Association of Obstructive Sleep Apnea with Post-Acute Sequelae of SARS-CoV-2 infection (PASC) (preprint)

BackgroundObstructive sleep apnea (OSA) is associated with COVID-19 infection. Fewer investigations have assessed OSA as a possible risk for the development of Post-Acute Sequelae of SARS-CoV-2 infection (PASC). Research QuestionIn a general population, is OSA associated with increased odds of PASC-related symptoms and with an overall definition of PASC? Study DesignCross-sectional survey of a general population of 24,803 U.S. adults. ResultsCOVID-19 infection occurred in 10,324 (41.6%) participants. Prevalence rates for a wide variety of persistent (> 3 months post infection) putative PASC-related physical and mental health symptoms ranged from 6.5% (peripheral edema) to 19.6% (nervous/anxious). In logistic regression models adjusted for demographic, anthropometric, comorbid medical and socioeconomic factors, OSA was associated with all putative PASC-related symptoms with the highest adjusted odds ratios (aOR) being fever (2.053) and nervous/anxious (1.939) respectively. Elastic net regression identified the 13 of 37 symptoms most strongly associated with COVID-19 infection. Four definitions of PASC were developed using these symptoms either weighted equally or proportionally by their regression coefficients. In all 4 logistic regression models using these definitions, OSA was associated with PASC (range of aORs: 1.934-2.071); this association was mitigated in those with treated OSA. In the best fitting overall model requiring [≥]3 symptoms, PASC prevalence was 21.9%. ConclusionIn a general population sample, OSA is associated with the development of PASC-related symptoms and a global definition of PASC. A PASC definition requiring the presence of 3 or more symptoms may be useful in identifying cases and for future research.

Association of Chronotype and Shiftwork with COVID-19 Infection (preprint)

Objective: This study assesses whether chronotype is related to COVID-19 infection and whether there is an interaction with shift work. Methods: Cross-sectional survey of 19,821 U.S. adults Results: COVID-19 infection occurred in 40% of participants, 32.6% morning and 17.2% evening chronotypes. After adjusting for demographic and socioeconomic factors, shift work, sleep duration and comorbidities, morning chronotype was associated with a higher (aOR: 1.15, 95% CI 1.10-1.21) and evening chronotype with a lower (aOR: 0.82, 95% CI: 0.78-0.87) prevalence of COVID-19 infection in comparison to an intermediate chronotype. Working exclusively night shifts was not associated with higher prevalence of COVID-19. Morning chronotype and working some evening shifts was associated with the highest prevalence of previous COVID-19 infection (aOR: 1.87, 95% CI: 1.28-2.74). Conclusion: Morning chronotype and working a mixture of shifts increase risk of COVID-19 infection.

US Public Opinion as to Whether "The Pandemic is Over," September to October 2022 (preprint)

Importance: US public health guidance has increasingly shifted responsibility for actions to minimize ongoing impacts of COVID-19 onto individuals. During September to October 2022, the World Health Organization continued to characterize COVID-19 as a pandemic. Yet, public perceptions of the pandemic status of COVID-19 and its associations with COVID-19-related behaviors were unknown. Objective: To assess US public opinion on the characterization of COVID-19 as a pandemic. Design, Setting, and Participants: The COVID-19 Outbreak Public Evaluation (COPE) Initiative internet-based surveys, administered to 4985 US adults during September to October 2022. Demographic quota sampling and survey weighting were employed to improve sample representativeness of the US population by age, sex, and combined race and ethnicity. Exposures: The COVID-19 pandemic. Main Outcomes and Measures: Response to the statement, "the pandemic is over." Response options included Strongly agree, Somewhat agree, Neutral, Somewhat disagree, and Strongly disagree. Results: Overall, 5015 US adults completed The COPE Initiative surveys (response rate, 56.2%), and 4985 (99.4%) provided complete information for all analyzed variables and were included in this analysis. Only 1657 (33.2%) respondents agreed with the statement "the pandemic is over," while 2141 (43.0%) disagreed and the remaining 1187 (23.8%) were neutral about the statement. Agreement that the pandemic was over was most strongly associated with having received fewer COVID-19 vaccines, lesser concern about SARS-CoV-2 variant viruses, and less frequent engagement in COVID-19 preventive behaviors, such as mask usage in public spaces, as well as increasingly conservative political ideology, roles as unpaid caregivers of both children and adults, younger age, male sex, and significant disabilities. Conclusions and Relevance: As of September to October 2022, US public opinion was mixed on the characterization of COVID-19 as a pandemic. Belief the pandemic was over was associated with less frequent engagement in COVID-19 preventive behaviors, highlighting the important role of public health communication. Demographic groups to prioritize tailored public health messaging about the pandemic status were identified. Continued assessment of public perceptions about the state of the pandemic is warranted entering Year 4 of the COVID-19 pandemic.

Intent among Parents to Vaccinate Children before Pediatric Vaccine Recommendations, Minnesota and Los Angeles County, California--May-September 2021 (preprint)

Objectives: This study assessed the associations between parent intent to have their child receive COVID-19 vaccination, and demographic factors and various child activities including attendance at in-person education or childcare. Methods: Persons undergoing COVID-19 testing residing in Minnesota and Los Angeles County, California with children aged <12 years completed anonymous internet-based surveys between May 10 and September 6, 2021 to assess factors associated with intention to vaccinate their child. Factors influencing parents’ decision to have their child attend in person school or childcare were examined. Estimated adjusted odds rations (AORs, 95% CI) were computed between parents’ intentions regarding children’s COVID-19 vaccination and participation in school and extra-curricular activities using multinomial logistic regression. Results: Compared to parents intending to vaccinate their children (n=4,686 [77.2%]), those undecided (n=874 [14.4%] or without intention to vaccinate (n=508 [8.4%]) tended to be younger, non-White, less educated and themselves not vaccinated against COVID-19. Their children more commonly participated in sports (aOR:1.51 1.17-1.95) and in-person faith or community activities (aOR:4.71 (3.62-6.11). They further indicated that additional information regarding vaccine safety and effectiveness would influence their decision. COVID-19 mitigation measures were the most common factors influencing parents’ decision to have their child attend in-person class or childcare. Conclusions: Several demographic and socioeconomic factors are associated with parents’ decision whether to vaccinate their <12-year-old children for COVID-19. Child participation in in-person activities was associated with parents’ intentions not to vaccinate. Tailored communications may be useful to inform parents’ decisions regarding safety and effectiveness of vaccination.

Years of Life Lost in the US During the COVID-19 Pandemic, March 2020 to October 2021 (preprint)

Background Given a downward age shift in COVID-19-involved deaths observed during the COVID-19 pandemic, we sought to estimate years of life lost (YLL) associated with leading causes of US death during the first 20 months of the pandemic. Findings Despite 4796 fewer COVID-19 deaths in Jan-Oct 2021 than in Mar-Dec 2020, the number of YLL due to COVID-19 increased by 1,159,761, from 4,474,186 to 5,633,947 (a 25.9% increase). YLL per COVID-19 death increased from 12.8 in 2020 to 16.3 in 2021, a 27.7% increase. YLL per death did not change by more than 2.3% for any other cause. Interpretation Increased YLL per COVID-19 death in 2021 result from younger-age COVID-19 mortality, contributing to a marked increase in YLL from this preventable cause of death at a later stage of the pandemic despite advancements in vaccines in treatments.

Prior sleep-wake behavior predicts mental health resilience among adults in the United States during the COVID-19 pandemic (preprint)

Rigorous nonpharmaceutical interventions (e.g., stay-at-home orders, remote-work directives) were implemented in early 2020 for coronavirus disease 2019 (COVID-19) pandemic containment in the U.S. During this time, increased sleep duration and delayed sleep timing were reported through surveys (Leone et al., 2021) and wearable data (Rezaei and Grandner, 2021), as were elevated adverse mental health symptom (Czeisler et al., 2020). Inter-relationships between sleep and mental health have not been examined using longitudinal objective sleep-wake data, during these abruptly imposed lifestyle changes. We examined objective sleep-wake data and surveyed mental health data collected among 4,912 U.S. adult users of a validated sleep wearable (WHOOP, Boston, Massachusetts) before and during the COVID-19 pandemic. Comparing the pre-pandemic (January 1 to March 12, 2020) and acute pandemic-onset intervals (March 13 to April 12, 2020), participants exhibited increased mean sleep duration (0.25h [95% CI = 0.237-0.270]), later sleep onset (18m [17.378-20.045]) and offset (36m [35.111-38.106]), and increased consistency of sleep timing (3.51 [3.295-3.728] out of 100); all P < 0.0001. Generally, participants with persistent sleep deficiency and low sleep consistency had higher odds of symptoms of anxiety or depression, burnout, and new or increased substance use during the pandemic. Decreases in sleep duration (adjusted odds ratio [aOR] = 1.30, 95% CI = 1.03-1.65, P = 0.025) and sleep consistency (2.05 [1.17-3.67], P = 0.009) were associated with increased anxiety and depression symptoms during the pandemic. We suggest that sleep duration and consistency may be important predictors of risk of adverse mental health outcomes during a pandemic. M.J. Leone, M. Sigman, D.A. Golombek. Effects of lockdown on human sleep and chronotype during the COVID-19 pandemic. Curr Biol 30(16), R930-R931 (2020). N. Rezaei N, M.A. Grandner. Changes in sleep duration, timing, and variability during the COVID-19 pandemic: Large-scale Fitbit data from 6 major US cities. Sleep Health 10.1016/j.sleh.2021.02.008. (2021). M.E. Czeisler, R.I. Lane, E. Petrosky, et al., Mental Health, Substance Use, and Suicidal Ideation During the COVID-19 Pandemic - United States, June 24-30, 2020. MMWR Morb Mortal Wkly Rep 69(32), 1049-1057 (2020).

COVID-19 Vaccine Intentions in the United States, December 2020 to March 2021 (preprint)

ImportanceSARS-CoV-2 containment is estimated to require attainment of high (>80%) post-infection and post-vaccination population immunity. ObjectiveTo assess COVID-19 vaccine intentions among US adults and their children, and reasons for vaccine hesitancy among potential refusers. DesignInternet-based surveys were administered cross-sectionally to US adults during December 2020 and February to March 2021 (March-2021). SettingSurveys were administered through Qualtrics using demographic quota sampling. ParticipantsA large, demographically diverse sample of 10,444 US adults (response rate, 63.9%). Main Outcomes and MeasuresCOVID-19 vaccine uptake, intentions, and reasons for potential refusal. Adults living with or caring for children aged 2 to 18 years were asked about their intent to have their children vaccinated. Multivariable weighted logistic regression models were used to estimate adjusted odds ratios for vaccine refusal. ResultsOf 5256 March-2021 respondents, 3467 (66.0%) reported they would definitely or most likely obtain a COVID-19 vaccine as soon as possible (ASAP Obtainers), and an additional 478 (9.1%) reported they were waiting for more safety and efficacy data before obtaining the vaccine. Intentions for children and willingness to receive a booster shot largely matched personal COVID-19 vaccination intentions. Vaccine refusal (ie, neither ASAP Obtainers nor waiting for more safety and efficacy data) was most strongly associated with not having obtained an influenza vaccine in 2020 (adjusted odds ratio, 4.11 [95% CI, 3.05-5.54]), less frequent mask usage (eg, rarely or never versus always or often, 3.92 [2.52-6.10]) or social gathering avoidance (eg, rarely or never versus always or often, 2.65 [1.95-3.60]), younger age (eg, aged 18-24 versus over 65 years, 3.88 [2.02-7.46]), and more conservative political ideology (eg, very conservative versus very liberal, 3.58 [2.16-5.94]); all P<.001. Conclusions and RelevanceThree-quarters of March-2021 respondents in our large, demographically diverse sample of US adults reported they would likely obtain a COVID-19 vaccine, and 60% of adults living with or caring for children plan to have them vaccinated as soon as possible. With an estimated 27% of the US population having been infected with SARS-CoV-2, once vaccines are available to children and they have been vaccinated, combined post-infection and post-vaccination immunity will approach 80% of the US population in 2021, even without further infections. Key PointsO_ST_ABSQuestionC_ST_ABSWhat are COVID-19 vaccines intentions, for adults and for children under their care? FindingsTwo-thirds of 5256 US adults surveyed in early 2021 indicated they would obtain a COVID-19 vaccine as soon as possible. Intentions for children and booster vaccines largely matched personal vaccine intentions. Refusal was more common among adults who were younger, female, Black, very politically conservative, less educated, less adherent with COVID-19 prevention behaviors (eg, wearing masks), had more medical mistrust, or had not received influenza vaccines in 2020. MeaningTailored vaccine promotion efforts and vaccine programs may improve vaccine uptake and contribute to US immunity against COVID-19.

Uncovering Survivorship Bias in Longitudinal Mental Health Surveys (preprint)

To our knowledge, survivorship bias in longitudinal mental health survey studies has not been systematically assessed. We therefore assessed potential survivorship bias among 4,039 respondents invited to complete multiple surveys in 2020 for The COVID-19 Outbreak Public Evaluation (COPE) Initiative. Demographic differences in follow-up survey participation included lower retention of younger adults. Adjusting for demographics, individuals who completed only one or two out of four surveys had higher prevalences of anxiety and depression symptoms in April 2020 (e.g., one-survey versus four-survey, anxiety symptoms, aPR=1.30, 95%CI=1.08-1.55, P=0.0045; depression symptoms, aPR=1.43, 95%CI=1.17-1.75, P=0.0005). Among respondents who completed April-2020 and May-2020 surveys, individuals who experienced incident anxiety or depression symptoms significantly higher odds of lower participation in subsequent follow-up surveys (aOR=1.68, 95%CI=1.49-2.48, aOR=1.56, 95%CI=1.15-2.12, respectively, both P<0.005). These findings indicate that longitudinal mental health survey studies may be subject to survivorship bias, which could lead to overly optimistic interpretations of mental health trends.

COVID-19: Public Compliance with and Public Support for Stay-at-Home Mitigation Strategies (preprint)

Objectives: Governments worldwide have recommended unprecedented measures to mitigate the coronavirus disease 2019 (COVID-19) pandemic. As pressure mounts to scale back these measures, understanding public compliance with and priorities for COVID-19 mitigation is critical. The main aim of this study was to assess public compliance with and support for government-imposed stay-at-home orders in nations and cities with different COVID-19 infection and death rates. Design: In this cross-sectional study, questionnaires were administered to nationally representative respondents from April 2-8, 2020. Setting: Regions with different disease prevalence included two nations [the United States (US, high) and Australia (AU, low)] and two cities [New York (NY, high) and Los Angeles (LA, low)]. Participants: For adults 18 years or older residing in specified regions, eligible respondents were empaneled until representative quotas were reached for age, gender, and either race and ethnicity (US, NY, LA) or ancestry (AU), matching the 2010 US or 2016 AU census. Of 8718 eligible potential respondents, 5573 (response rate, 63.9%) completed surveys (US: 3010; NY: 507; LA: 525; AU: 1531). The median age was 47 years (range, 18-89); 3039 (54.5%) were female. Exposure: The prevalence of COVID-19 in each region (cumulative infections, deaths) as of April 8, 2020: US (458610, 15659), AU (5956, 45), NY (81803, 4571), LA (7530, 198). Main Outcomes Measures: Public compliance with and attitudes regarding government-imposed stay-at-home orders were evaluated and compared between regions. Results: Of 5573 total respondents, 4560 (81.8%) reported compliance with recommended quarantine or stay-at-home policies (range of samples, 75.5%-88.2%). Despite significant disruptions of social and work life, health, and behavior, 5022 respondents (90.1%) supported government-imposed stay-at-home orders (range of samples, 88.9%-93.1%). Of these, 90.8% believe orders should last at least three more weeks or until public health or government officials recommend, with such support spanning the political spectrum. Conclusions: Public compliance with stringent quarantine and stay-at-home policies was very high, in both highly-affected (US, NY) and minimally-affected regions (AU, LA). Despite extensive disruption of respondents' lives, the vast majority supported continuation of long-term government-imposed stay-at-home orders. These findings have important implications for policymakers grappling with the decision as to when to lift restrictions.