Suicide deaths during the COVID-19 pandemic in the United States, by region, gender and age, March 1, 2020-June 30, 2022 (preprint)

The COVID-19 pandemic imposed substantial mental health stressors leading to concerns about an increased suicide risk. To investigate this issue, we investigated suicide mortality rates in the United States from March 1, 2020, through June 30, 2022, comparing them with data from the pre-pandemic period of January 2015 through February 2020. Suicide mortality in the United States was 3% below expected levels during the study period. However, there was an increased suicide incidence in adults ages 18–34 years. The concerns that the pandemic contributed to an overall marked increase in suicide risk is not supported by this analysis, but young adults did experience an increase.

Covid-19 Vaccine Booster Cadence by Immunocompromised Status (preprint)

BackgroundData suggest that vaccine effectiveness against Covid-19-associated hospital admission and mortality is augmented with booster doses, but the benefit wanes within several months. However, the CDC recently concluded that second doses of bivalent vaccines this Spring were not warranted because existing data were insufficient to analyze the benefits of such a strategy. Therefore, our objective was to assess whether routinely boosting high-risk populations at least every 6 months may be warranted, depending on age and immune status. MethodsUtilizing a database of 3,574,243 members of Clalit Health Services (CHS), we analyzed the medical records of individuals who received none, or at least one dose of the BNT162b2 mRNA COVID-19 vaccine between January 1, 2021, and April 5, 2022. We examined the risk of moderate-to-severe Covid-19 hospitalization or death stratified by age group, immune status and time since receipt of the last vaccine dose during the early Omicron wave in Israel (December 20, 2021 to April 5, 2022). The number needed to vaccinate (NNV) was calculated as the inverse of the absolute risk reduction for various subgroups and Covid-19 waves. ResultsEligibility criteria were met by 3,381,480 CHS members. The absolute risk of Covid-19 moderate-to severe hospitalization or death during the Omicron wave increased with age, immunocompromised status, and time since receipt of the last vaccine dose. The NNVs varied greatly by age and immune status and were contingent on various disease prevalence scenarios. Among the severely immunocompromised, boosting at the start of the Omicron wave had an NNV ranging from 87 (95% CI 70-109) in persons ages [≥]80 to 1,037 (95% CI 999 -1,513) in persons ages 12-59. In the lower prevalence periods, the NNV for 6-month booster cadencing remained favorable for immunocompromised people in all age groups and immunocompetent people ages [≥]60. ConclusionsOur study provides evidence for the potential benefit of a routine 6-month cadence for Covid-19 boosters for the highest-risk groups, and possibly more frequently, even during relatively lower Covid-19 prevalence.

Incidence of Symptoms Associated with Post-Acute Sequelae of SARS-CoV-2 infectionin Non-Hospitalized Vaccinated Patients Receiving Nirmatrelvir-Ritonavir (preprint)

Background: The role of Nirmatrelvir plus ritonavir (NMV-r) in preventing post-acute sequelae of SARS-CoV-2 infection (PASC) is unknown. The objective of this study is to assess the effect of NMV-r in non-hospitalized, vaccinated patients on the occurrence of PASC. Methods: We performed a comparative retrospective cohort study utilizing data from the TriNetX research network, including vaccinated patients [≥]18 years old who subsequently developed Covid-19 between December 2021-April 2022. Cohorts were based on NMV-r administration within five days of diagnosis. Based on previously validated broad and narrow definitions, the main outcome was the presence of symptoms associated with PASC. Outcomes were assessed between 30-180 days and 90-180 days after the index Covid-19 infection. Results 1,004 patients remained in each cohort after propensity-score matching. PASC (broad definition) occurred in 425 patients (42%) in the NMV-r cohort, vs. 480 patients (48%) in the control cohort (OR 0.8 CI 0.67-0.96; p=0.01) from 30-180 days and in 273 patients (27%) in the NMV-r cohort, as compared to 347 patients (35%) in the control cohort (OR 0.707, CI 0.59-0.86; p<0.001) from 90-180 days. Narrowly defined PASC was reported in 337 (34%) patients in the NMV-r and 404 (40%) in the control cohort between 30-180 days (OR=0.75, CI 0.62-0.9, p=0.002) and in 221 (22%) in the NMV-r cohort as compared to in 278 (28%) patients in the control cohort (OR=0.7, CI 0.63-0.9, p=0.003) between 90 -180 days. Conclusions NMV-r treatment in non-hospitalized vaccinated patients with Covid-19 was associated with a reduction in the development of symptoms commonly observed with PASC and healthcare utilization.

The uncoupling of all-cause excess mortality from Covid-19 cases and associated hospitalizations in late winter and spring of 2022 in a highly vaccinated state. (preprint)

Introduction: Since March 2020, all-cause excess mortality (the number of all-cause deaths exceeding the baseline number of expected deaths) has been observed in waves coinciding with Covid-19 outbreaks in the United States. We recently described high levels of excess mortality in Massachusetts during the initial 8-week Omicron wave. However, whether excess mortality continued after that period (during which an outbreak of Omicron subvariants occurred) is unknown. Methods: We applied seasonal autoregressive integrated moving averages to five years of pre-pandemic data provided by the Massachusetts Registry of Vital Records and Statistics (MRVRS) to project the weekly populations and expected deaths for the pandemic period. Observed deaths during the pandemic were also provided by MRVRS and are >99% complete for all study weeks. Results: During the 18-week Omicron subvariant period (the week ending February 27, 2022, through June 26, 2022) the incidence of all-cause excess mortality was 0.1 per 100,000-person weeks, corresponding to 148 excess deaths (95%. CI -907 to 1153), representing a 97.1% decrease from the initial Omicron period (during which all-cause excess mortality was 4.0 per 100,000-person-weeks), and a 91.9% reduction from the Delta and Delta-Omicron transition period (during which all-cause excess mortality was 1.5 per 100,000-person-weeks), despite >226,000 reported new Covid-19 cases during the subvariant/spring period. However, Covid-19-associated hospitalizations were observed during the subvariant/spring 2022 period. Conclusion: In a highly vaccinated state with a recent wave of SARS-CoV-2, all-cause excess mortality was uncoupled from new case counts, indicating the possibility of temporary protection from the most severe outcomes related to Covid-19 among high-risk individuals. However, given the possibility of waning immunity and the emerging of new variants, continued monitoring is warranted.

Mortality from injury, overdose and suicide during the 2020 COVID-19 pandemic, March-July, 2020 (preprint)

Introduction: The COVID-19 pandemic has been associated with substantial rates of all-cause excess mortality. The contribution of external causes of death to excess mortality including drug overdose, homicide, suicide, and unintentional injuries during the initial outbreak in the United States is less well documented. Methods Using public data published by the National Center for Health Statistics on February 10, 2021, we measured monthly excess mortality (the gap between observed and expected deaths) from five external causes using national-level data published by National Center for Health Statistics; assault (homicide); intentional self-harm (suicide); accidents (unintentional injuries); and motor vehicle accidents. We used seasonal autoregressive integrated moving average (sARIMA) models developed with cause-specific monthly mortality counts and US population data from 2015-2019 and estimated the contribution of individual cause-specific mortality to all-cause excess mortality from March-July 2020. Results From March-July, 2020, 212,825 (95% CI 136,236-290,776) all-cause excess deaths occurred in the US). There were 8,540 excess drug overdoses (all intents) (95% CI 5,106 to 11,975), accounting for 4% of all excess mortality; 1,455 excess homicide deaths (95% CI 708 to 2202, accounting for 0.7% of excess mortality; 5,492 excess deaths due to unintentional accidents occurred (95% CI 85 to 10,899, accounting for 2.6% of excess mortality. Though a non-significantly 135 (95% CI -1361 to 1,630) more MVA deaths were recorded during the study period, a significant decrease in April (525; 95% CI -817 to -233) and significant increases in June-July (965; 95% CI 348 to 1,587) were observed. Suicide deaths were statistically lower than projected by 2,067 (95% CI 941-3,193 fewer deaths). Meaning Excess deaths from drug overdoses, homicide, and addicents occurred during the pandemic but represented a small fraction of all-cause excess mortality. The excess external causes of death, however, still represent thousands of lives lost. Notably, deaths from suicide were lower than expected and therefore did not contribute to excess mortality.

Suicide Deaths during the Stay-at-Home Advisory in Massachusetts. (preprint)

Many believe that shelter-in-place or stay-at-home policies might cause an increase in so-called deaths of despair. While increases in psychiatric stressors during the COVID-19 pandemic are anticipated, whether suicide rates changed during stay-at-home periods has not been described. This was an observational cohort study that assembled suicide death data for persons aged 10 years or older from the Massachusetts Department of Health Registry of Vital Records and Statistics from January 2015 through May 2020. Using autoregressive integrated moving average (ARIMA) and seasonal ARIMA to analyze suicide deaths in Massachusetts, we compared the observed number of suicide deaths in Massachusetts during the stay-at-home period (March through May, 2020) in Massachusetts to the projected number of expected deaths. To be conservative, we also accounted for the deaths still pending final cause determination The incident rate for suicide deaths in Massachusetts was 0.67 per 100,000 person-month (95% CI 0.56-0.79) versus 0.81 per 100,000 person-month (95% CI 0.69-0.94) during the 2019 corresponding period (incident rate ratio of 0.83; 95% CI 0.66-1.03). The addition of the 57 deaths pending cause determination occurring from March through May 2020 and the 33 cases still pending determination from the 2019 corresponding period did not change these findings. The observed number of suicide deaths during the stay-at-home period did not deviate from ARIMA projected expectations using either preliminary data or an alternate scenario in which deaths pending investigation (exceeding the average remaining number of deaths still pending investigation which occurred during the corresponding 2015-2019 period) were ascribed to suicide. Decedent age and sex demographics were unchanged during the pandemic period compared to 2015-2019. The stable rates of suicide deaths during the stay-at-home advisory in Massachusetts parallel findings following ecological disasters. As the pandemic persists, uncertainty about its scope and economic impact may increase. However, our data are reassuring that an increase in suicide deaths in Massachusetts during the stay-at-home advisory period did not occur.

Heart Disease Deaths during the Covid-19 Pandemic (preprint)

The SARS-CoV-2 pandemic is associated with a reduction in hospitalization for an acute cardiovascular conditions. In a major health system in Massachusetts, there was a 43% reduction in these types of hospitalizations in March 2020 compared with March 2019.4 Whether mortality rates from heart disease have changed over this period is unknown. We assembled information from the National Center for Health Statistics (Centers for Disease Control and Prevention) for 118,356,533 person-weeks from Week 1 (ending January 4) through Week 17 (ending April 25) of 2020 for the state of Massachusetts. We found that heart disease deaths are unchanged during the Covid-19 pandemic period as compared to the corresponding period of 2019. This is despite reports that admissions for acute myocardial infarction have fallen during this time.

Relative disease burdens of COVID-19 and seasonal influenza in New York City, February 1 - April 18, 2020. (preprint)

Comparisons between the mortality burdens of COVID-19 and seasonal influenza often fail to account for the fact that the United States Centers for Disease Control and Prevention (CDC) reports annual influenza mortality estimates which are calculated based upon a series of assumptions about the underreporting of flu deaths. COVID-19 deaths, in contrast, are being reported as raw counts. In this report, we compare COVID-19 death counts to seasonal influenza death counts in New York City during the interval from February 1 - April 18, 2020. Using this approach, COVID-19 appears to have caused 21.4 times the number of deaths as seasonal influenza during the same period. We also assessed excess mortality in order to verify this finding. New York City has had approximately 13,032 excess all-cause mortality deaths during this time period. We assume that most of these deaths are COVID-19 related. We therefore calculated the ratio of excess deaths (i.e. assumed COVID-19 deaths) to seasonal influenza deaths during the same time interval and found a similar ratio of 21.1 COVID-19 to seasonal influenza deaths. Our findings are consistent with conditions on the ground today. Comparing COVID-19 deaths with CDC estimates of yearly influenza-related deaths would suggest that, this year, seasonal influenza has killed approximately the same number of Americans as COVID-19 has. This does not comport with the realities of the pandemic we see today.