Changes in Acute ED Visits by Race/Ethnicity During the Early COVID-19 Pandemic.

Emergency department (ED) visits for conditions unrelated to the Coronavirus Disease 2019 (COVID-19) pandemic decreased during the early pandemic, raising concerns about critically ill patients forgoing care and increasing their risk of adverse outcomes. It is unclear if Hispanic and Black adults, who have a high prevalence of chronic conditions, sought medical assistance for acute emergencies during this time. This study used 2018-2020 ED visit data from the largest safety net hospital in Los Angeles County to estimate ED visit differences for cardiac emergencies, diabetic complications, and strokes, during the first societal lockdown among Black and Hispanic patients using time series analyses. Emergency department visits were lower than the expected levels during the first societal lockdown. However, after the lockdown ended, Black patients experienced a rebound in ED visits while visits for Hispanics remained depressed. Future research could identify barriers Hispanics experienced that contributed to prolonged ED avoidance.

Psychiatric Emergencies in Los Angeles County During, and After, Initial COVID-19 Societal Restrictions: An Interrupted Time-Series Analysis.

Emergency department (ED) visits for psychiatric care in the US reportedly declined during the COVID-19 pandemic. This work, however, does not control for strong temporal patterning in visits before the pandemic and does not examine a potential "rebound" in demand for psychiatric care following the relaxation of initial societal restrictions. Here, we examine COVID-19-related perturbations in psychiatric care during and after the 1st stage of societal restrictions in the largest safety-net hospital in Los Angeles. We retrieved psychiatric ED visit data (98,888 total over 156 weeks, Jan 2018 to Dec 2020) from Los Angeles County + USC Medical Center. We applied interrupted time series methods to identify and control for autocorrelation in psychiatric ED visits before examining their relation with the 1st stage of societal restrictions (i.e., March 13 to May 8, 2020), as well as the subsequent "rebound" period of relaxed restrictions (i.e., after May 8, 2020). Psychiatric ED visits fell by 78.13 per week (i.e., 12%) during the 1st stage of societal restrictions (SD = 23.99, p < 0.01). Reductions in ED visits for alcohol use, substance use, and (to a lesser extent) anxiety disorders accounted for the overall decline. After the 1st stage of societal restrictions, however, we observe no "rebound" above expected values in psychiatric ED visits overall (coef = - 16.89, SD = 20.58, p = 0.41) or by diagnostic subtype. This pattern of results does not support speculation that, at the population level, foregoing ED care during initial societal restrictions subsequently induced a psychiatric "pandemic" of urgent visits.

Selection in utero against male twins in the United States early in the COVID-19 pandemic.

OBJECTIVES: We aim to contribute to the literature reporting tests of selection in utero. The theory of reproductive suppression predicts that natural selection would conserve mechanisms, referred to collectively as selection in utero, that spontaneously abort fetuses unlikely to thrive as infants in the prevailing environment. Tests of this prediction include reports that women give birth to fewer than expected male twins, historically among the frailest of infants, during stressful times. The onset of the COVID-19 pandemic in the United States in Spring 2020 demonstrably stressed the population. We test the hypothesis that conception cohorts in gestation at the onset of the pandemic in the United States yielded fewer than expected live male twin births. METHODS: We retrieved deidentified data on the universe of live births in the United States from the National Center for Health Statistics birth certificate records. We applied Box-Jenkins time-series methods to the twin secondary sex ratio computed for 77 monthly conception cohorts spanning August 2013 to December 2019 to detect outlying cohorts in gestation at the onset of the pandemic. RESULTS: The twin secondary sex ratio fell below expected values in three conception cohorts (i.e., July, September, and October 2019, all p < .05) exposed in utero to the onset of the pandemic. CONCLUSIONS: Our results add to prior findings consistent with selection in utero. The role of selection in utero in shaping the characteristics of live births cohorts, especially during the COVID-19 pandemic, warrants further scrutiny.

Exposure to the early COVID-19 pandemic and early, moderate and overall preterm births in the United States: A conception cohort approach.

BACKGROUND: The United States (US) data suggest fewer-than-expected preterm births in 2020, but no study has examined the impact of exposure to the early COVID-19 pandemic at different points in gestation on preterm birth. OBJECTIVE: Our objective was to determine-among cohorts exposed to the early COVID-19 pandemic-whether observed counts of overall, early and moderately preterm birth fell outside the expected range. METHODS: We used de-identified, cross-sectional, national birth certificate data from 2014 to 2020. We used month and year of birth and gestational age to estimate month of conception for birth. We calculated the count of overall (<37 weeks gestation), early (<33 weeks gestation) and moderately (33 to <37 weeks gestation) preterm birth by month of conception. We employed time series methods to estimate expected counts of preterm birth for exposed conception cohorts and identified cohorts for whom the observed counts of preterm birth fell outside the 95% detection interval of the expected value. RESULTS: Among the 23,731,146 births in our study, the mean prevalence of preterm birth among monthly conception cohorts was 9.7 per 100 live births. Gestations conceived in July, August or December of 2019-that is exposed to the early COVID-19 pandemic in the first or third trimester-yielded approximately 3245 fewer moderately preterm and 3627 fewer overall preterm births than the expected values for moderate and overall preterm. Gestations conceived in August and October of 2019-that is exposed to the early COVID-19 pandemic in the late second to third trimester-produced approximately 498 fewer early preterm births than the expected count for early preterm. CONCLUSIONS: Exposure to the early COVID-19 pandemic may have promoted longer gestation among close-to-term pregnancies, reduced risk of later preterm delivery among gestations exposed in the first trimester or induced selective loss of gestations.

Stress/depression across the COVID-19 pandemic in Denmark.

BACKGROUND: Global estimates suggest strained mental health during the first year of the COVID-19 pandemic, but the lack of nationally representative and longitudinal data with clinically validated measures limits knowledge longer into the pandemic. METHODS: Data from 10 rounds of nationally representative surveys from Denmark tracked trends in risk of stress/depression from just before the first lockdown and through to April 2022. We focused on age groups and men and women in different living arrangements and controlled for seasonality in mental health that could otherwise be spuriously related to pandemic intensity. RESULTS: Prior to first lockdown, we observed a "parent gap", which closed with the first lockdown. Instead, a gender gap materialized, with women experiencing higher risks than men-and higher than levels predating first lockdown. Older respondents (+ 70 years) experienced increasing risks of stress/depression early in the pandemic, while all other groups experienced decreases. But longer into the pandemic, risks increased for all age groups and reached (and sometimes exceeded) levels from before first lockdown. CONCLUSION: Denmark had low infection rates throughout most of the pandemic, low mortality rates across the entire pandemic, and offered financial aid packages to curb financial strains. Despite this circumstance, initial improvements to mental health during the first lockdown in Denmark were short-lived. Two years of pandemic societal restrictions correspond with deteriorating mental health, as well as a change from a parenthood gap in mental health before first lockdown to a gender gap two years into the pandemic.

COVID-19 case counts and COVID-19 related Emergency Department visits: differences by immigration status, March-December 2020.

BACKGROUND: Undocumented immigrants face barriers to health care access, which may have been exacerbated during the early days of the COVID-19 pandemic. We test whether undocumented immigrants in Los Angeles County accessed COVID-19 related medical care by examining their Emergency Department (ED) patterns through high and low periods of COVID-19 infection. If undocumented immigrants were underutilizing or foregoing health care, we expect null or weaker associations between COVID-19 cases and COVID-19 related ED visits relative to Medi-Cal patients. METHODS: We analyzed all ED visits to the Los Angeles County + University of Southern California (LAC + USC) Medical Center between March - December 2020 (n = 85,387). We conducted logistic regressions with Los Angeles County weekly COVID-19 case counts as our main independent variable and an interaction between case counts and immigration status, stratified by age (over and under 65 years). RESULTS: We found that undocumented immigrants under 65 years old had a higher odds for a COVID-19 related ED visit compared to Medi-Cal patients and that both undocumented and Medi-Cal patients had higher odds of a COVID-19 related ED visit as COVID-19 cases in Los Angeles County increased. For patients over 65 years, Medi-Cal patients actually had a weaker association between ED visits and county COVID-19 counts; as COVID-19 case counts rose, the odds of a COVID-19 related ED visit increased for the undocumented patients. CONCLUSION: While the overall likelihood of undocumented patients having a COVID-19 related ED visit varies compared to Medi-Cal patients - for younger patients, the odds is higher; for older patients, the odds is lower - it does not appear that undocumented patients underutilized the ED during the early COVID-19 pandemic relative to Medi-Cal patients. The ED may be a viable source of contact for this high-risk population for future outreach.

Emergency Department Utilization Among Undocumented Latino Patients During the COVID-19 Pandemic.

OBJECTIVE: To determine whether Latino undocumented immigrants had a steeper decline in Emergency Department (ED) utilization compared to Latino Medi-Cal patients in a Los Angeles safety-net hospital, March 13, 2020, to May 8, 2020. STUDY DESIGN: The data were extracted from patient medical records for ED visits at LAC + USC Medical Center from January 2018 to September 2020. We analyzed weekly ED encounters among undocumented Latino patients in the nine-week period after COVID was declared a national emergency. We applied time-series routines to identify and remove autocorrelation in ED encounters before examining its relation with the COVID-19 pandemic. We included Latino patients 18 years of age and older who were either on restricted or full-scope Medi-Cal (n = 230,195). RESULTS: All low-income Latino patients, regardless of immigration status, experienced a significant decline in ED utilization during the first nine weeks of the pandemic. Undocumented patients, however, experienced an even steeper decline. ED visits for this group fall below expected levels between March 13, 2020, and May 8, 2020 (coef. = - 38.67; 95% CI = - 71.71, - 5.63). When applied to the weekly mean of ED visits, this translates to a 10% reduction below expected levels in ED visits during this time period. CONCLUSION: Undocumented immigrants' health care utilization was influenced by external events that occurred early in the pandemic, such as strict stay-at-home orders and the public charge rule change. Health care institutions and local policy efforts could work to ensure that hospitals are safer spaces for undocumented immigrants to receive care without immigration concerns.

Thanksgiving and Christmas gatherings before the 2020-21 winter surge of COVID-19 in the United States.

Objective: COVID-19 in the US disproportionately affected, and continues to affect, racial/ethnic minorities. Although risky social gatherings for Thanksgiving and Christmas in 2020 contributed substantially to the "winter surge" in cases and deaths, no research examines potential racial/ethnic differences in behaviors related to holiday gatherings. Design: We used the Understanding America Survey (UAS) - Coronavirus Tracking, a nationally representative study of US adults, to examine associations between race/ethnicity and risky holiday gathering behavior (i.e., gathering with non-household members and with little to no social distancing or mask-wearing). We applied logistic regression models to examine racial/ethnic and socioeconomic differences in risky holiday gatherings while accounting for a person's pre-holiday perception of COVID-19 risk as well as related behaviors. Results: Non-Hispanic Black adults showed a lower prevalence of attending a risky Thanksgiving gathering than did non-Hispanic White adults (15 % vs 43 %, p <.001). The magnitude of this racial/ethnic difference was also found for risky Christmas gatherings. Hispanic and "Other" race/ethnicity adults also appeared less likely than non-Hispanic whites to attend a risky holiday gathering. Higher-income households attended a risky holiday gathering more frequently, when compared with lower income households (p <.001). Logistic regression results, which controlled for other COVID-19 related behaviors, support these main findings. Conclusions: Racial/ethnic minorities, and non-Hispanic Black adults in particular, appeared least likely to have engaged in risky holiday gatherings in late 2020. If replicated, our findings appear consistent with the notion that behavioral modification among racial/ethnic minorities may have reduced the intensity of the 2020/21 "winter surge" in COVID-19.

Patterned Outcomes, Unpatterned Counterfactuals, and Spurious Results: Perinatal Health Outcomes Following COVID-19.

The epidemiologic literature estimating the indirect or secondary effects of the coronavirus disease 2019 (COVID-19) pandemic on pregnant people and gestation continues to grow. Our assessment of this scholarship, however, leads us to suspect that the methods most commonly used may lead researchers to spurious inferences. This suspicion arises because the methods do not account for temporal patterning in perinatal outcomes when deriving counterfactuals, or estimates of the outcomes had the pandemic not occurred. We illustrate the problem in 2 ways. First, using monthly data from US birth certificates, we describe temporal patterning in 5 commonly used perinatal outcomes. Notably, for all but 1 outcome, temporal patterns appear more complex than much of the emerging literature assumes. Second, using data from France, we show that using counterfactuals that ignore this complexity produces spurious results. We recommend that subsequent investigations on COVID-19 and other perturbations use widely available time-series methods to derive counterfactuals that account for strong temporal patterning in perinatal outcomes.

Decreases in preterm birth during the first COVID-19 lockdown in France by gestational age sub-groups and regional COVID-19 incidence.

PURPOSE: Given contradictory evidence about preterm birth (PTB) decreases during COVID-19 lockdowns, we investigate PTB rates during France's strict nationwide lockdown (March 17, 2020 to May 10, 2020). METHODS: This is an interrupted time series analysis using data on maternal delivery hospitalizations in France from January 01, 2016 to July 31, 2020 (3,448,286 singleton births ≥22 weeks' gestational age (GA)). Outcomes were weekly PTB rates (overall and by GA sub-group: <28, 28-31, 32-34, 35-36 weeks), stillbirth and cesarean birth. We estimate odds ratios (OR) using the lockdown period as exposed and other weeks as unexposed, nationally and for districts grouped by COVID-19 incidence. RESULTS: Of 96,076 singleton live births during the lockdown, 4,799 were preterm. PTB rates were 6% (OR: 0.94, 95% CI: 0.90-0.98) lower than expected over this period. This decrease occurred among births 35-36 weeks' GA (OR: 0.92, 95% CI: 0.87-0.98), with no detectable reductions for other GA groups. Cesarean and stillbirth rates were stable. Larger differences were observed in districts with low (OR: 0.92, 95% CI 0.87-0.98) versus moderate/high COVID-19 incidence (OR: 0.97, 95% CI 0.92-1.03). CONCLUSIONS: Late preterm births decreased during France's first lockdown without concurrent change in cesareans and stillbirths. Effects were not more pronounced in moderate/high-COVID-19 districts, contradicting expectations if healthcare disruption were a principal cause.

Estimated seroprevalence of SARS-CoV-2 antibodies among adults in Orange County, California.

Clinic-based estimates of SARS-CoV-2 may considerably underestimate the total number of infections. Access to testing in the US has been heterogeneous and symptoms vary widely in infected persons. Public health surveillance efforts and metrics are therefore hampered by underreporting. We set out to provide a minimally biased estimate of SARS-CoV-2 seroprevalence among adults for a large and diverse county (Orange County, CA, population 3.2 million). We implemented a surveillance study that minimizes response bias by recruiting adults to answer a survey without knowledge of later being offered SARS-CoV-2 test. Several methodologies were used to retrieve a population-representative sample. Participants (n = 2979) visited one of 11 drive-thru test sites from July 10th to August 16th, 2020 (or received an in-home visit) to provide a finger pin-prick sample. We applied a robust SARS-CoV-2 Antigen Microarray technology, which has superior measurement validity relative to FDA-approved tests. Participants include a broad age, gender, racial/ethnic, and income representation. Adjusted seroprevalence of SARS-CoV-2 infection was 11.5% (95% CI: 10.5-12.4%). Formal bias analyses produced similar results. Prevalence was elevated among Hispanics (vs. other non-Hispanic: prevalence ratio [PR] = 1.47, 95% CI 1.22-1.78) and household income < $50,000 (vs. > $100,000: PR = 1.42, 95% CI: 1.14 to 1.79). Results from a diverse population using a highly specific and sensitive microarray indicate a SARS-CoV-2 seroprevalence of ~ 12 percent. This population-based seroprevalence is seven-fold greater than that using official County statistics. In this region, SARS-CoV-2 also disproportionately affects Hispanic and low-income adults.

State lockdown policies, mental health symptoms, and using substances.

OBJECTIVE: Previous literature finds an increase in depressive symptoms, substance use, and suicidal ideation following the COVID-19 pandemic in the US - suicides do not appear to increase. We examine whether 1) state lockdown policies in the US precede an increase in mental health symptoms; and 2) the extent to which using substances amplifies or attenuates the relation. METHODS: We specified, as our exposure variable, the timing of state-level lockdown orders. We used, as the outcome variable, the 4-item Patient Health Questionnaire (PHQ-4) that measures anxiety and depression symptoms. We utilized the Understanding America Study (UAS), a nationally representative sample of 7,597 adults across 50 states in the US, surveyed biweekly between March 10, 2020 and November 11, 2020. Linear fixed effect analyses controlled for time-invariant individual factors, as well as employment status, household income, and previous mental health diagnosis. RESULTS: Regression results indicate an increase in PHQ-4 scores of approximately 1.70 during lockdown, relative to no lockdown (p < 0.05). Relative to no lockdown, an increase in alcohol use corresponds with a 0.08 unit decrease in PHQ-4 scores during lockdown (p < 0.05). CONCLUSION: State lockdown policies precede greater mental health symptoms. Increases in consuming alcohol attenuates the relation between state lockdown policies and mental health symptoms. Results may portend greater addiction following the pandemic warranting further investigation into utilization of substance use treatment.

Risk of stress/depression and functional impairment in Denmark immediately following a COVID-19 shutdown.

BACKGROUND: Existing estimates of the impact of the COVID-19 burden on mental wellbeing come from countries with high mortality rates. This study therefore aimed to investigate the impact of the first COVID-19 lockdown (March-April 2020) on risk for stress/depression and functional impairment in a representative sample of adult individuals in Denmark, which had lower infection rates, and whether the impact of lockdown was heterogeneous across living situation. METHODS: Using a representative, randomly drawn sample from the complete Danish adult population interviewed in March 2 to April 13, 2020 (n = 2836) and again in July 2020 (n = 1526, 54% retention rate), we study how the imposed lockdown announced March 11 following the onset of the first Danish wave of COVID-19 infections affected mental wellbeing. We use the World Health Organization Five Well-being Index (WHO-5) and the Work and Social Adjustment Scale (WSAS) to capture risk for stress/depression (WHO-5 < 50) and functional impairment (WSAS > 10). Using covariate adjusted ordinary least squares linear probability models and exploiting variation in the timing of responses occurring just before and just after the introduction of lockdown, we compare respondents before lockdown to respondents that answered during lockdown, as well as to answers in re-interviews in July. RESULTS: In our fully controlled models, we find reduced depressive symptoms among adults immediately after the shutdown, concentrated in adults with children living at home (-.089, p < .01 (from pre lockdown baseline .273)). Measures of functional impairment also declined immediately after the March shutdown among adults with children living at home (-.066, p < .05 (from pre lockdown baseline .150)). Impairment intensified for the entire sample between March and July (+.199, p < .001 (from pre lockdown baseline .248)), but depressive symptoms remained at lower rate in July (-.033, p < .05 (from pre lockdown baseline .332). CONCLUSIONS: Findings in Denmark indicate that living with children at home may have, in the short term, buffered the potential mental health sequelae of the COVID-19 shutdown.

Non-COVID-19 deaths after social distancing in Norway.

Lay persons and policy makers have speculated on how national differences in the imposition of social distancing to reduce SARS CoV-2 (severe acute respiratory syndrome coronavirus 2) infection has affected non-COVID-19 deaths. No rigorous estimation of the effect appears in the scholarly literature. We use time-series methods to compare non-COVID-19 deaths in Norway during its 9 weeks of mandated social distancing to those expected from history as well as from non-COVID-19 deaths in relatively less restricted Sweden. We estimate that 430 fewer Norwegians than expected died from causes other than COVID-19. We argue that failing to account for averted non-COVID-19 deaths will lead to an underestimate of the benefits of social distancing policies.