Assessing differential impacts of COVID-19 on black communities

Increased alcohol use during the COVID-19 pandemic among people with HIV from racial/ethnic minority groups in South Florida

People with HIV (PWH) from racial/ethnic minority groups may be particularly vulnerable to the effects of the COVID-19 Pandemic. Exacerbated COVID-19-related stressors may lead to maladaptive coping mechanisms such as increased alcohol use. This study examined socioeconomic and psychosocial predictors of increased alcohol use during the first year of the COVID-19 Pandemic among PWH from racial/ethnic minority groups in South Florida. Data were collected from Ryan White Program clients during October 2020-January 2021 using a cross-sectional phone survey, and were analyzed using logistic regression modeling. Among 139 participants, 20% reported increased alcohol use. Findings showed that being unable to buy needed food (adjusted odds ratio [aOR]: 3.37; 95% confidence interval [CI]: 1.01-11.31) and spending more time caring for children (aOR: 5.22, 95% CI: 1.61-16.88) was associated with increased alcohol use during the Pandemic. Providing support to alleviate food insecurity and manage caregiving burden during public health crises like the COVID-19 Pandemic might help prevent increases in alcohol use among PWH.

Analysis of COVID-19 Case Demographics and Disease Outcomes in Gary, Indiana

BACKGROUND

The COVID-19 pandemic further exposed the prevalence of existing health disparities in Black communities in the U.S. The current study evaluates COVID-19 data collected in Gary, Indiana, from June 2020 to June 2021. We hypothesized that the number of COVID-19 cases, hospitalizations, and deaths were influenced by race and income.

METHODS

In collaboration with the Gary Health Department (GHD), we analyzed demographic data on COVID-19-positive cases.

RESULTS

Compared to Gary's non-Black population, age- and population-adjusted rates of hospitalizations and deaths in the Black population were 3-fold (p < 0.0001) and 2-fold (p < 0.05) higher, respectively. This is despite a higher infection rate (p < 0.0001) in the non-Black population. The median household income of a zip code was negatively correlated with COVID-19 hospitalizations (R2 = 0.6345, p = 0.03), but did not correlate with infections and deaths.

CONCLUSIONS

The current study demonstrates clear health disparities of income and race in the context of COVID-19-related infections and outcomes in the city of Gary. Indiana University School of Medicine Northwest and GHD officials can collaborate to utilize these data for the reallocation of resources and health education efforts in Gary's highly populated, low-income, and predominantly Black neighborhoods. It should also prompt further investigation into national health resource allocation.

Race, Healthcare, and Health Disparities: A Critical Review and Recommendations for Advancing Health Equity

An overwhelming body of evidence points to an inextricable link between race and health disparities in the United States. Although race is best understood as a social construct, its role in health outcomes has historically been attributed to increasingly debunked theories of underlying biological and genetic differences across races. Recently, growing calls for health equity and social justice have raised awareness of the impact of implicit bias and structural racism on social determinants of health, healthcare quality, and ultimately, health outcomes. This more nuanced recognition of the role of race in health disparities has, in turn, facilitated introspective racial disparities research, root cause analyses, and changes in practice within the medical community. Examining the complex interplay between race, social determinants of health, and health outcomes allows systems of health to create mechanisms for checks and balances that mitigate unfair and avoidable health inequalities. As one of the specialties most intertwined with social medicine, emergency medicine (EM) is ideally positioned to address racism in medicine, develop health equity metrics, monitor disparities in clinical performance data, identify research gaps, implement processes and policies to eliminate racial health inequities, and promote anti-racist ideals as advocates for structural change. In this critical review our aim was to (a) provide a synopsis of racial disparities across a broad scope of clinical pathology interests addressed in emergency departments-communicable diseases, non-communicable conditions, and injuries-and (b) through a race-conscious analysis, develop EM practice recommendations for advancing a culture of equity with the potential for measurable impact on healthcare quality and health outcomes.

Increasing overdose deaths among Black Americans: a review of the literature

In 2020, opioid overdose fatalities among Black Americans surpassed those among White Americans for the first time in US history. This Review analyses the academic literature on disparities in overdose deaths to highlight potential factors that could explain these increases in overdose deaths among Black Americans. Overall, we find that differences in structural and social determinants of health; inequality in the access, use, and continuity of substance use disorder and harm reduction services; variability in fentanyl exposure and risk; and changes in social and economic circumstances since the onset of the COVID-19 pandemic are central to explaining this trend. We conclude with a discussion of opportunities for US policy reform and opportunities for future research.

Hospitalization, Critical Illness, and Mortality Outcomes of COVID-19 in Patients With Rheumatoid Arthritis

OBJECTIVE

To investigate the clinical outcomes of patients with rheumatoid arthritis (RA) with COVID-19.

METHODS

This retrospective study consisted of 361 patients with RA+ and 45,954 patients with RA- (March 2020 to August 2022) who tested positive for SARS-CoV-2 by polymerase-chain-reaction in the Montefiore Health System, which serves a large low-income, minority-predominant population in the Bronx and was an epicenter of the initial pandemic and subsequent surges. Primary outcomes were hospitalization, critical illness, and all-cause mortality associated with SARS-CoV-2 infection. Comparisons were made with and without adjustment for covariates, as well as with 1083 matched controls of patients with RA- and COVID-19.

RESULTS

Patients with RA+ and COVID-19 were older (62.2 ± 23.5 vs. 45.5 ± 26.3; P < 0.001), were more likely females (83.1% vs. 55.8%; P < 0.001), were Black (35.5% vs. 30.3%; P < 0.05), and had higher rates of comorbidities (P < 0.05), hospitalization (52.4% vs. 32.5%; P < 0.005), critical illness (10.5% vs. 6.9%; P < 0.05), and mortality (11.1% vs. 6.2%; P < 0.01) compared with patients with RA- and COVID-19. Patients with RA+ with COVID-19 had higher odds of critical illness (adjusted odds ratio [aOR] = 1.46, 95% confidence interval [CI]: 1.09-1.93; P = 0.008) but no differences in hospitalization (aOR = 1.18 [95% CI: 0.93-1.49]; P = 0.16) and mortality (aOR = 1.34 [95% CI: 0.92-1.89]; P = 0.10) after adjusting for covariates. Odds ratio analysis identified age, hospitalization status, female sex, chronic kidney disease, chronic obstructive pulmonary disease, and Black race to be significant risk factors for COVID-19-related mortality. Pre-COVID-19 steroid and biologic therapy to treat RA were not significantly associated with worse outcomes (P > 0.05). Outcomes were not different between patients with RA+ and propensity-matched RA- controls (P > 0.05).

CONCLUSION

Our findings suggest that risk factors for adverse COVID-19 outcomes were not attributed to RA per se but rather age and preexisting medical conditions of patients with RA.

Positive COVID-19 Diagnosis Following Primary Elective Total Joint Arthroplasty: Increased Complication and Mortality Rates

BACKGROUND

This study analyzed complication rates following primary elective total joint arthroplasty (TJA) in patients who subsequently contracted COVID-19.

METHODS

A large national database was queried for adult patients who underwent primary elective TJA in 2020. Patients who contracted COVID-19 after total knee arthroplasty (TKA) or total hip arthroplasty (THA) underwent 1:6 matching (age [±6 years], sex, month of surgery, COVID-19-related comorbidities) to patients who did not. Differences between groups were assessed using univariate and multivariate analyses. Overall, 712 COVID-19 patients were matched to 4,272 controls (average time to diagnosis: 128-117 days [range, 0-351]).

RESULTS

Of patients diagnosed <90 days postoperatively, 32.5%-33.6% required COVID-19-driven readmission. Discharge to a skilled nursing facility (adjusted odds ratio [aOR] 1.72, P = .003) or acute rehabilitation unit (aOR 4.93, P < .001) and Black race (aOR 2.28, P < .001) were associated with readmission after TKA. Similar results were associated with THA. COVID-19 patients were at increased risk of pulmonary embolism (aOR 4.09, P = .001) after TKA and also periprosthetic joint infection (aOR 4.65, P < .001) and sepsis (aOR 11.11, P < .001) after THA. The mortality rate was 3.51% in COVID-19 patients and 7.94% in readmitted COVID-19 patients compared to 0.09% in controls, representing a 38.7 OR and 91.8 OR of death, respectively. Similar results were observed for TKA and THA separately.

CONCLUSION

Patients who contracted COVID-19 following TJA were at greater risk of numerous complications, including death. These patients represent a high-risk cohort who may require more aggressive medical interventions. Given the potential limitations presently, prospectively collected data may be warranted to validate these findings.

Community, risk assessment, prevention and control: Black American college students' information seeking on COVID-19

BACKGROUND

Despite the disproportionate impact of the novel coronavirus on Black Americans, there is little research that centres Black college students' information behaviours during the pandemic.

OBJECTIVE

The objective of this study is to identify information needs, resources and use regarding the novel coronavirus pandemic among Black American college students.

METHODS

This is a quantitative study among 389 college students in the USA. Data were collected using an online crowdsourced survey instrument. Descriptive and inferential statistics were used to analyse data through SPSS.

RESULTS

The most salient information needs related to Covid-19 symptoms, personal protective equipment, vulnerable populations, and risk assessment; however, students also wanted information on Covid-19's impact on the Black community. There were no statistically significant gender differences in students' information seeking, resources or use with one exception; male students believed the internet alone could provide all relevant information about the coronavirus in comparison to female students. Barriers related to the volume of information, information fluidity and determining the quality of information.

CONCLUSION

Colleges and universities can play a critical role in information dissemination during crisis events. Students need critical information literacy skills that intersect with everyday information needs, particularly health literacy.

Psychological Toll of the COVID-19 Pandemic: An In-Depth Exploration of Anxiety, Depression, and Insomnia and the Influence of Quarantine Measures on Daily Life

The COVID-19 pandemic, on a global scale, has prompted multifaceted challenges, including a notable psychological toll on the general population. This study uses mixed-method approach for a nuanced exploration of these experiences. Using a phenomenological strategy, qualitative responses from 999 participants were analyzed regarding their pandemic-induced anxiety and the influence of quarantine measures on their lives. Quantitative measures, including the revised Impact of Event Scale (IES-R), patient health questionnaire-9 (PHQ-9), the seven-item generalized anxiety disorder assessment (GAD-7), and Insomnia Severity Index (ISI), were used to quantify trauma, depression, anxiety, and insomnia attributed to COVID-19. Partial least squares structural equation modeling (PLS-SEM) was utilized for quantitative data analysis. The anxiety-related responses were mainly clustered into four themes: life threats, support shortage, economic consequences, and disruptions to family and social life. Subthemes that addressed the perceived effects encapsulated disruptions to academic and professional lives, familial and social relationships, psychopathological stress, and movement limitations. The findings from quantitative analysis revealed the significant associations between COVID-19-related trauma and symptoms of anxiety, depression, and insomnia, as indicated by coefficients exceeding 0.10 (all z-values > 1.96; p-values < 0.05). In conclusion, the findings underscore COVID-19's role in escalating anxiety, influenced by various factors, and its disruptive effects on daily life due to quarantine measures. The strong associations between the pandemic and the symptoms of depression, anxiety, and insomnia underscore the urgency of comprehensive psychological and public health interventions to alleviate these impacts.

Inequalities in COVID-19 severe morbidity and mortality by country of birth in Sweden

Migrants have been more affected by the COVID-19 pandemic. Whether this has varied over the course of the pandemic remains unknown. We examined how inequalities in intensive care unit (ICU) admission and death related to COVID-19 by country of birth have evolved over the course of the pandemic, while considering the contribution of social conditions and vaccination uptake. A population-based cohort study was conducted including adults living in Sweden between March 1, 2020 and June 1, 2022 (n = 7,870,441). Poisson regressions found that migrants from Africa, Middle East, Asia and European countries without EU28/EEA, UK and Switzerland had higher risk of COVID-19 mortality and ICU admission than Swedish-born. High risks of COVID-19 ICU admission was also found in migrants from South America. Inequalities were generally reduced through subsequent waves of the pandemic. In many migrant groups socioeconomic status and living conditions contributed to the disparities while vaccination campaigns were decisive when such became available.

Understanding disruptions in cancer care to reduce increased cancer burden

Background

This study seeks to understand how and for whom COVID-19 disrupted cancer care to understand the potential for cancer health disparities across the cancer prevention and control continuum.

Methods

In this cross-sectional study, participants age 30+residing in an 82-county region in Missouri and Illinois completed an online survey from June-August 2020. Descriptive statistics were calculated for all variables separately and by care disruption status. Logistic regression modeling was conducted to determine the correlates of care disruption.

Results

Participants (N=680) reported 21% to 57% of cancer screening or treatment appointments were canceled/postponed from March 2020 through the end of 2020. Approximately 34% of residents stated they would need to know if their doctor's office is taking the appropriate COVID-related safety precautions to return to care. Higher education (OR = 1.26, 95% CI:1.11-1.43), identifying as female (OR = 1.60, 95% CI:1.12-2.30), experiencing more discrimination in healthcare settings (OR = 1.40, 95% CI:1.13-1.72), and having scheduled a telehealth appointment (OR = 1.51, 95% CI:1.07-2.15) were associated with higher odds of care disruption. Factors associated with care disruption were not consistent across races. Higher odds of care disruption for White residents were associated with higher education, female identity, older age, and having scheduled a telehealth appointment, while higher odds of care disruption for Black residents were associated only with higher education.

Conclusions

This study provides an understanding of the factors associated with cancer care disruption and what patients need to return to care. Results may inform outreach and engagement strategies to reduce delayed cancer screenings and encourage returning to cancer care.

Funding

This study was supported by the National Cancer Institute's Administrative Supplements for P30 Cancer Center Support Grants (P30CA091842-18S2 and P30CA091842-19S4). Kia L. Davis, Lisa Klesges, Sarah Humble, and Bettina Drake were supported by the National Cancer Institute's P50CA244431 and Kia L. Davis was also supported by the Breast Cancer Research Foundation. Callie Walsh-Bailey was supported by NIMHD T37 MD014218. The content does not necessarily represent the official view of these funding agencies and is solely the responsibility of the authors.

Impacts of the COVID-19 pandemic on life expectancy at birth in Asia

OBJECTIVE

To investigate the impact of the COVID-19 pandemic on life expectancy at birth (e0) for 51 Asian countries and territories from January 1, 2020 to December 31, 2021.

METHOD

Based on age-sex-specific mortality used for estimating the changes in e0 for years 2019, 2020, and 2021 from the 2022 revision of the World Population Prospects, we employed Arriaga's discrete method to decompose changes in e0 into both absolute and relative contributions of changes in age-specific death rate, and further obtained the age-sex-specific contribution to changes in e0 by country/territory and period (i.e., 2019-2020 and 2020-2021) for Asia.

FINDINGS

The COVID-19 pandemic reduced 1.66 years in e0 of the Asian population from 2019 to 2021, slightly lower than the world average of 1.74 years. South Asia had a high loss of 3.01 years, whereas Eastern Asia had almost no changes. Oman, Lebanon, India, Armenia, Azerbaijan, Indonesia, and the Philippines experienced a high loss of above 2.5 years in e0. Despite significant national and territorial variations, the decline of e0 in Asia was mostly from the age group of 60-79 years, followed by age groups of 80 + and 45-59 years; and age groups of children contributed little (i.e., 0-4 and 5-14 years old). Males suffered more losses than females in this pandemic. Asian nations saw less loss in e0 in the second year of the pandemic, i.e., 2020-2021, than in the first year, i.e., 2019-2020, but this recovery trend was not observed in Southern Asia and South-Eastern Asia. Countries from Central Asia and Western Asia, such as Kazakhstan, Armenia, Azerbaijan, Lebanon, and Oman, had extraordinarily more losses in e0 in the first year at ages around 70.

CONCLUSION

The COVID-19 pandemic had significantly affected e0 of Asian populations, and most contribution to the reduction of e0 came from the three older age groups, 60-79 years, 80 + years, and 45-59 years, with great variations across countries/territories. Our findings could have important implications for development of more resilient public health systems in Asian societies with better policy interventions for vulnerable demographic groups.

Unpacking racism during COVID-19: narratives from racialized Canadian gay, bisexual, and queer men

OBJECTIVE

Epidemics impact individuals unevenly across race, gender, and sexuality. In addition to being more vulnerable to COVID-19 infection, evidence suggests racialized gender and sexual minorities experienced disproportionate levels of discrimination and stigma during the COVID-19 epidemic. Drawing on Critical Race Theory (CRT), we examined the experiences of gay, bisexual, queer, and other men who have sex with men (GBQM) of colour facing discrimination during COVID-19.

DESIGN

Engage-COVID-19 is a mixed methods study examining the impact of COVID-19 on GBQM living in Vancouver, Toronto, and Montréal, Canada. We conducted two rounds of qualitative interviews (November 2020 to February 2021, and June to October 2021) with 93 GBQM to explore the evolving impact of COVID-19 on their lives. Transcripts were coded using inductive thematic analysis. Data analysis was conducted using Nvivo software.

RESULTS

Fifty-nine participants identified as Black, Indigenous, and/or a Person of Colour (BIPOC). These GBQM of colour described multiple experiences of discrimination during COVID-19. Although participants did not report experiences of discrimination based on their sexual identity during COVID-19, we found that experiences of racism affected how they were treated within their sexual networks. Experiences of racism were most often reported by East Asian and Black GBQM. These participants faced racism in public and online spaces, primarily in the form of verbal harassment. Several participants were also harassed because they wore face masks. Verbal abuse against GBQM of colour was largely prompted by racist discourses related to COVID-19.

CONCLUSION

Racism remains a pernicious threat to the well-being of GBQM of colour. CRT highlights the importance of assessing how sexualized and gendered discourses about race shape the experiences of GBQM of colour navigating multiple epidemics like COVID-19 and HIV. These pervasive discourses unevenly affect racial and sexual minorities across multiple epidemics, and negatively impact health outcomes for these populations.

What was a gap is now a chasm: Remote schooling, the digital divide, and educational inequities resulting from the COVID-19 pandemic

COVID-19 resulted in the unexpected transition to remote learning for K-12 schools, exacerbating the existing digital divide and impacting the educational outcomes of marginalized youth. This article reviews the literature on the impacts of the pandemic on the educational outcomes of marginalized youth due to remote learning and the digital divide. Here, we provide an overview of the pandemic and remote schooling from an intersectional lens, discuss the impacts of the digital divide on learning for students during the pandemic, and then consider impacts on the delivery of special education supports. Additionally, we review the literature on the widening achievement gap in relation to the COVID-19 pandemic. Future directions for research and practice are discussed.

Vaccine perceptions among Black adults with long COVID

OBJECTIVES

Low uptake of COVID vaccines within Black communities is a concern given the stark racial inequities associated with the pandemic. Prior research details COVID vaccine perceptions within the general population and Black communities specifically. However, Black individuals with long COVID may be more or less receptive to future COVID vaccination than their peers without long COVID. The impact of COVID vaccination on long COVID symptoms is still controversial, since some studies suggest that vaccination can improve long COVID symptoms, whereas other studies report no significant change in symptoms or a worsening of symptoms. In this study, we aimed to characterize the factors influencing perceptions of COVID vaccines among Black adults with long COVID to inform future vaccine-related policies and interventions.

DESIGN

We conducted 15 semi-structured, race-concordant interviews over Zoom with adults who reported physical or mental health symptoms that lingered for a month or more after acute COVID infection. We transcribed and anonymized the interviews and implemented inductive, thematic analysis to identify factors influencing COVID vaccine perceptions and the vaccine decision-making process.

RESULTS

We identified five themes that influenced vaccine perceptions: (1) Vaccine safety and efficacy; (2) Social implications of vaccination status; (3) Navigating and interpreting vaccine-related information; (4) Possibility of abuse and exploitation by the government and scientific community; and (5) Long COVID status. Safety concerns were amplified by long COVID status and mistrust in social systems due to mistreatment of the Black community.

CONCLUSIONS

Among the factors influencing COVID vaccine perceptions, participants reported a desire to avoid reinfection and a negative immune response. As COVID reinfection and long COVID become more common, achieving adequate uptake of COVID vaccines and boosters may require approaches that are tailored in partnership with the long COVID patient community.

Depression and anxiety among college students at Historically Black and Predominantly White universities during the COVID-19 pandemic: A cross-sectional study

OBJECTIVE

To assess depression and anxiety among college students during the COVID-19 pandemic and its association with race.

PARTICIPANTS

Using a cross-sectional survey, depression and anxiety among college students at a Predominantly White (PWU) and a Historically Black University (HBU) during 2021 were evaluated.

METHODS

The patient health questionnaire-9 (PHQ-9), general anxiety disorder-7 (GAD-7), and self-reported sociodemographic characteristics were collected. Chi-square and logistic regression tests examined differences in depression and anxiety based on race.

RESULTS

Depression and anxiety among 3,102 students (87% female) were analyzed. Minority racial groups were associated with anxiety (p < 0.01) but not depression in the PWU. Moderately severe and severe depression was higher among the minority race at both the universities (1.76% compared to 0.53% at PWU, and 11.1% compared to 2.4% at HBU).

CONCLUSIONS

Depression and anxiety among college students is influenced by racial status. First-generation students were more likely to report depression in both HBU and PWU.

Beyond Mortality: The Social and Health Impacts of COVID-19 among Older (55+) BIPOC and LGBT Respondents in a Canada-Wide Survey

This study focused on the effects of the COVID-19 pandemic on the marginalized populations-specifically Black and Indigenous people as well as People of Color (BIPOC) compared to White older adults and LGBT individuals compared to heterosexual older adults. Data were derived from our national online survey of Canadians aged 55+, conducted from 10 August to 10 October 2020. The survey explored the influence of COVID-19 on lifestyle changes, well-being, and planning for the future. Our sample comprised 4292 respondents. We compared sets of dichotomous variables with White vs. BIPOC, LGBT vs. heterosexual, and LGBT White vs. LGBT BIPOC respondents. Significantly more BIPOC than White individuals reported changes in accessing food (44.3% vs. 33.2%) and in family income (53.9% vs. 38.9%) and fewer reported feeling accepted and happy, and more felt isolated and judged. Significantly more LGBT than heterosexual respondents reported changes in routines and in accessing social support, medical and mental health care and more feeling depressed, lonely, anxious, and sad. More LGBT-BIPOC than LGBT-White respondents reported changes in access to food (66.7 vs. 30.6, p < 0.001); in family income (66.7 vs. 41.5, p < 0.005); and in access to mental health care (38.5 vs. 24.0, p < 0.05). The only difference in emotional response to COVID-19 was that more BIPOC-LGBT than White-LGBT respondents reported feeling judged (25.9 vs. 14.5, p < 0.05). These findings reflect a complex mix of the effects of marginalization upon BIPOC and LGBT older adults, revealing both hardship and hardiness and warranting further research.

Emotional responses to a global stressor: Average patterns and individual differences

Major stressors often challenge emotional well-being-increasing negative emotions and decreasing positive emotions. But how long do these emotional hits last? Prior theory and research contain conflicting views. Some research suggests that most individuals' emotional well-being will return to, or even surpass, baseline levels relatively quickly. Others have challenged this view, arguing that this type of resilient response is uncommon. The present research provides a strong test of resilience theory by examining emotional trajectories over the first 6 months of the COVID-19 pandemic. In two pre-registered longitudinal studies (total N =1147), we examined average emotional trajectories and predictors of individual differences in emotional trajectories across 13 waves of data from February through September 2020. The pandemic had immediate detrimental effects on average emotional well-being. Across the next 6 months, average negative emotions returned to baseline levels with the greatest improvements occurring almost immediately. Yet, positive emotions remained depleted relative to baseline levels, illustrating the limits of typical resilience. Individuals differed substantially around these average emotional trajectories and these individual differences were predicted by socio-demographic characteristics and stressor exposure. We discuss theoretical implications of these findings that we hope will contribute to more nuanced approaches to studying, understanding, and improving emotional well-being following major stressors.

Spatialising urban health vulnerability: An analysisof NYC's critical infrastructure during COVID-19

This paper examines how fragmentation of critical infrastructure impacts the spread of the coronavirus outbreak in New York City at the neighbourhood level. The location of transportation hubs, grocery stores, pharmacies, hospitals and parks plays an important role in shaping spatial disparities in virus spread. Using supervised machine learning and spatial regression modelling we examine how the geography of COVID-19 case rates is influenced by the spatial arrangement of four critical sectors of the built environment during the public health emergency in New York City: health care facilities, mobility networks, food and nutrition and open space. Our models suggest that an analysis of urban health vulnerability is incomplete without the inclusion of critical infrastructure metrics in dense urban geographies. Our findings show that COVID-19 risk at the zip code level is influenced by (1) socio-demographic vulnerability, (2) epidemiological risk, and (3) availability and access to critical infrastructure.

Microbiome and intestinal pathophysiology in post-acute sequelae of COVID-19

Long COVID, also known for post-acute sequelae of COVID-19, describes the people who have the signs and symptoms that continue or develop after the acute COVID-19 phase. Long COVID patients suffer from an inflammation or host responses towards the virus approximately 4 weeks after initial infection with the SARS CoV-2 virus and continue for an uncharacterized duration. Anyone infected with COVID-19 before could experience long-COVID conditions, including the patients who were infected with SARS CoV-2 virus confirmed by tests and those who never knew they had an infection early. People with long COVID may experience health problems from different types and combinations of symptoms over time, such as fatigue, dyspnea, cognitive impairments, and gastrointestinal (GI) symptoms (e.g., nausea, vomiting, diarrhea, decreased or loss of appetite, abdominal pain, and dysgeusia). The critical role of the microbiome in these GI symptoms and long COVID were reported in clinical patients and experimental models. Here, we provide an overall view of the critical role of the GI tract and microbiome in the development of long COVID, including the clinical GI symptoms in patients, dysbiosis, viral-microbiome interactions, barrier function, and inflammatory bowel disease patients with long COVID. We highlight the potential mechanisms and possible treatment based on GI health and microbiome. Finally, we discuss challenges and future direction in the long COVID clinic and research.

Rapid-cycle designs to adapt interventions for COVID-19 in safety-net healthcare systems

Racial/ethnic minority, low socioeconomic status, and rural populations are disproportionately affected by COVID-19. Developing and evaluating interventions to address COVID-19 testing and vaccination among these populations are crucial to improving health inequities. The purpose of this paper is to describe the application of a rapid-cycle design and adaptation process from an ongoing trial to address COVID-19 among safety-net healthcare system patients. The rapid-cycle design and adaptation process included: (a) assessing context and determining relevant models/frameworks; (b) determining core and modifiable components of interventions; and (c) conducting iterative adaptations using Plan-Do-Study-Act (PDSA) cycles. PDSA cycles included: Plan. Gather information from potential adopters/implementers (e.g., Community Health Center [CHC] staff/patients) and design initial interventions; Do. Implement interventions in single CHC or patient cohort; Study. Examine process, outcome, and context data (e.g., infection rates); and, Act. If necessary, refine interventions based on process and outcome data, then disseminate interventions to other CHCs and patient cohorts. Seven CHC systems with 26 clinics participated in the trial. Rapid-cycle, PDSA-based adaptations were made to adapt to evolving COVID-19-related needs. Near real-time data used for adaptation included data on infection hot spots, CHC capacity, stakeholder priorities, local/national policies, and testing/vaccine availability. Adaptations included those to study design, intervention content, and intervention cohorts. Decision-making included multiple stakeholders (e.g., State Department of Health, Primary Care Association, CHCs, patients, researchers). Rapid-cycle designs may improve the relevance and timeliness of interventions for CHCs and other settings that provide care to populations experiencing health inequities, and for rapidly evolving healthcare challenges such as COVID-19.

Explaining the higher COVID-19 mortality rates among disproportionately Black counties: A decomposition analysis

Background

Why is COVID-19 mortality higher in counties with a disproportionately large (>13.4%) share of Black residents (hereafter "Black counties") relative to others ("non-Black counties")? Existing literature points to six categories of determinants: (1) social distancing, (2) COVID-19 testing, (3) socioeconomic characteristics, (4) environmental characteristics, (5) prevalence of (pre-existing) chronic health conditions, and (6) demographic characteristics. The relative importance of these determinants has not yet been thoroughly examined.

Methods

We built a dataset consisting of 21 sub-indicators across the six categories of determinants for 3108 US counties and their COVID-19 mortality over the period of January 22, 2020-December 31, 2020. Applying the Gelbach's decomposition, we quantified which determinants were most (or least) associated with the COVID-19 mortality disparity between Black and non-Black counties.

Results

We find that COVID-19 death rates were 26 percent higher in Black counties compared to non-Black counties. This disparity was almost completely explained by the six categories of determinants included in our model. Decomposition analyses indicate that county-level demographic and population health characteristics explained most of this disparity. Among all sub-indicators considered, the greater proportion of females and smaller proportion of rural residents in Black counties were the two largest contributors to the COVID-19 mortality gap between Black and non-Black counties. Proportions of diabetic residents, uninsured residents, and the degree of income inequality also significantly contributed to the gap in COVID-19 mortality.

Conclusion

The COVID-19 mortality gap between Black and non-Black counties was largely explained by pre-pandemic differences in demographic and population health characteristics. Policies aiming to reduce the prevalence of chronic conditions and uninsured residents in Black counties would have helped narrow the COVID-19 mortality gap between Black and non-Black counties in 2020.

Racial differences in COVID-19 vaccine acceptance in Arkansas

Vaccines are one of the most successful tools for protecting the public's health. However, widespread vaccine hesitancy in the Southern United States is preventing effective mitigation of the current COVID-19 pandemic. The purpose of this study was to assess COVID-19 vaccine acceptance among adults living in a largely rural Southern state. This cross-sectional study collected data from 1,164 Arkansas residents between October 3 and October 17, 2020 using random digit dialing. The primary outcome was a multidimensional COVID-19 vaccine acceptance measure with scores between -3 to +3. The full COVID-19 vaccine acceptance scale was measured along with perceived vaccine safety, effectiveness, acceptance, value, and legitimacy subscales. Statistical analyses were conducted using multivariable linear regression. Results indicated Black participants had the lowest overall vaccine acceptance (0.5) compared to White participants (1.2). Hispanic participants had the highest scores (1.4). In adjusted models, Black participants had 0.81 points lower acceptance than White participants, and Hispanic participants had 0.35 points higher acceptance. Hispanic participants had the highest scores for all five vaccine acceptance subscales, relatively equivalent to White participants. Black participants had consistently lower scores, especially perceived vaccine safety (mean -0.2, SD 0.1). In conclusion, the lowest vaccine acceptance rates were among Black participants particularly on perceived vaccine safety. While Black participants had the lowest acceptance scores, Hispanic participants had the highest. This variability shows the value of a multidimensional vaccine acceptance measure to inform COVID-19 vaccination campaign strategies.

The Most Vulnerable Hispanic Immigrants in New York City: Structural Racism and Gendered Differences in COVID-19 Deaths

This paper explores the structural and group-specific factors explaining the excess death rates experienced by the Hispanic population in New York City during the peak years of the coronavirus pandemic. Neighborhood-level analysis of Census data allows an exploration of the relation between Hispanic COVID-19 deaths and spatial concentration, conceived in this study as a proxy for structural racism. This analysis also provides a more detailed exploration of the role of gender in understanding the effects of spatial segregation among different Hispanic subgroups, as gender has emerged as a significant variable in explaining the structural and social effects of COVID-19. Our results show a positive correlation between COVID-19 death rates and the share of Hispanic neighborhood residents. However, for men, this correlation cannot be explained by the characteristics of the neighborhood, as it is for women. In sum, we find: (a) differences in mortality risks between Hispanic men and women; (b) that weathering effects increase mortality risks the longer Hispanic immigrant groups reside in the U.S.; (c) that Hispanic males experience greater contagion and mortality risks associated with the workplace; and (d) we find evidence corroborating the importance of access to health insurance and citizenship status in reducing mortality risks. The findings propose revisiting the Hispanic health paradox with the use of structural racism and gendered frameworks.

Lasting Declines in Couples' Social Network Interactions in the First Years of COVID

Since the onset of COVID-19, a rise in loneliness has raised concerns about the social impact of lockdowns and distancing mandates. Yet, to date, the effects of the pandemic on social networks have been studied only indirectly. To evaluate how the pandemic affected social networks, the current analyses analyzed five waves of detailed social network interviews conducted before and during the first 18 months of the pandemic in a sample especially vulnerable to contracting the virus: mostly non-White couples (243 husbands and 250 wives) recruited from lower income neighborhoods. Pre-COVID interviews asked spouses to name 24 individuals with whom they interact regularly. Post-COVID interviews indicated a nearly 50% decline in face-to-face interactions and a nearly 40% decline in virtual interactions, with little recovery over the first 18 months of the pandemic. Compared with less affluent couples, those with higher incomes maintained more of their network relationships, especially when virtual interactions were taken into account.

Facilitators and barriers to access hospital medical specialty telemedicine consultations during the COVID-19 pandemic: Systematic Review

BACKGROUND

COVID-19 pandemic accelerated the digital transition in healthcare, which required a rapid adaptation of stakeholders. Telemedicine has emerged as an ideal tool to ensure continuity of care by allowing remote access to specialized medical services. However, its rapid implementation has exacerbated disparities in healthcare access, especially for the most vulnerable populations.

OBJECTIVE

To characterize the determinants factors (facilitators and barriers) of access to hospital medical specialty telemedicine consultations during the COVID-19 pandemic; to identify the main opportunities and challenges (technological, ethical, legal and/or social) generated by the use of telemedicine in the context of the COVID-19 pandemic.

METHODS

A systematic review was conducted according to PRISMA guidelines. Four databases (Scopus, Web of Science, PubMed and Cochrane COVID-19 Study Register) were searched for empirical studies published between January 3rd, 2020, and December 31st, 2021, using established criteria. The protocol of this review was registered and published in PROSPERO (CRD42022302825). A methodological quality assessment was performed, and results were integrated into a thematic synthesis. The identification of main opportunities and challenges was done by interpreting and aggregating the thematic synthesis results.

RESULTS

Of the 106 studies identified, 9 met the inclusion criteria and the intended quality characteristics. All studies were originally from the United States of America (USA). The following facilitating factors of telemedicine use were identified: health insurance coverage; prevention of SARS-CoV-2 infection; access to Internet services; access to technological devices; better management of work-life balance; and savings in travel costs. We identified the following barriers to telemedicine use: lack of access to Internet services; lack of access to technological devices; racial and ethnic disparities; low digital literacy; low income; age; language barriers; health insurance coverage; concerns about data privacy and confidentiality; geographic disparities; and need for complementary diagnostic tests or for the delivery of test results.

CONCLUSIONS

The facilitating factors and barriers identified in this systematic review present different opportunities and challenges, including those of technological nature (access to technological devices and internet services, level of digital literacy), sociocultural and demographic nature (ethnic and racial disparities, geographical disparities, language barriers, age), socioeconomic nature (income level and health insurance coverage), and ethical and legal nature (data privacy and confidentiality). To expand telemedicine access to hospital-based specialty medical consultations and provide high-quality care to all, including the most vulnerable communities, the challenges identified must be thoroughly researched and addressed with informed and dedicated responses.

CLINICALTRIAL

"To feel supported in your community is to feel loved": Cultivating community and support for Black transmasculine people navigating anti-Black racism, transphobia, and COVID-19 pandemic

Background: Black transmasculine people are disproportionately affected by a myriad of intersecting stressors including racism (specifically anti-Black racism), sexism, and cissexism. Black transmasculine people are exposed daily to systemic oppression such as transphobia, dehumanization, and violence, making this community more vulnerable to mental health and physical health concerns. These experiences are further compounded by the lack of relevant research about the unique experiences of Black transmasculine people during the COVID-19 pandemic. Aims: Utilizing a critical intersectionality lens and Prilleltensky's psychopolitical validity as guiding frameworks, the present study investigates the need for support and community for Black transmasculine people when navigating anti-Black racism and transphobia during the COVID-19 pandemic. Methods: The researchers integrated intersectionality and Prilleltensky's psychopolitical validity as frameworks paired with the constructivist grounded theory paradigm outlined by Charmaz to analyze data. The researchers co-constructed meaning from participants' (N = 32) perspectives to provide a theoretical understanding of how Black transmasculine participants' perceived community and support during COVID-19 pandemic. Results: The researchers developed a model of pathways toward community and support. The model suggests two levels: (a) locating awareness of community and support, and (b) integrated action toward community and support. The approaches are integrated from within group actions that can be facilitated from outside the community on micro and macro sociological levels to provide holistic support and community for Black transmasculine people. Discussion: This model extends the current literature on liberation and community psychology regarding the different levels of support for Black transmasculine people. This intervention can provide awareness and insight about working alongside the Black transmasculine community to address their unique needs of support and community. These findings hope to enhance clinical practices and identify strategies to promote wellness among Black transmasculine people.

Effectiveness of Remdesivir Treatment Protocols Among Patients Hospitalized with COVID-19: A Target Trial Emulation

BACKGROUND

Remdesivir is recommended for certain hospitalized patients with COVID-19. However, these recommendations are based on evidence from small randomized trials, early observational studies, or expert opinion. Further investigation is needed to better inform treatment guidelines with regard to the effectiveness of remdesivir among these patients.

METHODS

We emulated a randomized target trial using chargemaster data from 333 US hospitals from 1 May 2020 to 31 December 2021. We compared three treatment protocols: remdesivir within 2 days of hospital admission, no remdesivir within the first 2 days of admission, and no remdesivir ever. We used baseline comorbidities recorded from encounters up to 12 months before admission and identified the use of in-hospital medications, procedures, and oxygen supplementation from charges. We estimated the cumulative incidence of mortality or mechanical ventilation/extracorporeal membrane oxygenation with an inverse probability of censoring weighted estimator. We conducted analyses in the total population as well as in subgroups stratified by level of oxygen supplementation.

RESULTS

A total of 274,319 adult patients met the eligibility criteria for the study. Thirty-day in-hospital mortality risk differences for patients adhering to the early remdesivir protocol were -3.1% (95% confidence interval = -3.5%, -2.7%) compared to no early remdesivir and -3.7% (95% confidence interval -4.2%, -3.2%) compared to never remdesivir, with the strongest effect in patients needing high-flow oxygen. For mechanical ventilation/extracorporeal membrane oxygenation, risk differences were minimal.

CONCLUSIONS

We estimate that, among hospitalized patients with COVID-19, remdesivir treatment within 2 days of admission reduced 30-day in-hospital mortality, particularly for patients receiving supplemental oxygen on the day of admission.

COVID-19 Mortality by Race and Ethnicity in US Metropolitan and Nonmetropolitan Areas, March 2020 to February 2022

Importance

Prior research has established that Hispanic and non-Hispanic Black residents in the US experienced substantially higher COVID-19 mortality rates in 2020 than non-Hispanic White residents owing to structural racism. In 2021, these disparities decreased.

Objective

To assess to what extent national decreases in racial and ethnic disparities in COVID-19 mortality between the initial pandemic wave and subsequent Omicron wave reflect reductions in mortality vs other factors, such as the pandemic's changing geography.

Design, Setting, and Participants

This cross-sectional study was conducted using data from the US Centers for Disease Control and Prevention for COVID-19 deaths from March 1, 2020, through February 28, 2022, among adults aged 25 years and older residing in the US. Deaths were examined by race and ethnicity across metropolitan and nonmetropolitan areas, and the national decrease in racial and ethnic disparities between initial and Omicron waves was decomposed. Data were analyzed from June 2021 through March 2023.

Exposures

Metropolitan vs nonmetropolitan areas and race and ethnicity.

Main Outcomes and Measures

Age-standardized death rates.

Results

There were death certificates for 977 018 US adults aged 25 years and older (mean [SD] age, 73.6 [14.6] years; 435 943 female [44.6%]; 156 948 Hispanic [16.1%], 140 513 non-Hispanic Black [14.4%], and 629 578 non-Hispanic White [64.4%]) that included a mention of COVID-19. The proportion of COVID-19 deaths among adults residing in nonmetropolitan areas increased from 5944 of 110 526 deaths (5.4%) during the initial wave to a peak of 40 360 of 172 515 deaths (23.4%) during the Delta wave; the proportion was 45 183 of 210 554 deaths (21.5%) during the Omicron wave. The national disparity in age-standardized COVID-19 death rates per 100 000 person-years for non-Hispanic Black compared with non-Hispanic White adults decreased from 339 to 45 deaths from the initial to Omicron wave, or by 293 deaths. After standardizing for age and racial and ethnic differences by metropolitan vs nonmetropolitan residence, increases in death rates among non-Hispanic White adults explained 120 deaths/100 000 person-years of the decrease (40.7%); 58 deaths/100 000 person-years in the decrease (19.6%) were explained by shifts in mortality to nonmetropolitan areas, where a disproportionate share of non-Hispanic White adults reside. The remaining 116 deaths/100 000 person-years in the decrease (39.6%) were explained by decreases in death rates in non-Hispanic Black adults.

Conclusions and Relevance

This study found that most of the national decrease in racial and ethnic disparities in COVID-19 mortality between the initial and Omicron waves was explained by increased mortality among non-Hispanic White adults and changes in the geographic spread of the pandemic. These findings suggest that despite media reports of a decline in disparities, there is a continued need to prioritize racial health equity in the pandemic response.

Covering the Distance: A Study of Parent and Teen Attitudes on COVID-19 Mitigation Measures During the COVID-19 Pandemic

Background The Unity® Consortium surveyed teens and parents and guardians of teens across the country at three distinct time points or waves during the COVID-19 pandemic to assess participant attitudes and beliefs regarding COVID-19 mitigation guidelines, such as mask-wearing and physical distancing. Methodology A third-party market research company conducted 15-minute, online surveys from nationally representative panels. Surveys were conducted at three distinct time points or waves (August 2020, February 2021, and June 2021) with 300 teens aged 13-18 years in each wave and 593/531/500 parents and guardians of teens aged 13-18 years in each wave, respectively. Participants responded using a five-point Likert scale (strongly agree to strongly disagree) on their COVID-19 experiences, including the perceived importance of strictly following mask-wearing and/or social distancing guidelines and the perceived effectiveness of mask-wearing and social distancing in preventing the spread of COVID-19. Data were analyzed for differences across waves and demographic variables. Statistical analyses included frequencies, analysis of variance (ANOVA), and t-tests/z-tests. Results While significantly more parents and teens in Waves 2 and 3 knew someone who was hospitalized or died due to COVID-19 compared to Wave 1, significantly fewer in Wave 3 reported experiencing a lot or some stress and worry regarding the pandemic. By Wave 3, 58% of teens and 56% of parents had received at least one dose of a COVID-19 vaccine. Despite changes in experiences over time, a significant majority of parents and teens consistently agreed on the importance and effectiveness of social distancing and masking guidelines against the spread of COVID-19. In Wave 3, the demographic variables significantly associated with agreement on importance included race (Black (92%) > White (80%)), community type (urban (91%) > suburban (79%) and rural (73%)), and positive vaccination status of parents and teens (92%/89%) > not vaccinated (73%/73%), respectively). The demographic variables significantly associated with agreement on effectiveness included race (Black (91%) > White (81%)), community type (urban (89%) > suburban (83%) and rural (71%)), and positive vaccination status of parents and teens (94%/90% > not vaccinated (72%/70%), respectively). Conclusions This study into the perceived importance and perceived effectiveness of mitigation strategies during the COVID-19 pandemic revealed differences in attitudes among sociodemographic groups. Understanding these differences can help shape how adherence to public health guidelines in a pandemic is promoted.

Diversity and inclusion in clinical trials: Evolution throughout the development of an mRNA COVID-19 vaccine

Despite the importance of equitable representation in clinical trials, disparities persist with racial and ethnic minorities remaining largely underrepresented in trial populations. During the coronavirus disease 2019 (COVID-19) pandemic, wherein disease disproportionately affected racial and ethnic minority groups, the necessity for diverse and inclusive representation in clinical trials has been further highlighted. Considering the urgent need for a safe and efficacious vaccine, COVID-19 vaccine clinical trials faced marked challenges in rapidly enrolling participants without forgoing diverse representation. In this perspective, we summarize Moderna's approach toward achieving equitable representation in mRNA-1273 COVID-19 vaccine clinical trials, including the COVID-19 efficacy (COVE) study, a large, randomized, controlled, phase 3 trial of mRNA-1273 safety and efficacy in adults. We describe the dynamics of enrollment diversity throughout the COVE trial and the need for continuous, efficient monitoring and rapid pivoting from initial approaches to address early challenges. Insights gained from our varied and evolved initiatives provide key learnings toward achieving equitable representation in clinical trials, including establishing and listening to a Diversity and Inclusion Advisory Committee, repeatedly engaging with key stakeholders on the necessity for diverse representation, creating and disseminating inclusive materials to all trial participants, establishing methods to raise awareness for interested participants, and enhancing transparency with trial participants to build trust. This work shows that diversity and inclusion in clinical trials can be attained even in the most extreme circumstances and highlights the importance of efforts toward building trust and empowering racial and ethnic minorities with the knowledge to make informed medical treatment decisions.

Pregnant in a Pandemic: Mental Wellbeing and Associated Healthy Behaviors Among Pregnant People in California During COVID-19

INTRODUCTION

Pregnancy is a time of increased vulnerability to mental health disorders. Additionally, the COVID-19 pandemic has increased the incidence of depression and anxiety. Thus, we aimed to assess mental health and associated healthy behaviors of pregnant people in California during the pandemic in order to contextualize prenatal well-being during the first pandemic of the twenty-first century.

METHODS

We conducted an online cross-sectional study of 433 pregnant people from June 6 through July 29, 2020. We explored 3 hypotheses: (1) mental health would be worse during the pandemic than in general pregnant samples to date; (2) first-time pregnant people would have worse mental health; and (3) healthy behaviors would be positively related to mental health.

RESULTS

Many of our participants (22%) reported clinically significant depressive symptoms and 31% reported clinically significant anxiety symptoms. Multiparous pregnant people were more likely to express worries about their own health and wellbeing and the process of childbirth than were primiparous pregnant people. Additionally, as pregnancy advanced, sleep and nutrition worsened, while physical activity increased. Lastly, anxious-depressive symptomology was significantly predictive of participant sleep behaviors, nutrition, and physical activity during the past week.

DISCUSSION

Pregnant people had worse mental health during the pandemic, and this was associated with worse health-promoting behaviors. Given that the COVID-19 pandemic and associated risks are likely to persist due to low vaccination rates and the emergence of variants with high infection rates, care that promotes mental and physical well-being for the pregnant population should be a public health priority.

The mediating effect of health literacy on COVID-19 vaccine confidence among a diverse sample of urban adults in Boston and Chicago

BACKGROUND

A high rate of COVID-19 vaccination is critical to reduce morbidity and mortality related to infection and to control the COVID-19 pandemic. Understanding the factors that influence vaccine confidence can inform policies and programs aimed at vaccine promotion. We examined the impact of health literacy on COVID-19 vaccine confidence among a diverse sample of adults living in two major metropolitan areas.

METHODS

Questionnaire data from adults participating in an observational study conducted in Boston and Chicago from September 2018 through March 2021 were examined using path analyses to determine whether health literacy mediates the relationship between demographic variables and vaccine confidence, as measured by an adapted Vaccine Confidence Index (aVCI).

RESULTS

Participants (N = 273) were on average 49 years old, 63 % female, 4 % non-Hispanic Asian, 25 % Hispanic, 30 % non-Hispanic white, and 40 % non-Hispanic Black. Using non-Hispanic white and other race as the reference category, Black race and Hispanic ethnicity were associated with lower aVCI (-0.76, 95 % CI -1.00 to -0.50; -0.52, 95 % CI -0.80 to -0.27, total effects from a model excluding other covariates). Lower education was also associated with lower aVCI (using college or more as the reference, -0.73 for 12th grade or less, 95 % CI -0.93 to -0.47; -0.73 for some college/associate's/technical degree, 95 % CI -1.05 to -0.39). Health literacy partially mediated these effects for Black and Hispanic participants and those with lower education (indirect effects -0.19 and -0.19 for Black race and Hispanic ethnicity; 0.27 for 12th grade or less; -0.15 for some college/associate's/technical degree).

CONCLUSIONS

Lower levels of education, Black race, and Hispanic ethnicity were associated with lower scores on health literacy, which in turn were associated with lower vaccine confidence. Our findings suggest that efforts to improve health literacy may improve vaccine confidence, which in turn may improve vaccination rates and vaccine equity.

CLINICAL TRIALS NUMBER

NCT03584490.

Ten Takeaways from the COVID-19 Pandemic for Transportation Planners

The COVID-19 pandemic has created significant challenges but also unprecedented opportunities for transportation researchers and practitioners. In this article, the major lessons and gaps in knowledge for those working in the transportation sector are identified, including the following: (1) integration between public health and transportation; (2) technology to support contact tracing and tracking of travelers; (3) focus on vulnerable, at-risk operators, patrons, and underserved members of society; (4) re-engineering of travel demand models to support social distancing, quarantine, and public health interventions; (5) challenges with Big Data and information technologies; (6) trust relationships between the general public, government, private sector, and others in disaster management; (7) conflict management during disasters; (8) complexities of transdisciplinary knowledge and engagement; (9) demands for training and education; and (10) transformative change to support community resilience. With a focus on transportation planning and community resilience, the lessons from the pandemic need to be shared and customized for different systems, services, modalities, and users. While many of the interventions during the pandemic have been based on public health, the management, response, recovery, adaptation, and transformation of transportation systems resulting from the crisis require multi-disciplinary, multi-jurisdictional communications and coordination, and resource sharing. Further research to support knowledge to action is needed.

Exploratory Study of Determinants of the Spread of COVID-19 before Shelter-in-Place Orders

This study explores the impact of relevant characteristics of counties and their relationship with increases in COVID-19 cases before shelter-in-place (SIP) orders in the U.S. The recent emergence of COVID-19 occurs when there is little understanding of the related factors affecting the growth and spread of the disease. These relationships are examined through an analysis of 672 counties before SIP orders were issued. Areas that experienced the most significant transmission of disease are identified, and their characteristics are analyzed. A meaningful relationship was found between the increase of COVID-19 cases and several factors. Average commute time and the proportion of commuters using transit had a positive relationship. Along with other socio-economic factors, such as median house value and proportion of the Black population, several transportation-related factors had a significant association with the transmission of the disease. The decrease rate of total vehicle miles traveled (VMT) before and after SIP orders also had a solid and positive relationship with the expansion of the disease. The findings suggest that planners and transportation service providers must integrate evolving public health considerations into transportation services which affect the increase in the transmission of infectious diseases.

Place, Race, and Case: Examining Racialized Economic Segregation and COVID-19 in Louisiana

Early COVID-19 pandemic data suggested racial/ethnic minority and low-income earning people bore the greatest burden of infection. Structural racism, the reinforcement of racial and ethnic discrimination via policy, provides a framework for understanding disparities in health outcomes like COVID-19 infection. Residential racial and economic segregation is one indicator of structural racism. Little attention has been paid to the relationship of infection to relative overall concentrations of risk (i.e., segregation of the most privileged from the most disadvantaged). We used ordinary least squares and geographically weighted regression models to evaluate the relationship between racial and economic segregation, measured by the Index of Concentration at the Extremes, and COVID-19 cases in Louisiana. We found a significant global association between racial segregation and cumulative COVID-19 case rate in Louisiana and variation across the state during the study period. The northwest and central regions exhibited a strong negative relationship indicating greater risk in areas with high concentrations of Black residents. On the other hand, the southeastern part of the state exhibited more neutral or positive relationships indicating greater risk in areas with high concentrations of White residents. Our findings that the relationship between racial segregation and COVID-19 cases varied within a state further support evidence that social and political determinants, not biological, drive racial disparities. Small area measures and measures of polarization provide localized information better suited to tailoring public health policy according to the dynamics of communities at the census tract level, which may lead to better health outcomes.

COVID-19: Factors Predicting Depressive Symptoms in People Aging With Long-Term Physical Disabilities

The mental health impact of the COVID-19 pandemic may be greater than that of the viral infection. This impact is likely greater for disadvantaged groups such as people with long-term physical disabilities (PwLTPD). This cross-sectional study used a multiple linear regression model to examine factors associated with depressive symptoms and to understand their relative importance during the onset of the COVID-19 pandemic. The model explained 58% of the variance in depressive symptoms. Anxiety was the most important predictor, accounting for 8% of variance. Higher levels of anxiety, loneliness, and financial stress; prior diagnosis of depression; and non-Black race predicted a higher level of depressive symptoms in PwLTPD during the onset of the COVID-19 pandemic. Occupational therapy practitioners should strategically acknowledge predictors of depression that cannot be modified and actively address those that can be modified through evidence-based interventions to improve depressive symptoms in PwLTPD.

Social Determinants of Health and Racial/Ethnic Disparities in COVID-19 Mortality at the County Level in the Commonwealth of Virginia

BACKGROUND

Mortality due to coronavirus disease-2019 (COVID-19) among Black and Hispanic populations is disproportionately high compared to white populations. This study aimed to explore the association between COVID-19 mortality and social determinants of health (SDOH) among Black and Hispanic populations in Virginia.

METHOD

County-level publicly available COVID-19 mortality data from Virginia, covariates, and SDOH indicators were used. An independent t-test and hierarchical multiple regression analysis were performed to assess the association between SDOH and COVID-19 death rates, with a focus on racial/ethnic disparities.

RESULTS

Counties in the lowest quartile had a mean death rate of 44.72 (SD = 13.8), while those in the highest quartile had a mean death rate of 239.02 (SD = 123.9) per 100, 000 people ( P < .001). Counties with the highest death rates had significantly lower mean socioeconomic status. The regression analysis revealed that 32% of the variance in the COVID-19 mortality rate was associated with SDOH after controlling for the covariates ( P < .01). Identifying as Hispanic ethnicity accounted for 8.5% of the variance, while median household income, being uninsured, and education accounted for 32.7%, 12.9%, and 7.1%, respectively.

CONCLUSIONS

The findings provide evidence that disparities in SDOH experienced by Hispanic populations play a significant role in increased COVID-19 mortality, thus highlighting the social needs of low-income, low-education, and Hispanic populations to advance equity in health outcomes.

Insights from a Rapidly Implemented COVID-19 Biobank Using Electronic Consent and Informatics Tools

Biobanking during the COVID-19 pandemic presented unique challenges regarding patient enrollment, sample collection, and experimental analysis. This report details the ways in which we rapidly overcame those challenges to create a robust database of clinical information and patient samples while maintaining clinician and researcher safety. We developed a pipeline using REDCap (Research Electronic Data Capture) to coordinate electronic informed consent, sample collection, immunological assay execution, and data analysis for biobanking samples from patients with COVID-19. We then integrated immunological assay data with clinical data extracted from the electronic health record to link study parameters with clinical readouts. Of the 193 inpatients who participated in this study, 138 consented electronically and 56 provided paper consent. We collected and banked blood samples to measure circulating cytokines and chemokines, peripheral immune cell composition and activation status, anti-COVID-19 antibodies, and germline gene polymorphisms. In addition, we collected DNA and RNA from nasopharyngeal swabs to assess viral titer and microbiome composition by 16S sequencing. The rapid spread and contagious nature of COVID-19 required special considerations and innovative solutions to biobank samples quickly while protecting researchers and clinicians. Overall, this workflow and computational pipeline allowed for comprehensive immune profiling of 193 inpatients infected with COVID-19, as well as 89 outpatients, 157 patients receiving curbside COVID-19 testing, and 86 healthy controls. We describe a novel electronic framework for biobanking and analyzing patient samples during COVID-19, and present insights and strategies that can be applied more broadly to other biobank studies.

Parental decision-making on summer program enrollment: A mixed methods Covid-19 impact study

BACKGROUND

The closure of childcare organizations (e.g. schools, childcare centers, afterschool programs, summer camps) during the Covid-19 pandemic impacted the health and wellbeing of families. Despite their reopening, parents may be reluctant to enroll their children in summer programming. Knowledge of the beliefs that underlie parental concerns will inform best practices for organizations that serve children.

METHODS

Parents (n = 17) participated in qualitative interviews (October 2020) to discuss Covid-19 risk perceptions and summer program enrollment intentions. Based on interview responses to perceived Covid-19 risk, two groups emerged for analysis- "Elevated Risk (ER)" and "Conditional Risk (CR)". Themes were identified utilizing independent coding and constant-comparison analysis. Follow-up interviews (n = 12) in the Spring of 2021 evaluated the impact of vaccine availability on parent risk perceptions. Additionally, parents (n = 17) completed the Covid-19 Impact survey to assess perceived exposure (Range: 0-25) and household impact (Range: 2-60) of the pandemic. Scores were summed and averaged for the sample and by risk classification group.

RESULTS

Parents overwhelmingly supported the operation of summer programming during the pandemic due to perceived child benefits. Parent willingness to enroll their children in summer programming evolved with time and was contingent upon the successful implementation of safety precautions (e.g. outdoor activities, increased handwashing/sanitizing of surfaces). Interestingly, parents indicated low exposure (ER: Avg. 6.3 ± 3.1 Range [2-12], CR: Avg. 7.5 ± 3.6 Range [1-14]) and moderate family impact (ER: Avg. 27.1 ± 6.9 Range [20-36], CR: Avg. 33.7 ± 11.4 Range [9-48]) on the impact survey.

CONCLUSION

Childcare organizations should mandate and evaluate the implementation of desired Covid-19 safety precautions for their patrons.

Narratives from African American/Black, American Indian/Alaska Native, and Hispanic/Latinx community members in Arizona to enhance COVID-19 vaccine and vaccination uptake

The state of Arizona has experienced one of the highest novel coronavirus disease 2019 (COVID-19) positivity test rates in the United States with disproportionally higher case rates and deaths among African-American/Black (AA/B), American Indian/Alaska Native (Native), and Hispanic/Latinx (HLX) individuals. To reduce disparities and promote health equity, researchers from Arizona State University, Mayo Clinic in Arizona, Northern Arizona University, and the University of Arizona formed a partnership with community organizations to conduct state-wide community-engaged research and outreach. This report describes results from 34 virtually-held focus groups and supplemental survey responses conducted with 153 AA/B, HLX, and Native community members across Arizona to understand factors associated with COVID-19 vaccine hesitancy and confidence. Focus groups revealed common themes of vaccine hesitancy stemming from past experiences of research abuses (e.g., Tuskegee syphilis experiment) as well as group-specific factors. Across all focus groups, participants strongly recommended the use of brief, narrative vaccination testimonials from local officials, community members, and faith leaders to increase trust in science, vaccine confidence and to promote uptake.

The Impact of COVID-19 on Education Experiences of High School Students in Semi-Rural Georgia

BACKGROUND

This study examines the consequences of COVID-19 pandemic on academic and career concerns of high school students; relationship between attendance and grades with educational concerns; and association between student perception of the pandemic and decision to attend school virtually or in-person.

METHODS

Diverse students in grades 9-12 from two public high schools in semi-rural Georgia (n = 666) completed a survey shortly after school closures. Survey results were linked to academic and demographic data. Analyses were examined for differences by demographic and education measures.

RESULTS

Overall, 60% expressed academic worry and reported obstacles to virtual learning. Hispanic students expressed more worry and less confidence while black students reported less worry than peers. Females indicated more worry than males. Grade 12 students reported greater academic and career worry than younger students. Students eligible for free and reduced lunch expressed more worry and obstacles than peers. Non-honors and low-attendance students reported more worry about grades and graduation than their counterparts.

CONCLUSIONS

Results can inform targeted multi-level interventions to reduce the pandemic's effects on learning and ensure healthy trajectories for development across demographics. Stakeholders must take proactive measures to recover from academic loss to ensure our youth's healthy development.

Collateral consequences of COVID-19 for people on probation and parole

BACKGROUND

While the severe detrimental impact of COVID-19 on incarcerated people is well known, little is known about the experience of COVID-19 on those on community supervision. Our objective was to better understand the experience of the COVID-19 pandemic and its collateral consequences for those on community supervision (e.g., probation, parole). Beginning in December 2020, we conducted 185 phone surveys about COVID-19 with participants in The Southern Pre-Exposure Prophylaxis (PrEP) Study across its three sites - Florida, Kentucky, and North Carolina. We conducted rapid assessment interviews with both closed- and open-ended questions. We calculated descriptive statistics for close-ended questions and conducted a content analysis for open-ended questions.

RESULTS

The COVID-19 pandemic affected those on community supervision through their experiences in the community and while incarcerated with over one-quarter of participants being reincarcerated during this time. In addition to many (128/185) experiencing COVID-19 symptoms, about half (85/185) of participants reported a diagnosis in their network with 16 of those participants losing loved ones to the pandemic. Participants experienced disruptions to their social network, healthcare, and livelihoods. Though many maintained their support systems, others felt isolated and depressed. Experiences during COVID-19 exacerbated difficulties already faced by those with criminal involvement.

CONCLUSIONS

The public health community must recognize those experiencing probation and parole, not only those housed in carceral facilities, as disproportionately impacted by the COVID-19 pandemic. We must tailor programs and services to meet their needs.

Essential Principles to Create an Equitable, Inclusive, and Diverse EMS Workforce and Work Environment: A Position Statement and Resource Document

POSITION STATEMENTEmergency medical services (EMS), similar to all aspects of health care systems, can play a vital role in examining and reducing health disparities through educational, operational, and quality improvement interventions. Public health statistics and existing research highlight that patients of certain socioeconomic status, gender identity, sexual orientation, and race/ethnicity are disproportionately affected with respect to morbidity and mortality for acute medical conditions and multiple disease processes, leading to health disparities and inequities. With regard to care delivery by EMS, research demonstrates that the current attributes of EMS systems may further contribute to these inequities, such as documented health disparities existing in EMS patient care management, and access along with EMS workforce composition not being representative of the communities served influencing implicit bias. EMS clinicians need to understand the definitions, historical context, and circumstances surrounding health disparities, health care inequities, and social determinants of health in order to reduce health care disparities and promote care equity. This position statement focuses on systemic racism and health disparities in EMS patient care and systems by providing multifaceted next steps and priorities to address these disparities and workforce development. NAEMSP believes that EMS systems should:Adopt a multifactorial approach to workforce diversity implemented at all levels within EMS agencies.Hire more diverse workforce by intentionally recruiting from marginalized communitiesIncrease EMS career pathway and mentorship programs within underrepresented minorities (URM) communities and URM-predominant schools starting at a young age to promote EMS as an achievable profession.Examine policies that promote systemic racism and revise policies, procedures, and rules to promote a diverse, inclusive, and equitable environment.Involve EMS clinicians in community engagement and outreach activities to promote health literacy, trustworthiness, and education.Require EMS advisory boards whose composition reflects the communities they serve and regularly audit membership to ensure inclusion.Increase knowledge and self-awareness of implicit/unconscious bias and acts of microaggression through established educational and training programs (i.e., anti- racism, upstander, and allyship) such that individuals recognize and mitigate their own biases and can act as allies.Redesign structure, content, and classroom materials within EMS clinician training programs to enhance cultural sensitivity, humility, and competency and to meet career development, career planning, and mentoring needs, particularly of URM EMS clinicians and trainees.Discuss cultural views that affect health care and medical treatment and the effects of social determinants of health on care access and outcomes during all aspects of training.Design research and quality improvement initiatives related to health disparities in EMS that are focused on racial/ethnic and gender inequities and include URM community leaders as essential stakeholders involved in all stages of research development and implementation.

Changes in caregiver mental health and pediatric asthma control during COVID-19

OBJECTIVE

This study evaluated caregivers' stress and depressive symptoms, and children's asthma control, before COVID-19 began and after its onset among families in the RVA Breathes program.

METHODS

The RVA Breathes intervention, which took place in an urban city in the United States, includes asthma education delivered by a community health worker (CHW), a home assessment, and school nurse components. Participants included 125 children (5-11 years) with asthma and their caregivers (48% household income <$25,000) enrolled prior to the pandemic. Families were randomized to an active intervention arm (full intervention or intervention without school nurse component) or the control group. Caregivers completed the Center for Epidemiological Studies Depression Scale (CES-D) and the Perceived Stress Scale (PSS); children and caregivers completed the Childhood Asthma Control Test (cACT). Assessments pre-COVID-19 were compared to those completed after the pandemic's onset.

RESULTS

Children in both intervention groups had better cACT scores after the start of COVID-19 compared to before (t(55) = -2.131, p = .019; t(28) = -2.893, p = .004). Caregivers in the intervention groups had lower PSS scores after the start of COVID-19 compared to pre-COVID-19 (t(53) = 3.928, p < .001; t(28) = 2.568, p = .008). Furthermore, CES-D scores improved among caregivers in the full intervention (t(48) = 1.789, p = .040). Caregivers in the control condition did not report significant changes in stress or depressive symptoms.

CONCLUSIONS

Findings suggest that support from interventionists, including CHWs, might have alleviated stress and depressive symptoms during COVID-19, as well as improved asthma control during the pandemic.

Differential Patterns by Area-Level Social Determinants of Health in Coronavirus Disease 2019 (COVID-19)-Related Mortality and Non-COVID-19 Mortality: A Population-Based Study of 11.8 Million People in Ontario, Canada

BACKGROUND

Social determinants of health (SDOH) have been associated with coronavirus disease 2019 (COVID-19) outcomes. We examined patterns in COVID-19-related mortality by SDOH and compared these patterns to those for non-COVID-19 mortality.

METHODS

Residents of Ontario, Canada, aged ≥20 years were followed from 1 March 2020 to 2 March 2021. COVID-19-related death was defined as death within 30 days following or 7 days prior to a positive COVID-19 test. Area-level SDOH from the 2016 census included median household income; proportion with diploma or higher educational attainment; proportion essential workers, racially minoritized groups, recent immigrants, apartment buildings, and high-density housing; and average household size. We examined associations between SDOH and COVID-19-related mortality, and non-COVID-19 mortality using cause-specific hazard models.

RESULTS

Of 11 810 255 individuals, we observed 3880 COVID-19-related deaths and 88 107 non-COVID-19 deaths. After accounting for demographics, baseline health, and other area-level SDOH, the following were associated with increased hazards of COVID-19-related death (hazard ratio [95% confidence interval]: lower income (1.30 [1.04-1.62]), lower educational attainment (1.27 [1.07-1.52]), higher proportions essential workers (1.28 [1.05-1.57]), racially minoritized groups (1.42 [1.08-1.87]), apartment buildings (1.25 [1.07-1.46]), and large vs medium household size (1.30 [1.12-1.50]). Areas with higher proportion racially minoritized groups were associated with a lower hazard of non-COVID-19 mortality (0.88 [0.84-0.92]).

CONCLUSIONS

Area-level SDOH are associated with COVID-19-related mortality after accounting for demographic and clinical factors. COVID-19 has reversed patterns of lower non-COVID-19 mortality among racially minoritized groups. Pandemic responses should include strategies to address disproportionate risks and inequitable coverage of preventive interventions associated with SDOH.

Spatial-temporal distribution of incidence, mortality, and case-fatality ratios of coronavirus disease 2019 and its social determinants in Brazilian municipalities

The COVID-19 pandemic caused impact on public health worldwide. Brazil gained prominence during the pandemic due to the magnitude of disease. This study aimed to evaluate the spatial-temporal dynamics of incidence, mortality, and case fatality of COVID-19 and its associations with social determinants in Brazilian municipalities and epidemiological week. We modeled incidence, mortality, and case fatality rates using spatial-temporal Bayesian model. "Bolsa Família Programme" (BOLSAFAM) and "proportional mortality ratio" (PMR) were inversely associated with the standardized incidence ratio (SIR), while "health insurance coverage" (HEALTHINSUR) and "Gini index" were directly associated with the SIR. BOLSAFAM and PMR were inversely associated with the standardized mortality ratio (SMR) and standardized case fatality ratio (SCFR). The highest proportion of excess risk for SIR and the SMR started in the North, expanding to the Midwest, Southeast, and South regions. The highest proportion of excess risk for the SCFR outcome was observed in some municipalities in the North region and in the other Brazilian regions. The COVID-19 incidence and mortality in municipalities that most benefited from the cash transfer programme and with better social development decreased. The municipalities with a higher proportion of non-whites had a higher risk of becoming ill and dying from the disease.

Evaluating disparities by social determinants in hospital admission decisions for patients with COVID-19 quaternary hospital early in the pandemic

The COVID-19 pandemic has highlighted significant disparities in hospital outcomes when focusing on social determinants of health. Better understanding the drivers of these disparities is not only critical for COVID-19 care but also to ensure equitable treatment more generally. In this paper, we look at how hospital admission patterns, both to the medical ward and the intensive care unit (ICU), may have differed by race, ethnicity, and social determinants of health. We conducted a retrospective chart review of all patients who presented to the Emergency Department of a large quaternary hospital between March 8 and June 3, 2020. We built logistic regression models to analyze how race, ethnicity, area deprivation index, English as a primary language, homelessness, and illicit substance use impacted the likelihood of admission while controlling for disease severity and timing of admission in relation to the start of data collection. We had 1302 recorded Emergency Department visits of patients diagnosed with SARS-CoV-2. White, Hispanic, and African American patients made up 39.2%, 37.5%, and 10.4% of the population respectively. Primary language was recorded as English for 41.2% and non-English for 30% of patients. Among the social determinants of health assessed, we found that illicit drug use significantly increased the likelihood for admission to the medical ward (odds ratio 4.4, confidence interval 1.1-17.1, P = .04), and that having a language other than English as a primary language significantly increased the likelihood of ICU admission (odds ratio 2.6, confidence interval 1.2-5.7, P = .02). Illicit drug use was associated with an increased likelihood of medical ward admission, potentially due to clinician concerns for complicated withdrawal or blood-stream infections from intravenous drug use. The increased likelihood of ICU admission associated with a primary language other than English may have been driven by communication difficulties or differences in disease severity that our model did not detect. Further work is required to better understand drivers of disparities in hospital COVID-19 care.

Clinical Characteristics, Racial Inequities, and Outcomes in Patients with Breast Cancer and COVID-19: A COVID-19 and Cancer Consortium (CCC19) Cohort Study

Background

Limited information is available for patients with breast cancer (BC) and coronavirus disease 2019 (COVID-19), especially among underrepresented racial/ethnic populations.

Methods

This is a COVID-19 and Cancer Consortium (CCC19) registry-based retrospective cohort study of females with active or history of BC and laboratory-confirmed severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection diagnosed between March 2020 and June 2021 in the US. Primary outcome was COVID-19 severity measured on a five-level ordinal scale, including none of the following complications, hospitalization, intensive care unit admission, mechanical ventilation, and all-cause mortality. Multivariable ordinal logistic regression model identified characteristics associated with COVID-19 severity.

Results

1,383 female patient records with BC and COVID-19 were included in the analysis, the median age was 61 years, and median follow-up was 90 days. Multivariable analysis revealed higher odds of COVID-19 severity for older age (aOR per decade, 1.48 [95% CI, 1.32 - 1.67]); Black patients (aOR 1.74; 95 CI 1.24-2.45), Asian Americans and Pacific Islander patients (aOR 3.40; 95 CI 1.70 - 6.79) and Other (aOR 2.97; 95 CI 1.71-5.17) racial/ethnic groups; worse ECOG performance status (ECOG PS ≥2: aOR, 7.78 [95% CI, 4.83 - 12.5]); pre-existing cardiovascular (aOR, 2.26 [95% CI, 1.63 - 3.15])/pulmonary comorbidities (aOR, 1.65 [95% CI, 1.20 - 2.29]); diabetes mellitus (aOR, 2.25 [95% CI, 1.66 - 3.04]); and active and progressing cancer (aOR, 12.5 [95% CI, 6.89 - 22.6]). Hispanic ethnicity, timing and type of anti-cancer therapy modalities were not significantly associated with worse COVID-19 outcomes. The total all-cause mortality and hospitalization rate for the entire cohort was 9% and 37%, respectively however, it varied according to the BC disease status.

Conclusions

Using one of the largest registries on cancer and COVID-19, we identified patient and BC related factors associated with worse COVID-19 outcomes. After adjusting for baseline characteristics, underrepresented racial/ethnic patients experienced worse outcomes compared to Non-Hispanic White patients.

Caregivers of Black and Latino/a/x Students and School Personnel Perspectives on School-Based SARS-CoV-2 Testing: Implications for Testing and Test-to-Stay Programs in K-12 Schools

BACKGROUND

"Test-to-stay" (TTS) is an effective approach for keeping students in school post-exposure to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). To prepare for school-based SARS-CoV-2 testing, we implemented formative research to gather perspectives on school-based testing among school personnel, as well as caregivers of Black and Latino/a/x students given systemic racism, existing school inequalities, and the disproportionate effect of COVID-19 on Black and Latino/a/x populations.

METHODS

We conducted in-depth interviews with caregivers of K-12 grade Black and Latino/a/x students and focus group discussions with K-12 school personnel. We described the forthcoming school-based SARS-CoV-2 testing program and explored potential benefits and concerns, including concerns about testing-related stigma and discrimination, particularly toward Black and Latino/a/x students, and implementation recommendations.

RESULTS

Perceived testing benefits included school community reassurance and preventing school outbreaks. Concerns included potential student anxiety, classroom disruption, inaccurate results, and limited information for caregivers. Some participants mentioned that testing-related stigma and discrimination could happen based on the testing selection process or results but not due to race or ethnicity. Participants provided numerous testing recommendations, including suggestions to prevent negative outcomes.

CONCLUSIONS

Participants believed that stigma and discrimination from SARS-CoV-2 testing is possible, although differential treatment based on race or ethnicity was not anticipated. Participants' narratives provide support for school-based testing and the testing component of TTS.