Hospitalization Associated With Comorbid Psychiatric and Substance Use Disorders Among Adults With COVID-19 Treated in US Emergency Departments From April 2020 to August 2021.

Importance: During the COVID-19 pandemic, US emergency department (ED) visits for psychiatric disorders (PDs) and drug overdoses increased. Psychiatric disorders and substance use disorders (SUDs) independently increased the risk of COVID-19 hospitalization, yet their effect together is unknown. Objective: To assess how comorbid PD and SUD are associated with the probability of hospitalization among ED patients with COVID-19. Design, Setting, and Participants: This retrospective cross-sectional study analyzed discharge data for adults (age ≥18 years) with a COVID-19 diagnosis treated in 970 EDs and inpatient hospitals in the United States from April 2020 to August 2021. Exposures: Any past diagnosis of (1) SUD from opioids, stimulants, alcohol, cannabis, cocaine, sedatives, or other substances and/or (2) PD, including attention-deficit/hyperactivity disorder (ADHD), anxiety, bipolar disorder, major depression, other mood disorder, posttraumatic stress disorder (PTSD), or schizophrenia. Main Outcomes and Measures: The main outcome was any hospitalization. Differences in probability of hospitalization were calculated to assess its association with both PD and SUD compared with PD alone, SUD alone, or neither condition. Results: Of 1 274 219 ED patients with COVID-19 (mean [SD] age, 54.6 [19.1] years; 667 638 women [52.4%]), 18.6% had a PD (mean age, 59.0 years; 37.7% men), 4.6% had a SUD (mean age, 50.1 years; 61.7% men), and 2.3% had both (mean age, 50.4 years; 53.1% men). The most common PDs were anxiety (12.9%), major depression (9.8%), poly (≥2) PDs (6.4%), and schizophrenia (1.4%). The most common SUDs involved alcohol (2.1%), cannabis (1.3%), opioids (1.0%), and poly (≥2) SUDs (0.9%). Prevalence of SUD among patients with PTSD, schizophrenia, other mood disorder, or ADHD each exceeded 21%. Based on significant specific PD-SUD pairs (Q < .05), probability of hospitalization of those with both PD and SUD was higher than those with (1) neither condition by a weighted mean of 20 percentage points (range, 6 to 36; IQR, 16 to 25); (2) PD alone by 12 percentage points (range, -4 to 31; IQR, 8 to 16); and (3) SUD alone by 4 percentage points (range, -7 to 15; IQR, -2 to 7). Associations varied by types of PD and SUD. Substance use disorder was a stronger predictor of hospitalization than PD. Conclusions and Relevance: This study found that patients with both PD and SUD had a greater probability of hospitalization, compared with those with either disorder alone or neither disorder. Substance use disorders appear to have a greater association than PDs with the probability of hospitalization. Overlooking possible coexisting PD and SUD in ED patients with COVID-19 can underestimate the likelihood of hospitalization. Screening and assessment of both conditions are needed.

Association Between State-Issued COVID-19 Vaccine Mandates and Vaccine Administration Rates in 12 US States and the District of Columbia.

Importance: Some US states have issued COVID-19 vaccine mandates; however, the association of these mandates with vaccination rates remains unknown. Objective: To examine the association between announcing state-issued COVID-19 vaccine mandates that did not provide a test-out option for workers and the vaccine administration rates in terms of state-level first-dose vaccine administration and series completion coverage. Design, Setting, and Participants: This cross-sectional study used publicly available, state-level aggregated panel data to fit linear regression models with 2-way fixed effects (state and time) estimating vaccine coverage changes 8 weeks before and 8 weeks after a state-issued COVID-19 vaccine mandate was announced. Mandates were announced on or after July 26, 2021, and were included only if they went into effect before December 31, 2021. Data were included from 13 state-level jurisdictions with a vaccine mandate in effect as of December 31, 2021, that did not allow recurring testing in lieu of vaccination (mandate group), and 14 state-level jurisdictions that allowed a test-out option and/or did not restrict vaccine requirements (comparison group). Interventions/Exposures: The event of interest was the announcement of a state-issued COVID-19 vaccine mandate applicable to specific groups of workers. Main Outcomes and Measures: The outcome measures were state-level daily COVID-19 vaccine first-dose administration and series completion coverage, reported as mean percentage point changes. Results: Of 5 508 539 first-dose administrations in the 8-week postannouncement period, an estimated 634 831 (11.5%) were associated with the mandate announcement. First-dose administration coverage among 13 jurisdictions increased starting at 3 weeks after the mandate announcement, with statistically significant differences of 0.20, 0.33, 0.39, 0.45, 0.49, and 0.59 percentage points higher than the referent category coverage of 62.9%. Increases in vaccine series completion coverage were observed from 5 to 8 weeks after the announcement, but statistically significant differences from the referent category coverage of 56.3% were observed only during weeks 7 and 8 after the announcement (both differed by 0.2 percentage points; P = .05 and P = .02, respectively). Conclusions and Relevance: The findings of this cross-sectional event study suggest that the announcement of state-issued vaccine mandates may be associated with short-term increases in vaccine uptake. This observed association may be a product of both a direct outcome experienced by groups governed by the mandate as well as the spillover outcome due to a government signaling the importance of vaccination to the general population of the state.

The Association Between State-Issued Mask Mandates and County COVID-19 Hospitalization Rates.

CONTEXT: Mask mandates are one form of nonpharmaceutical intervention that has been utilized to combat the spread of SARS-CoV2, the virus that causes COVID-19. OBJECTIVE: This study examines the association between state-issued mask mandates and changes in county-level and hospital referral region (HRR)-level COVID-19 hospitalizations across the United States. DESIGN: Difference-in-difference and event study models were estimated to examine the association between state-issued mask mandates and COVID-19 hospitalization outcomes. PARTICIPANTS: All analyses were conducted with US county-level data. INTERVENTIONS: State-issued mask mandates. County-level data on the mandates were collected from executive orders identified on state government Web sites from April 1, 2020, to December 31, 2020. MAIN OUTCOME MEASURES: Daily county-level (and HRR-level) estimates of inpatient beds occupied by patients with confirmed or suspected COVID-19 were collected by the US Department of Health and Human Services. RESULTS: The state issuing of mask mandates was associated with an average of 3.6 fewer daily COVID-19 hospitalizations per 100 000 people (P < .05) and a 1.2-percentage-point decrease in the percentage of county beds occupied with COVID-19 patients (P < .05) within 70 days of taking effect. Event study results suggest that this association increased the longer mask mandates were in effect. In addition, the results were robust to analyses conducted at the HRR level. CONCLUSIONS: This study demonstrated that state-issued mask mandates were associated with reduction in COVID-19 hospitalizations across the United States during the earlier portion of the pandemic. As new variants of the virus cause spikes in COVID-19 cases, reimposing mask mandates in indoor and congested public areas, as part of a layered approach to community mitigation, may reduce the spread of COVID-19 and lessen the burden on our health care system.

Association of Trends in Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Seroprevalence and State-Issued Nonpharmaceutical Interventions: United States, 1 August 2020 to 30 March 2021.

BACKGROUND: We assess if state-issued nonpharmaceutical interventions (NPIs) are associated with reduced rates of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection as measured through anti-nucleocapsid (anti-N) seroprevalence, a proxy for cumulative prior infection that distinguishes seropositivity from vaccination. METHODS: Monthly anti-N seroprevalence during 1 August 2020 to 30 March 2021 was estimated using a nationwide blood donor serosurvey. Using multivariable logistic regression models, we measured the association of seropositivity and state-issued, county-specific NPIs for mask mandates, gathering bans, and bar closures. RESULTS: Compared with individuals living in a county with all three NPIs in place, the odds of having anti-N antibodies were 2.2 (95% confidence interval [CI]: 2.0-2.3) times higher for people living in a county that did not have any of the 3 NPIs, 1.6 (95% CI: 1.5-1.7) times higher for people living in a county that only had a mask mandate and gathering ban policy, and 1.4 (95% CI: 1.3-1.5) times higher for people living in a county that had only a mask mandate. CONCLUSIONS: Consistent with studies assessing NPIs relative to COVID-19 incidence and mortality, the presence of NPIs were associated with lower SARS-CoV-2 seroprevalence indicating lower rates of cumulative infections. Multiple NPIs are likely more effective than single NPIs.

The Differential Impact of Reopening States With and Without COVID-19 Face Mask Mandates on County-Level Consumer Spending.

OBJECTIVES: By the end of 2020, 38 states and the District of Columbia had issued requirements that people wear face masks when in public settings to counter SARS-CoV-2 transmission. To examine the role face mask mandates played in economic recovery, we analyzed the interactive effect of having a state face mask mandate in place on county-level consumer spending after state reopening, adjusting for county rates of new COVID-19 cases and deaths, time trends, and county-specific effects. METHODS: We collected county-specific data from state executive orders, consumer spending data from the Opportunity Insights Economic Tracker, and COVID-19 case and death data from the Centers for Disease Control and Prevention COVID-19 tracker. Using an event study approach, we compared county-level changes in consumer spending before and after state-issued closure orders were lifted and assessed the interactive effect of state-issued face mask mandates. RESULTS: The lifting of state-issued closures was associated with an average increase in consumer spending across all counties studied within 1 month. However, the increase was 1.2-1.7 percentage points higher in counties with a state face mask mandate in place than in counties without a state face mask mandate. CONCLUSIONS: In addition to their public health benefits, face mask mandates may have assisted economic recovery during the COVID-19 pandemic, suggesting they are a strong public health strategy for policy makers to consider now and for potential future pandemics arising from airborne viruses.

The Impact of Covid-19 State Closure Orders on Consumer Spending, Employment, and Business Revenue.

CONTEXT: In response to the COVID-19 pandemic, states across the United States implemented various strategies to mitigate transmission of SARS-CoV-2 (the virus that causes COVID-19). OBJECTIVE: To examine the effect of COVID-19-related state closures on consumer spending, business revenue, and employment, while controlling for changes in COVID-19 incidence and death. DESIGN: The analysis estimated a difference-in-difference model, utilizing temporal and geographic variation in state closure orders to analyze their impact on the economy, while controlling for COVID-19 incidence and death. PARTICIPANTS: State-level data on economic outcomes from the Opportunity Insights data tracker and COVID-19 cases and death data from usafacts.org. INTERVENTIONS: The mitigation strategy analyzed within this study was COVID-19-related state closure orders. Data on these orders were obtained from state government Web sites containing executive or administrative orders. MAIN OUTCOME MEASURES: Outcomes include state-level estimates of consumer spending, business revenue, and employment levels. RESULTS: Analyses showed that although state closures led to a decrease in consumer spending, business revenue, and employment, they accounted for only a small portion of the observed decreases in these outcomes over the first wave of COVID-19. CONCLUSIONS: The impact of COVID-19 on economic activity likely reflects a combination of factors, in addition to state closures, such as individuals' perceptions of risk related to COVID-19 incidence, which may play significant roles in impacting economic activity.

Association of State-Issued Mask Mandates and Allowing On-Premises Restaurant Dining with County-Level COVID-19 Case and Death Growth Rates - United States, March 1-December 31, 2020.

CDC recommends a combination of evidence-based strategies to reduce transmission of SARS-CoV-2, the virus that causes COVID-19 (1). Because the virus is transmitted predominantly by inhaling respiratory droplets from infected persons, universal mask use can help reduce transmission (1). Starting in April, 39 states and the District of Columbia (DC) issued mask mandates in 2020. Reducing person-to-person interactions by avoiding nonessential shared spaces, such as restaurants, where interactions are typically unmasked and physical distancing (≥6 ft) is difficult to maintain, can also decrease transmission (2). In March and April 2020, 49 states and DC prohibited any on-premises dining at restaurants, but by mid-June, all states and DC had lifted these restrictions. To examine the association of state-issued mask mandates and allowing on-premises restaurant dining with COVID-19 cases and deaths during March 1-December 31, 2020, county-level data on mask mandates and restaurant reopenings were compared with county-level changes in COVID-19 case and death growth rates relative to the mandate implementation and reopening dates. Mask mandates were associated with decreases in daily COVID-19 case and death growth rates 1-20, 21-40, 41-60, 61-80, and 81-100 days after implementation. Allowing any on-premises dining at restaurants was associated with increases in daily COVID-19 case growth rates 41-60, 61-80, and 81-100 days after reopening, and increases in daily COVID-19 death growth rates 61-80 and 81-100 days after reopening. Implementing mask mandates was associated with reduced SARS-CoV-2 transmission, whereas reopening restaurants for on-premises dining was associated with increased transmission. Policies that require universal mask use and restrict any on-premises restaurant dining are important components of a comprehensive strategy to reduce exposure to and transmission of SARS-CoV-2 (1). Such efforts are increasingly important given the emergence of highly transmissible SARS-CoV-2 variants in the United States (3,4).