COVID-19 vaccine acceptance and associated factors among people living with HIV in the Middle East and North Africa region

AJOL : Background: Identifying coronavirus disease 2019 (COVID-19) vaccine acceptance and associated factors among people living with HIV (PLHIV) in the Middle East and North Africa region is important to meet the need for broad-scale vaccination against COVID-19. Objectives: To investigate the COVID-19 vaccine acceptance rate and factors among PLHIV in the Middle East and North Africa region. Method: An online cross-sectional survey was conducted among PLHIV currently living in Egypt, Tunisia and Saudi Arabia between March 2021 and August 2021. Results: Of the 540 respondents, 19.3% reported already being vaccinated against COVID-19 (n = 104), 32.0% responded 'definitely yes' (n = 173), and 13.3% responded 'probably yes' (n = 72) for intention to receive a COVID-19 vaccine, with an overall COVID-19 vaccine acceptance rate of 64.6% among PLHIV in the region. The most significant predictors of COVID-19 vaccine acceptance included feeling less worried about COVID-19 transmission post- vaccination (221.0% higher odds), and believing the disease is vaccine-preventable (160.0% higher odds). Reported barriers to COVID-19 vaccine acceptance include concerns about vaccine effectiveness and belief that HIV medications protect against COVID-19 transmission, living in a rural area and reporting less-frequent engagement with HIV care. Nine out of 10 participants reported that the chances of them getting COVID-19 vaccine would increase if given adequate information and if their doctor recommended it. Conclusion: Findings of the study can help researchers, health officials, and other health system actors understand the predictors and barriers to COVID-19 vaccine acceptance reported by PLHIV. This understanding could inform the future planning of interventions tailored to PLHIV

State-specific fertility rate changes across the USA following the first two waves of COVID-19.

STUDY QUESTION: How did the first two coronavirus disease 2019 (COVID-19) waves affect fertility rates in the USA? SUMMARY ANSWER: States differed widely in how their fertility rates changed following the COVID-19 outbreak and these changes were influenced more by state-level economic, racial, political, and social factors than by COVID-19 wave severity. WHAT IS KNOWN ALREADY: The outbreak of the COVID-19 pandemic contributed to already declining fertility rates in the USA, but not equally across states. Identifying drivers of differential changes in fertility rates can help explain variations in demographic shifts across states in the USA and motivate policies that support families in general, not only during crises. STUDY DESIGN, SIZE, DURATION: This is an ecological study using state-level data from 50 US states and the District of Columbia (n = 51). The study period extends from 2020 to 2021 with historical data from 2016 to 2019. We identified Wave 1 as the first apex for each state after February 2020 and Wave 2 as the second apex, during Fall/Winter 2020-2021. PARTICIPANTS/MATERIALS, SETTING, METHODS: State-level COVID-19 wave severity, defined as case acceleration during each 3-month COVID-19 wave (cases/100 000 population/month), was derived from 7-day weekly moving average COVID-19 case rates from the US Centers for Disease Control and Prevention (CDC). State-level fertility rate changes (change in average monthly fertility rate/100 000 women of reproductive age (WRA)/year) were derived from the CDC Bureau of Vital Statistics and from 2020 US Census and University of Virginia 2021 population estimates 9 months after each COVID-19 wave. We performed univariate analyses to describe national and state-level fertility rate changes following each wave, and simple and multivariable linear regression analyses to assess the relation of COVID-19 wave severity and other state-level characteristics with fertility rate changes. MAIN RESULTS AND THE ROLE OF CHANCE: Nationwide, fertility dropped by 17.5 births/month/100 000 WRA/year following Wave 1 and 9.2 births/month/100 000 WRA/year following Wave 2. The declines following Wave 1 were largest among majority-Democrat, more non-White states where people practiced greater social distancing. Greater COVID-19 wave severity was associated with steeper fertility rate decline post-Wave 1 in simple regression, but the association was attenuated when adjusted for other covariates. Adjusting for the economic impact of the pandemic (hypothesized mediator) also attenuated the effect. There was no relation between COVID-19 wave severity and fertility rate change following Wave 2. LIMITATIONS, REASONS FOR CAUTION: Our study harnesses state-level data so individual-level conclusions cannot be inferred. There may be residual confounding in our multivariable regression and we were underpowered to detect some effects. WIDER IMPLICATIONS OF THE FINDINGS: The COVID-19 pandemic initially impacted the national fertility rate but, overall, the fertility rate rebounded to the pre-pandemic level following Wave 2. Consistent with prior literature, COVID-19 wave severity did not appear to predict fertility rate change. Economic, racial, political, and social factors influenced state-specific fertility rates during the pandemic more than the severity of the outbreak alone. Future studies in other countries should also consider whether these factors account for internal heterogeneity when examining the impact of the COVID-19 pandemic and other crises on fertility. STUDY FUNDING/COMPETING INTEREST(S): L.G.K. received funding from the National Institute of Environmental Health Sciences (R00ES030403), M.C. from the National Science Foundation Graduate Research Fellowship Program (20-A0-00-1005789), and M.L. and E.S. from the National Institute of Environmental Health Sciences (R01ES032808). None of the authors have competing interests. TRIAL REGISTRATION NUMBER: N/A.

The Psychological Science Accelerator's COVID-19 rapid-response dataset.

In response to the COVID-19 pandemic, the Psychological Science Accelerator coordinated three large-scale psychological studies to examine the effects of loss-gain framing, cognitive reappraisals, and autonomy framing manipulations on behavioral intentions and affective measures. The data collected (April to October 2020) included specific measures for each experimental study, a general questionnaire examining health prevention behaviors and COVID-19 experience, geographical and cultural context characterization, and demographic information for each participant. Each participant started the study with the same general questions and then was randomized to complete either one longer experiment or two shorter experiments. Data were provided by 73,223 participants with varying completion rates. Participants completed the survey from 111 geopolitical regions in 44 unique languages/dialects. The anonymized dataset described here is provided in both raw and processed formats to facilitate re-use and further analyses. The dataset offers secondary analytic opportunities to explore coping, framing, and self-determination across a diverse, global sample obtained at the onset of the COVID-19 pandemic, which can be merged with other time-sampled or geographic data.

The Modified and Extended Hospital Elder Life Program: A remote model of care to expand delirium prevention.

BACKGROUND: Delirium is a common complication of hospitalization and is associated with poor outcomes. Multicomponent delirium prevention strategies such as the Hospital Elder Life Program (HELP) have proven effective but rely on face-to-face intervention protocols and volunteer staff, which was not possible due to restrictions during the COVID-19 pandemic. We developed the Modified and Extended Hospital Elder Life Program (HELP-ME), an innovative adaptation of HELP for remote and/or physically distanced applications. METHODS: HELP-ME protocols were adapted from well-established multicomponent delirium prevention strategies and were implemented at four expert HELP sites. Each site contributed to the protocol modifications and compilation of a HELP-ME Operations Manual with standardized protocols and training instructions during three expert panel working groups. Implementation was overseen and monitored during seven learning sessions plus four coaching sessions from January 8, 2021, through September 24, 2021. Feasibility of implementing HELP-ME was measured by protocol adherence rates. Focus groups were conducted to evaluate the acceptability, provide feedback, and identify facilitators and barriers to implementation. RESULTS: A total of 106 patients were enrolled across four sites, and data were collected for 214 patient-days. Overall adherence was 82% (1473 completed protocols/1798 patient-days), achieving our feasibility target of >75% overall adherence. Individual adherence rates ranged from 55% to 96% across sites for the individual protocols. Protocols with high adherence rates included the nursing delirium protocol (96%), nursing medication review (96%), vision (89%), hearing (87%), and orientation (88%), whereas lower adherence occurred with fluid repletion (64%) and range-of-motion exercises (55%). Focus group feedback was generally positive for acceptability, with recommendations that an optimal approach would be hybrid, balancing in-person and remote interventions for potency and long-term sustainability. CONCLUSIONS: HELP-ME was fully implemented at four HELP sites, demonstrating feasibility and acceptability. Testing hybrid approaches and evaluating effectiveness is recommended for future work.

Consumer experience of mental health services during the COVID-19 pandemic: Evidence from an Australian mental health system

COVID-19 has increased the need for mental health care but disrupted its delivery. We examined impacts of the first year of the COVID-19 pandemic on consumer experience of NSW hospital and community mental health services, compared to their pre-COVID baseline. We also examined whether increased telehealth use was associated with changes in the quantity or experience of community mental health care. Data were 73,488 Your Experience of Service (YES) surveys from state mental health services in New South Wales (NSW), Australia, grouped into three periods: pre-COVID (January 2018 to March 2020), early-COVID (April to June 2020) and stable-COVID (July to December 2020). Experience scores were compared using mixed effects ordinal logistic regression. Supplementary questions on telehealth and community care (n=621) were examined by multinomial logistic regression. Experience scores improved significantly during the early-COVID period for community consumers and during the stable-COVID period for hospital consumers. Of community clients, 78% received some or all care by telehealth. Positive experience was more likely when most or all care was by telehealth and the amount of care increased. A reduced quantity of care, regardless of care modality, was the strongest predictor of worse experience. Increased service provision and telehealth support were well received over the first year of the pandemic. When contact hours are reduced due to COVID-19 risk mitigation strategies, it is vital to provide alternative methods of care such as telephone, or internet support, rather than just reducing face to face contact hours. © The Author(s), 2022.

COVID-19 vaccine acceptance and associated factors among people living with HIV in the Middle East and North Africa region.

Background: Identifying coronavirus disease 2019 (COVID-19) vaccine acceptance and associated factors among people living with HIV (PLHIV) in the Middle East and North Africa region is important to meet the need for broad-scale vaccination against COVID-19. Objectives: To investigate the COVID-19 vaccine acceptance rate and factors among PLHIV in the Middle East and North Africa region. Method: An online cross-sectional survey was conducted among PLHIV currently living in Egypt, Tunisia and Saudi Arabia between March 2021 and August 2021. Results: Of the 540 respondents, 19.3% reported already being vaccinated against COVID-19 (n = 104), 32.0% responded 'definitely yes' (n = 173), and 13.3% responded 'probably yes' (n = 72) for intention to receive a COVID-19 vaccine, with an overall COVID-19 vaccine acceptance rate of 64.6% among PLHIV in the region. The most significant predictors of COVID-19 vaccine acceptance included feeling less worried about COVID-19 transmission post-vaccination (221.0% higher odds), and believing the disease is vaccine-preventable (160.0% higher odds). Reported barriers to COVID-19 vaccine acceptance include concerns about vaccine effectiveness and belief that HIV medications protect against COVID-19 transmission, living in a rural area and reporting less-frequent engagement with HIV care. Nine out of 10 participants reported that the chances of them getting COVID-19 vaccine would increase if given adequate information and if their doctor recommended it. Conclusion: Findings of the study can help researchers, health officials, and other health system actors understand the predictors and barriers to COVID-19 vaccine acceptance reported by PLHIV. This understanding could inform the future planning of interventions tailored to PLHIV.

COVID-19 vaccine acceptance and associated factors among people living with HIV in the Middle East and North Africa region

Background Identifying coronavirus disease 2019 (COVID-19) vaccine acceptance and associated factors among people living with HIV (PLHIV) in the Middle East and North Africa region is important to meet the need for broad-scale vaccination against COVID-19. Objectives To investigate the COVID-19 vaccine acceptance rate and factors among PLHIV in the Middle East and North Africa region. Method An online cross-sectional survey was conducted among PLHIV currently living in Egypt, Tunisia and Saudi Arabia between March 2021 and August 2021. Results Of the 540 respondents, 19.3% reported already being vaccinated against COVID-19 (n = 104), 32.0% responded ‘definitely yes’ (n = 173), and 13.3% responded ‘probably yes’ (n = 72) for intention to receive a COVID-19 vaccine, with an overall COVID-19 vaccine acceptance rate of 64.6% among PLHIV in the region. The most significant predictors of COVID-19 vaccine acceptance included feeling less worried about COVID-19 transmission post-vaccination (221.0% higher odds), and believing the disease is vaccine-preventable (160.0% higher odds). Reported barriers to COVID-19 vaccine acceptance include concerns about vaccine effectiveness and belief that HIV medications protect against COVID-19 transmission, living in a rural area and reporting less-frequent engagement with HIV care. Nine out of 10 participants reported that the chances of them getting COVID-19 vaccine would increase if given adequate information and if their doctor recommended it. Conclusion Findings of the study can help researchers, health officials, and other health system actors understand the predictors and barriers to COVID-19 vaccine acceptance reported by PLHIV. This understanding could inform the future planning of interventions tailored to PLHIV.

GROWTH IN EMERGENCY SELF-HARM PRESENTATIONS IN YOUNG PEOPLE IN NSW: COMPARING TRENDS BEFORE AND SINCE THE COVID-19 FIRST WAVE

Background: Self-harm presentations in young people have increased internationally over the last decade. The COVID-19 pandemic has the potential to worsen these trends. Objectives: To describe trends in Emergency Department (ED) self-harm presentation for young people in New South Wales (NSW) before and since the COVID-19 pandemic. Methods: We studied presentations to NSW EDs by 10- to 24-year-olds for self-harm or suicidal ideation. Interrupted time series compared annualised growth before COVID-19 (2015-20) and since (March 2020-June 2021). Subgroup analyses compared age group, gender, triage category, rurality and disadvantage. Time series decomposition identified long-term, seasonal and shortterm trends. Findings: Self-harm presentations by young people in NSW increased by 8.9% per annum (pa) pre-COVID. Growth accelerated to 19.9% pa post-COVID, specifically due to increased presentations by females aged 13-17 (up 47.1% pa, from 290 per 10,000 in 2019 to 466 per 10,000 in 2021). Self-harm presentations in males aged 10-24 did not increase post-COVID (105.4 per 10,000 in 2019, 109.8 per 10,000 in 2021) despite growing 9.9% pa before COVID. Presentation rates accelerated significantly in socially advantaged areas and in non-aboriginal youth. Conclusion: ED self-harm presentations by NSW young people grew steadily before COVID. Growth has increased since COVID specifically for adolescent girls, but not among adolescent males. Surprisingly, the largest post-COVID increases in annual growth occurred in socio-economically advantaged and urban regions and non- Aboriginal young people. The COVID-19 pandemic appears to have added new challenges, particularly in females in the developmentally critical early adolescent and teenage years.

VACCINE-PREVENTABLE HOSPITALISATION IN MENTAL HEALTH SERVICE USERS: A BOOSTER IS NEEDED

Background: COVID-19 has highlighted the essential role of vaccination in preventing illness, modifying illness severity and averting hospital care. Mental health (MH) service users have low vaccination rates for many conditions, but evidence on individual and health system impacts is limited. Methods: The NSW Mental Health Living Longer links population-wide data from NSW hospitals and community MH services. We calculated hospitalisation rates and incidence rate ratios for vaccine-preventable conditions including hepatitis, influenza and pneumococcal pneumonia, comparing MH service users to other NSW residents. Rates were standardised for age and socio-economic disadvantage. Results: Over 12 months there were 14,530 vaccine preventable admissions in NSW, occupying 94,241 bed days. MH service users had a more than fourfold increased risk of admission for vaccine-preventable conditions (adjusted incidence rate ratio = 4.7;95% confidence interval = [4.5, 5.0]), with the highest relative risk in people aged 40-65 years. One-quarter of total excess potentially preventable bed days in MH service users were due to vaccine-preventable conditions, including respiratory illness. MH service users comprised 2.3% of the NSW population but contributed nearly 15% of vaccine-preventable bed days. Additional analyses will be presented examining specific conditions, demographic and clinical subgroups. Conclusion: Low vaccination rates have serious impacts for MH service users. Strategies to overcome barriers and support vaccination uptake could have quick and substantial benefits for individuals and health systems. Supporting uptake of COVID-19 vaccination will be essential to avoid further amplifying health inequalities for people using MH services.

MENTAL HEALTH DATA, MODELLING AND THE PANDEMIC RESPONSE

Background: Dr Sara is the Director of InforMH, the unit responsible for mental health (MH) data collection, analysis and reporting for NSW Health. Objectives: To discuss how NSW Health used data and modelling during the pandemic to understand population vulnerabilities, changes in demand and MH outcomes. Methods: The pandemic response has demanded new data sources and methods. Population vulnerabilities were assessed using census data, employment vulnerability indices and data on natural disasters. Weekly reporting tools were implemented using crisis line, Medicare, community, emergency department (ED) and hospital data supported by new Commonwealth-State data sharing agreements. The NSW Suicide Monitoring System was implemented along with enhanced methods for detecting self-harm in ED data. The 'Your Experience of Service' survey was supplemented with questions specific to telehealth and COVID-19. Findings: The pandemic had high potential effects in disadvantaged communities with high pre-COVID selfharm rates and recent natural disasters. Fluctuating COVID-19 rates and restrictions have been strongly linked to community distress and service contacts. Distress and self-harm have increased in young people, but effects differed by gender and socio-economic status. For some consumer groups, greater telehealth led to more frequent and convenient contact and more positive experience. NSW Suicide rates do not appear significantly increased. Conclusion: The pandemic highlights the need for comprehensive, timely, linked and accessible data on populations and MH services. Progress has been made but more work is needed to monitor long-term impacts on self-harm and suicide, vaccination rates and long-term impacts on physical health and mortality of people using MH services.

PEAK OF THE PANDEMIC: THE NEW SOUTH WALES MENTAL HEALTH EXPERIENCE

Background: New South Wales (NSW) experienced a significant outbreak of COVID-19 which sent greater Sydney into a 115-day lockdown from June to October 2021. System-wide changes were required as inpatient mental health (MH) units managed outbreaks and new infection control measures were introduced more broadly. The MH impacts of the lockdown itself were also highly publicised with reference to the looming 'shadow pandemic'. Objectives: To discuss the NSW MH response to the COVID-19 pandemic from multiple perspectives and describe the ways in which MH services re-oriented to meet the needs of the population. Explore the lessons learnt and consider the NSW experience within the national and global context. Methods: A team of clinicians who worked together during the peak of the pandemic provide firsthand accounts and discuss case studies from the outbreak. International literature related to the psychological impacts of the COVID-19 pandemic is reviewed. Findings: The health system response during the pandemic required creativity, agility and teamwork. The impacts were not uniform, and responses needed to be tailored to the local context. Some disparities can be understood in terms of pre-existing social vulnerabilities. Advocating for the MH patient population was a cornerstone of the response. Conclusion: The challenges faced during the outbreak provided enormous opportunity to think creatively about the care of people with mental illness. These insights can be taken forward beyond the pandemic. We continue to learn lessons as COVID-19 transitions from pandemic to endemic status.

CREATING SOLUTIONS FOR THE CHILD AND ADOLESCENT MENTAL HEALTH PANDEMIC

Background: Increasing demand for Child and Adolescent Mental Health services over the last decade, in Australia and across the Western world, has been compounded by the COVID-19 pandemic. Reports and inquiries within Australia show the need for long-term creative solutions. Objectives: To explore strategic solutions for the CAMHS response to the pandemic during the recovery phase and into the future. Methods: First, the changing patterns of mental health presentations in children and adolescents will be presented, including analysis of NSW-wide data. In NSW new child and adolescent mental health response teams have been developed;the collaborative approaches to designing the new service, and the challenges associated, will be presented. The response presents serious challenges for workforce development, given long-standing specialist mental health worker shortages. Training and workforce strategy will be discussed, followed by a presentation on the continuum of care for children and young people that demonstrates the need for better integration across health and psychosocial services. Audience discussion is encouraged during the symposium, to explore potential creative solutions. Findings: Trends that emerged during the pandemic demonstrate the need for reform of the mental health care system for children, adolescents and young people. The problem is complex and requires collaboration and sharing of ideas that can be applied bi-nationally. Conclusion: The pandemic created opportunities to improve CAMHS services. An understanding of trends in presentations informs the multi-faceted strategic response to the mental health recovery. Planning is key to improving collaborative and integrated approaches for the future design of CAMHS.

Cumulative climatic stressors strangles marine aquaculture: ancillary effects of COVID 19 on Spanish mariculture. (Special issue: Impact of COVID-19 on the aquaculture sector and supply-chains.)

Marine aquaculture takes advantage of marine ecosystem services to produce goods that can be relevant from a food security point of view. However, this activity is subject to multiple stressors as the ones exerted by global climate change. Local stressed conditions due to environmental drivers may be exacerbated by the COVID19 pandemic crisis. In this paper we analyze the pre-COVID-19 situation in two Spanish regions with the highest aquaculture production, Galicia and the Valencian Community. The incidence of storms, heat waves and mussel farming closure were analyzed, and surveys were used to define the perception of producers in terms of economic problems derived from COVID-19 and synergistic environmental concerns. Also the temporal trend of mussel production was analyzed. Spanish marine aquaculture has been intensively subjected to climatic stressors that made it more vulnerable to COVID-19, showing some weakness in terms of production as can be seen in mussel production and fresh consumption. Anyway, extensive aquaculture and aquaculture developed by Integrated Multi-Trophic Aquaculture (IMTA) was reported as somewhat more resilient to the impact of COVID-19. In order to ensure the environmental and economic sustainability of marine aquaculture - under a future uncertain pandemic scenario - our outcomes underline the need for more resilient adaptation programs and recovery plans taking into account the climate change effects.

From research to practice: a model for clinical implementation of evidence-based outpatient interventions for eating disorders.

BACKGROUND: A question frequently raised in the field is whether evidence-based interventions have adequate translational capacity for delivery in real-world settings where patients are presumed to be more complex, clinicians less specialized, and multidisciplinary teams less coordinated. The dual purpose of this article is to (a) outline a model for implementing evidence-driven, outpatient treatments for eating disorders in a non-academic clinical setting, and (b) report indicators of feasibility and quality of care. MAIN BODY: Since our inception (2015), we have completed nearly 1000 phone intakes, with first-quarter 2021 data suggesting an increase in the context of COVID-19. Our caseload for the practice currently consists of approximately 200 active patients ranging from 6 to 66 years of age. While the center serves a transdiagnostic and trans-developmental eating disorder population, modal concerns for which we receive inquiries are Anorexia Nervosa and Avoidant Restrictive Food Intake Disorder, with the most common age range for prospective patients spanning childhood through late adolescence/emerging adulthood; correspondingly, the modal intervention employed is Family-based treatment. Our team for each case consists, at a minimum, of a primary internal therapist and a physician external to the center. SHORT CONCLUSION: We will describe our processes of recruiting, training and coordinating team members, of ensuring ongoing fidelity to evidence-based interventions, and of training the next generation of clinicians. Future research will focus on a formal assessment of patient outcomes, with comparison to benchmark outcomes from randomized controlled trials.

A question frequently raised in the eating disorders field is whether treatments that were developed and tested in research environments can achieve the same results in real-world clinical settings, where patients' diagnoses are presumed to be more complex, clinicians less specialized, and multi-professional care teams less coordinated. The purpose of this article is to outline a model for implementing evidence-driven, outpatient treatments for eating disorders in non-academic clinical settings, specifically private practices and specialty programs. We describe the philosophy, infrastructure, training processes, personnel, and procedures utilized to optimize care delivery and to create accountability for both scientifically-adherent practice and positive patient outcomes. We also outline ways to be producers­not just consumers­of research in the private sector, and to train the next generation of scientifically-informed eating disorder specialists, all with the goal to bridge the research-practice divide.

Maternal Perceived Stress During the COVID-19 Pandemic: Pre-Existing Risk Factors and Concurrent Correlates in New York City Women.

Objective: We examined whether pre-pandemic mental health and sociodemographic characteristics increased the susceptibility of pregnant women and mothers of young children to stress in the early months of the COVID-19 pandemic. Methods: Between April and August 2020, we surveyed 1560 women participating in a sociodemographically diverse birth cohort in New York City. Women reported their perceived stress, resiliency, and financial, familial/societal, and health-related concerns. We extracted pre-pandemic information from questionnaires and electronic health records. Results: Pre-pandemic history of depression, current financial difficulties, and COVID-19 infection were the main risk factors associated with high perceived stress. Being Hispanic and having higher resiliency scores and preexisting social support were protective against high perceived stress. Major contributors to current perceived stress were financial and familial/societal factors related to the COVID-19 pandemic. Among pregnant women, changes to prenatal care were common, as were changes to experiences following birth among postpartum women and difficulties in arranging childcare among mothers of young children. Conclusion: Our findings suggest that major risk factors of higher stress during the pandemic were similar to those of other major traumatic events.

The stakeholder's perception of socio-economic impacts generated by COVID-19 pandemic within the Italian aquaculture systems.

From the beginning of March 2020 and for the following two and half months, many European countries comprising Italy have been forced into an unprecedented lockdown, allowing only the opening of essential economic activities needed to address the problems created by the pandemic (e.g. sanitary, food provision). Like many sectors of the Italian economy, aquaculture has also slowed down due to the ongoing emergency and the consequent closure of business. In our study we provided a 'snapshot' of the socio-economic effects of the lockdown on the aquaculture sector in Italy, immediately following the adoption of the COVID-19 restrictions as they were perceived by the workers. Although it was surveyed for a short-time period, differences in perception have been detected both in relation to the type of aquaculture as well as to the geographic locations where farms were placed, partially reflecting the economic gaps already existing within the northern and the southern part of the country before the lockdown.

Spontaneous muscle hematomas presenting with hemorrhagic shock in critically ill patients with SARSCoV-2 pneumonia

Background: Spontaneous muscle hematomas (SMH) are rare but potentially life-threatening. We report three patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia who developed hemorrhagic shock, due to large SMHs, during their intensive care unit stay. Case Presentation: All the patients were receiving mechanical ventilation and anticoagulation therapy with enoxaparin. The bleeding was located in the gluteal muscles in two of the patients and in the iliopsoas muscle with retroperitoneal extension in the other. Anemia and hemodynamic instability were the main signs;however, because of their gradual onset, they were initially confused with the anemia of the critically ill patient and sepsis related to secondary infections. All received conservative medical treatment, but unfortunately one patient died within hours of diagnosis. Conclusion: This report highlights that clinicians should also be alert to major spontaneous hemorrhage in patients with SARSCoV-2 infection. Since it is a novel disease, a possible association with bleeding events cannot be disregarded and, on the contrary, should be considered, particularly to determine the appropriate use of anticoagulation in this type of patients.