatic to overwhelming symptoms that result in hospitalization, intubation, or death. The number of COVID-19 related deaths among older adults in the outpatient practice during the peak of the pandemic is unclear.
Methods
The objective is to describe the COVID-19 status and clinical characteristics of patients in a Geriatrics Ambulatory Practice who died during the peak of the COVID-19 pandemic. Design: Retrospective chart review Participants: 54 adults age 65 years and older. Methods: COVID-19 status defined by positive test result and presumed COVID-19 status based upon clinical presentation.
Results
Out of 1200 active patients in the Geriatrics Ambulatory Practice, 54 (4.5%) died between January 1st, 2020 and June 30th, 2020. The study sample was 63% female, 33% Hispanic/Latino, 27% Black/African American, and 22% white. The mean (SD) age was 86(8.6) years, range (72-107 years). The most prevalent medical comorbidities in decreasing order of frequency were hypertension (88.9%), diabetes (51.9%), and cognitive impairment (51.9%). Nineteen (35%) were COVID-19 positive and 8 had presumed COVID-19. There were no statistically significant differences in age, gender, race/ethnicity, and medical comorbidities between the COVID-19 or presumed COVID-19 group compared to those with No COVID-19.
Conclusion
Approximately 35% of Geriatric patients who died during the first 6 months of 2020 had confirmed COVID-19 and an additional 15% had presumed COVID-19. The actual number of COVID-19 related deaths among older adults in the ambulatory practice during the peak of the pandemic is difficult to estimate and likely underestimated.
As individuals undergoing a developmental process characterized by identity exploration, Jewish young adults are particularly vulnerable to the disruption of social connections related to the COVID-19 pandemic. Recent research has demonstrated that young adults, including young Jews, have experienced higher rates of mental health difficulties than older individuals during the pandemic. Using data from a survey of Jewish young adults who applied to participate in Birthright Israel summer 2020 trips but were unable to participate due to the pandemic, we examined the factors contributing to young adults’ mental health difficulties. We found that loneliness, rather than financial worries or concerns about the health impacts of COVID-19, was the single most important driver of reported emotional or mental health difficulties. Results also suggested that simply increasing the frequency of contacts between individuals is unlikely to reduce loneliness, unless these are positive, substantial connections, such as those among members of a “social support network.” Building and rebuilding deep, meaningful social connections between Jewish young adults should be a top priority for Jewish organizations going forward.
Background
The COVID-19 pandemic has caused excess deaths (all causes) and has disproportionately affected the elderly with certain characteristics.
Objectives
To study how COVID-19 affected cancer deaths regarding age, sex, socio-economic status, comorbidities, and access to palliative care. An additional objective was to study changes in place of care and death.
Material and methods
A descriptive, retrospective study of all cancer patients who died during March–May 2020 in the Stockholm region, n = 1467 of which 278 died with a COVID-19 diagnosis, compared with deaths in 2016–2019. The Stockholm Regional Council’s central data warehouse was used. T-tests, 95% CI, Wilcoxon and chi-squared tests were used for comparisons.
Results
There were excess cancer deaths compared with 2016–2019 (p < 0.001) and patients dying with a COVID-19 diagnosis were older (79.7 vs. 75.9 years, p < 0.0001), more often male (67% vs. 55%, p < 0.0001), and had more comorbidities (Charlson Comorbidity Index 1.6 vs. 1.1, p < 0.0001). Patients with COVID-19 more seldom had access to palliative care (34% vs. 59%, p = 0.008), had more changes in place of care during the last two weeks of life (p < 0.0001) and died more often in acute hospitals (34% vs. 14%, p < 0.0001). For the subgroup with access to palliative care, the hospital deaths for individuals with and without a COVID-19 diagnosis were 11% and 4%, respectively (p = 0.008).
Conclusion
Cancer patients dying with a COVID-19 diagnosis were older, more often male, and had more comorbidities. A COVID-19 diagnosis negatively affected the probability of being admitted to specialized palliative care and increased the likelihood of dying in an acute hospital.
Objective: Early reports demonstrate that patients with Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) infection have high rates of hospitalization, intensive care unit (ICU) admission, and death. We sought to examine characteristics of ICU admissions with and without Coronavirus 2019 (COVID-19) and to compare outcomes between these two critically ill cohorts.Methods: A retrospective analysis of 600 unique adult ICU admissions was conducted at an academic medical center in Boston, MA from March 22 to May 31, 2020.Results: Of 600 ICU admissions, 170 (28.3%) tested positive for COVID-19. Those with COVID-19 had greater severity of illness and were more likely to require mechanical ventilation (MV). Hospital and ICU mortality rates were greater in the COVID-19 group (22.4% vs. 9.5%; 18.2% vs. 7.2%, respectively), but lower than previous reports. Unadjusted odds ratio (OR) for COVID-19 as a predictor of hospital mortality was 2.73 (95% CI 1.68 to 4.43), but when accounting for clinical characteristics and severity of illness, adjusted OR for hospital mortality was no different (1.09 [95% CI 0.50 to 2.41]) among those with and without COVID-19.Conclusions: COVID-19 admissions had greater severity of illness and suffered higher crude mortality rates compared to the non-COVID-19 cohort. However, there was no significant difference in the adjusted OR for hospital mortality between patients with and without COVID-19. This novel finding may be attributed to the “learning curve” from other healthcare system experiences, early hospital-wide preparation, and dedicated intensive care.
US Census Bureau website
- Quickfacts
QuickFacts: New York City, New York. US Census Bureau website. Accessed
May 15, 2020. https://www.census.gov/quickfacts/newyorkcitynewyork