Age-Specific All-Cause Mortality Disparities by Race and Ethnicity During the COVID-19 Pandemic (preprint)

BACKGROUND. The end of the public health emergency provides an opportunity to fully describe disparities during the Covid-19 pandemic. METHODS. In this retrospective cohort analysis of US deaths during the Covid-19 public health emergency (March 2020-April 2023), all-cause excess mortality and years of potential life lost (YPLL) were calculated by race or ethnicity overall and by age groups (ages <25 years, 25-64 years, [≥]65 years). Temporal correlations with Covid-19-specific mortality were measured. RESULTS. >1.38 million all-cause excess deaths and ~23 million corresponding YPLL occurred during the pandemic. Had the rate of excess mortality observed among the White population been observed among the total population, >252,300 (18%) fewer excess deaths, and >5,192,000 fewer (22%) YPLL would have occurred. The highest excess mortality rates were among the American Indian/Alaska Native (AI/AN, 822 per 100,000; ~405,700 YPLL) and the Black (549 per 100,000; ~4,289,200 YPLL) populations. The highest relative increase in mortality was observed in the AI/AN population (1.34; 95% CI 1.31-1.37), followed by Hispanic (1.31; 95% CI 1.27-1.34), Native Hawaiian or Other Pacific Islander (1.24; 95% CI 1.21-1.27), Asian (1.20; 95% CI 1.18-1.20), Black (1.20; 95% CI 1.18-1.22) and White (1.12; 95% CI 1.09-1.15) populations. Greater disparities occurred among children and adults <65 years. CONCLUSIONS. Excess mortality occurred in all groups during the Covid-19 pandemic, with disparities by race and ethnicity, especially in younger and middle-aged populations. >252,000 and 5.2 million fewer YPLL would have been observed had increases in mortality among the total population been similar to the White population.

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.

An estimate of pediatric lives saved due to non-pharmacologic interventions during the early COVID-19 pandemic (preprint)

The net effect of the pandemic mitigation strategies on childhood mortality is not known. During the first year of the COVID-19 pandemic, mitigation policies and behaviors were widespread, and although vaccinations and effective treatments were not yet widely available, the risk of death from SARS-CoV-2 infection was low. In that first year, there was a 7% decrease in medical ("natural causes") mortality among children ages 0-9 during the first pandemic year (5% among infants <1 year and 15% among children ages 1-9) in the United States, resulting in an estimated 1,488 deaths due to medical causes averted among children ages 0-9, and 1,938 deaths averted over 24 months. The usual expected surge in winter medical deaths, particularly among children ages >1 year was absent. However, smaller increases in external ("non-natural causes") mortality were also observed during the study period, which decreased the overall number of pediatric deaths averted during both years and the pandemic period. In total, 1,468 fewer all-cause pediatric deaths than expected occurred in the United States during the first 24 months of the COVID-19 pandemic.

State-Level Excess Mortality in US Adults During the Delta and Omicron Waves of COVID-19 (preprint)

Introduction The US has continued to see excess mortality through the Delta and Omicron periods. We sought to quantify excess mortality on a state level and calculate potential deaths averted if all states matched the excess mortality rates of those with the 10 lowest excess mortality rates. Methods Observational cohort, US and state-level data. Expected monthly deaths were modeled using pre-pandemic US and state-level data (2015-2020). Mortality data was accessed from CDC public reporting. Results We find that during the Delta and Omicron waves, the US recorded over 596,000 excess deaths. 60% of the nation's total excess mortality during these periods could have been averted if all states had excess mortality rates equal to those with the 10 lowest excess mortality rates. Conclusion With large differences in excess mortality across US states in our 15-month study period, we note that a significant portion of deaths could have been averted with higher vaccination rates, policies and other behaviors.

Excess Mortality in the Vaccination Era in the United States, By State and 6-Month Period (preprint)

Introduction The US continued to record all-cause excess mortality after the rollout of vaccines. We sought to quantify excess mortality by state and compare these rates to primary series vaccination completion levels. Methods Observational cohort, US and state-level data. Expected monthly deaths were modeled using pre-pandemic US and state-level data (2015-2020). Mortality data was accessed from CDC public reporting. Results We find that in a two-year period since the rollout of vaccines, the US recorded >874,000 excess deaths. Vaccination rates and excess mortality were most strongly correlated in first two periods before the Omicron variant. Conclusion The association between vaccination and lower excess mortality rates was strongest in 2021 and early 2022, prior to high population rates of infection-acquired immunity. The findings underscore the benefits of the rapid vaccination rollout campaign and the continued need to boost at-risk populations.

Two years of COVID-19: Excess mortality by age, region, gender, and race/ethnicity in the United States during the COVID-19 pandemic, March 1, 2020, through February 28, 2022 (preprint)

Introduction Excess mortality does not depend on labeling the cause of death and is an accurate representation of the pandemic population-level effects. A comprehensive evaluation of all-cause excess mortality in the United States during the first two years of the COVID-19 pandemic, stratified by age, sex, region, and race/ethnicity can provide insight into the extent and variation in harm. Methods With Centers for Disease Control and Prevention (CDC)/National Center for Health Statistics (NCHS) data from 2014-2022, we use seasonal autoregressive integrated moving averages (sARIMA) to estimate excess mortality during the pandemic, defined as the difference between the number of observed and expected deaths. We continuously correct monthly expected deaths to reflect the decreased population owing to cumulative pandemic-associated excess deaths recorded. We calculate excess mortality for the total US population, and by age, sex, US census division, and race/ethnicity. Results From March 1, 2020, through February 28, 2022, there were 1.17 million excess deaths in the United States. Overall, mortality was 20% higher than expected during the study period. Of the excess deaths, 799,477 (68%) were among residents aged 65 and older. The largest relative increase in all-cause mortality was 27% among adults ages 18-49 years. Males comprised most of the excess mortality (57%), but this predominance declined with age. A higher relative mortality occurred among non-Hispanic American Indian/Alaskan Native, non-Hispanic Black, non-Hispanic Native Hawaiian and Other Pacific Islander, Hispanic people. Excess mortality differed by region; the highest rates were in the South, including in the population ages ≥65 years. Excess mortality rose and fell contemporaneously with COVID-19 waves. Conclusion In the first two years of the pandemic, the US experienced 1.17 million excess deaths, with greater relative increases in all-cause mortality among men, in American Indian/Alaskan Native, Black and Hispanic people, and the South.

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.

Racial and ethnic disparities in COVID-19 vaccinations in the United States during the booster rollout. (preprint)

Background: We sought to quantify whether there were statistically significant disparities along race and ethnicity lines during the early rollout of Covid-19 vaccine booster doses in the United States. We also studied whether such disparities replicated or widened disparities that had already been observed during the initial series rollout as of 2 months earlier (Janssen) or 6 months earlier (Pfizer-BioNTech or Moderna), which comprised the booster-eligible population. Methods: This cross-sectional study of US adults (ages [≥]18 years) used public data from US Centers for Disease Control and Prevention. The observed shares of vaccine doses for each race and ethnicity were compared to the expected shares, predicted based upon the compositions of the booster-eligible and initial series-eligible populations. Results: As of November 16, 2021, 123.5 million US adults were eligible for a booster dose of either the Pfizer-BioNTech, Moderna, or Janssen vaccines. Of these, 21.7 million had received a booster dose, among whom race and ethnicity information was available for 18.8 million booster recipients. A statistically significant higher share of Non-Hispanic White and Non-Hispanic Multiple/Other race individuals had received a booster vaccination than projected based on the composition of the booster-eligible population. A statistically significant lower share of Hispanic, Non-Hispanic American Indian/Alaskan Native, Non-Hispanic Asian, Non-Hispanic Black, and Non-Hispanic Native Hawaiian/Other Pacific Islander individuals had received a booster vaccination than expected based on the booster-eligible population. A secondary analysis of the booster-eligible population found that some of these disparities had already occurred at the time of the initial series. However, the booster campaign widened all of those disparities and added new disparities for Non-Hispanic American Indian/Alaskan Native and Non-Hispanic Native Hawaiian/Other Pacific Islander individuals. Conclusion: Disparities in Covid-19 vaccine administration on race and ethnicity lines occurred during the initial series rollout in the US. However, these disparities were not merely replicated but widened by the early booster rollout.

Absence of Excess Mortality in a Highly Vaccinated Population During the Initial Covid-19 Delta Period. (preprint)

BackgroundAll-cause excess mortality (the number of deaths that exceed projections in any period) has been widely reported during the Covid-19 pandemic. Whether excess mortality has occurred during the Delta wave is less well understood. MethodsWe performed an observational study using data from the Massachusetts Department of Health. Five years of US Census population data and CDC mortality statistics were applied to a seasonal autoregressive integrated moving average (sARIMA) model to project the number of expected deaths for each week of the pandemic period, including the Delta period (starting in June 2021, extending through August 28th 2021, for which mortality data are >99% complete). Weekly Covid-19 cases, Covid-19-attributed deaths, and all-cause deaths are reported. County-level excess mortality during the vaccine campaign are also reported, with weekly rates of vaccination in each county that reported 100 or more all-cause deaths during any week included in the study period. ResultsAll-cause mortality was not observed after March 2021, by which time over 75% of persons over 65 years of age in Massachusetts had received a vaccination. Fewer deaths than expected (which we term deficit mortality) occurred both during the summer of 2020, the spring of 2021 and during the Delta wave (beginning June 13, 2021 when Delta isolates represented >10% of sequenced cases). After the initial wave in the spring of 2020, more Covid-19-attributed deaths were recorded that all-cause excess deaths, implying that Covid-19 was misattributed as the underlying cause, rather than a contributing cause of death in some cases. ConclusionIn a state with high vaccination rates, excess mortality has not been recorded during the Delta period. Deficit mortality has been recorded during this period.

Accuracy of Computable Phenotyping Approaches for SARS-CoV-2 Infection and COVID-19 Hospitalizations from the Electronic Health Record (preprint)

ABSTRACT Objective Real-world data have been critical for rapid-knowledge generation throughout the COVID-19 pandemic. To ensure high-quality results are delivered to guide clinical decision making and the public health response, as well as characterize the response to interventions, it is essential to establish the accuracy of COVID-19 case definitions derived from administrative data to identify infections and hospitalizations. Methods Electronic Health Record (EHR) data were obtained from the clinical data warehouse of the Yale New Haven Health System (Yale, primary site) and 3 hospital systems of the Mayo Clinic (validation site). Detailed characteristics on demographics, diagnoses, and laboratory results were obtained for all patients with either a positive SARS-CoV-2 PCR or antigen test or ICD-10 diagnosis of COVID-19 (U07.1) between April 1, 2020 and March 1, 2021. Various computable phenotype definitions were evaluated for their accuracy to identify SARS-CoV-2 infection and COVID-19 hospitalizations. Results Of the 69,423 individuals with either a diagnosis code or a laboratory diagnosis of a SARS-CoV-2 infection at Yale, 61,023 had a principal or a secondary diagnosis code for COVID-19 and 50,355 had a positive SARS-CoV-2 test. Among those with a positive laboratory test, 38,506 (76.5%) and 3449 (6.8%) had a principal and secondary diagnosis code of COVID-19, respectively, while 8400 (16.7%) had no COVID-19 diagnosis. Moreover, of the 61,023 patients with a COVID-19 diagnosis code, 19,068 (31.2%) did not have a positive laboratory test for SARS-CoV-2 in the EHR. Of the 20 cases randomly sampled from this latter group for manual review, all had a COVID-19 diagnosis code related to asymptomatic testing with negative subsequent test results. The positive predictive value (precision) and sensitivity (recall) of a COVID-19 diagnosis in the medical record for a documented positive SARS-CoV-2 test were 68.8% and 83.3%, respectively. Among 5,109 patients who were hospitalized with a principal diagnosis of COVID-19, 4843 (94.8%) had a positive SARS-CoV-2 test within the 2 weeks preceding hospital admission or during hospitalization. In addition, 789 hospitalizations had a secondary diagnosis of COVID-19, of which 446 (56.5%) had a principal diagnosis consistent with severe clinical manifestation of COVID-19 (e.g., sepsis or respiratory failure). Compared with the cohort that had a principal diagnosis of COVID-19, those with a secondary diagnosis had a more than 2-fold higher in-hospital mortality rate (13.2% vs 28.0%, P<0.001). In the validation sample at Mayo Clinic, diagnosis codes more consistently identified SARS-CoV-2 infection (precision of 95%) but had lower recall (63.5%) with substantial variation across the 3 Mayo Clinic sites. Similar to Yale, diagnosis codes consistently identified COVID-19 hospitalizations at Mayo, with hospitalizations defined by secondary diagnosis code with 2-fold higher in-hospital mortality compared to those with a primary diagnosis of COVID-19. Conclusions COVID-19 diagnosis codes misclassified the SARS-CoV-2 infection status of many people, with implications for clinical research and epidemiological surveillance. Moreover, the codes had different performance across two academic health systems and identified groups with different risks of mortality. Real-world data from the EHR can be used to in conjunction with diagnosis codes to improve the identification of people infected with SARS-CoV-2.

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.

Correcting excess mortality for pandemic-associated population decreases (preprint)

Objectives We identify a correction for excess mortality that takes the sudden unexpected changes in the size of the United States population into account. Design This is a weekly cross-sectional analysis of all-cause mortality since week 5, 2020. We describe and apply a simple correction that takes population changes into account in order to provide corrected weekly estimates of expected deaths for 2020 and 2021. Setting The United States. Participants All United States residents. Interventions The covid-19 pandemic. Main outcome measures Expected and excess mortality for the United States during the covid-19 period. Results As of week 53, 2020 (ending January 2, 2021), approximately >10,200 more excess deaths have occurred in the United States than could be detected if expected deaths projections were not amended to reflect population decreases during 2020. The figure is projected to rise to >12,600 (>600 weekly) by week 5, 2021. Assuming recent excess mortality and pandemic-associated visa reductions continue until the earliest time herd immunity could be approached resulting from a combination of infections and vaccinations (week 17, 2021), if point estimates of expected deaths are not corrected, expected deaths will be overestimated (and therefore potential excess mortality underestimated) by ∼43,000 during 2021, or >53,300 since the outbreak of the pandemic measurement period (beginning week 5, 2020). By late December 2021, weekly expected death differences are projected to approach 1,000 per week. Conclusions Current models measuring excess mortality should be revised immediately so that public health officials do not lose the ability to detect ongoing excess mortality as the population changes continue to compound, lowering the number of weekly expected deaths. A similar approach should be used in the middle and late phases of all future pandemics.

Mortality among Adults Ages 25-44 in the United States During the COVID-19 Pandemic. (preprint)

Abstract: Introduction: Coronavirus disease-19 (COVID-19) has caused a marked increase in all-cause deaths in the United States, mostly among adults aged 65 and older. Because younger adults have far lower infection fatality rates, less attention has been focused on the mortality burden of COVID-19 in this demographic. Methods: We performed an observational cohort study using public data from the National Center for Health Statistics at the United States Centers for Disease Control and Prevention, and CDC Wonder. We analyzed all-cause mortality among adults ages 25-44 during the COVID-19 pandemic in the United States. Further, we compared COVID-19-related deaths in this age group during the pandemic period to all drug overdose deaths and opioid-specific overdose deaths in each of the ten Health and Human Services (HHS) regions during the corresponding period of 2018, the most recent year for which data are available. Results: As of September 6, 2020, 74,027 all-cause deaths occurred among persons ages 25-44 years during the period from March 1st to July 31st, 2020, 14,155 more than during the same period of 2019, a 23% relative increase (incident rate ratio 1.23; 95% CI 1.21-1.24), with a peak of 30% occurring in May (IRR 1.30; 95% CI 1.27-1.33). In HHS Region 2 (New York, New Jersey), HHS Region 6 (Arkansas, Louisiana, New Mexico, Oklahoma, Texas), and HHS Region 9 (Arizona, California, Hawaii, Nevada), COVID-19 deaths exceeded 2018 unintentional opioid overdose deaths during at least one month. Combined, 2,450 COVID-19 deaths were recorded in these three regions during the pandemic period, compared to 2,445 opioid deaths during the same period of 2018. Meaning: We find that COVID-19 has likely become the leading cause of death (surpassing unintentional overdoses) among young adults aged 25-44 in some areas of the United States during substantial COVID-19 outbreaks.

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 mortality during the early pandemic period in the United States. (preprint)

Importance: The coronavirus disease 2019 (COVID-19) outbreak has been associated with decreases in acute myocardial infarction diagnoses (AMI) and admissions in the United States. Whether this affected heart disease deaths is unknown. Objective: To determine whether changes in heart disease deaths occurred during the early pandemic period in the US, we analyzed areas without large COVID-19 outbreaks. This isolated the effect of decreased healthcare-seeking behavior during the early outbreak. Design, Setting, and Participants: We performed an observational study of heart disease-specific mortality using National Center for Health Statistics data (NCHS). Weekly provisional counts were disaggregated by jurisdiction of occurrence during 2019 and 2020 for all-cause deaths, COVID-19 deaths, and heart disease deaths. For the primary analysis, jurisdictions were included if; 1) There was no all-cause excess mortality during the early pandemic period (weeks 14-17, 2020); 2) The completeness of that data was estimated by NCHS to be >97% as of July 22, 2020, and; 3) Decreases in emergency department (ED) visits occurred during the study period. We compared heart disease death rates during the early pandemic period with corresponding weeks in 2019 and a pre-pandemic control period of 2020 as a sensitivity analysis. Incident rate and rate ratios were calculated. Exposure: The US COVID-19 outbreak. Main Outcomes and Measures: Incidence of heart disease deaths. Results: Twelve states met the primary inclusion criteria, capturing 747,375,188 person-weeks for the early pandemic period and 740,987,984 person-weeks for the 2019 control period. The mean incidence rate (per 100,000 person-weeks) for heart disease in states without excess deaths during the early pandemic period was 3.95 (95% CI 3.83 to 4.06) versus 4.19 (95% CI 4.14 to 4.23) during the corresponding period in 2019. The incident rate ratio (2020/2019) was 0.91 (95% CI 0.87 to 0.97). No state recorded an increase from either the corresponding period in 2019 or the 2020 pre-pandemic control period. Two states recorded fewer heart disease deaths. Conclusions and Relevance: This observational study found a decrease in heart disease deaths during the early US outbreak in regions without significant COVID-19 burdens, despite decreases in ED utilization. Long term follow-up data are needed.

Seroprevalence of SARS-CoV-2-Specific IgG Antibodies Among Adults Living in Connecticut Between March 1 and June 1, 2020: Post-Infection Prevalence (PIP) Study (preprint)

BackgroundA seroprevalence study can estimate the percentage of people with SARS-CoV-2 antibodies in the general population, however, most existing reports have used a convenience sample, which may bias their estimates. MethodsWe sought a representative sample of Connecticut residents, aged [≥]18 years and residing in non-congregate settings, who completed a survey between June 4 and June 23, 2020 and underwent serology testing for SARS-CoV-2-specific IgG antibodies between June 10 and July 29, 2020. We also oversampled non-Hispanic Black and Hispanic subpopulations. We estimated the seroprevalence of SARS-CoV-2-specific IgG antibodies and the prevalence of symptomatic illness and self-reported adherence to risk mitigation behaviors among this population. ResultsOf the 567 respondents (mean age 50 [{+/-}17] years; 53% women; 75% non-Hispanic White individuals) included at the state-level, 23 respondents tested positive for SARS-CoV-2-specific antibodies, resulting in weighted seroprevalence of 4.0 (90% confidence interval [CI] 2.0-6.0). The weighted seroprevalence for the oversampled non-Hispanic Black and Hispanic populations was 6.4% (90% CI 0.9-11.9) and 19.9% (90% CI 13.2-26.6), respectively. The majority of respondents at the state-level reported following risk mitigation behaviors: 73% avoided public places, 75% avoided gatherings of families or friends, and 97% wore a facemask, at least part of the time. ConclusionsThese estimates indicate that the vast majority of people in Connecticut lack antibodies against SARS-CoV-2 and there is variation by race/ethnicity. There is a need for continued adherence to risk mitigation behaviors among Connecticut residents to prevent resurgence of COVID-19 in this region.

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.

Association of Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers with the Risk of Hospitalization and Death in Hypertensive Patients with Coronavirus Disease-19 (preprint)

BackgroundWhether angiotensin-converting enzyme (ACE) Inhibitors and angiotensin receptor blockers (ARBs) mitigate or exacerbate SARS-CoV-2 infection remains uncertain. In a national study, we evaluated the association of ACE inhibitors and ARB with coronavirus disease-19 (COVID-19) hospitalization and mortality among individuals with hypertension. MethodsAmong Medicare Advantage and commercially insured individuals, we identified 2,263 people with hypertension, receiving [≥]1 antihypertensive agents, and who had a positive outpatient SARS-CoV-2 test (outpatient cohort). In a propensity score-matched analysis, we determined the association of ACE inhibitors and ARBs with the risk of hospitalization for COVID-19. In a second study of 7,933 individuals with hypertension who were hospitalized with COVID-19 (inpatient cohort), we tested the association of these medications with in-hospital mortality. We stratified all our assessments by insurance groups. ResultsAmong individuals in the outpatient and inpatient cohorts, 31.9% and 29.8%, respectively, used ACE inhibitors and 32.3% and 28.1% used ARBs. In the outpatient study, over a median 30.0 (19.0 - 40.0) days after testing positive, 12.7% were hospitalized for COVID-19. In propensity score-matched analyses, neither ACE inhibitors (HR, 0.77 [0.53, 1.13], P = 0.18), nor ARBs (HR, 0.88 [0.61, 1.26], P = 0.48), were significantly associated with risk of hospitalization. In analyses stratified by insurance group, ACE inhibitors, but not ARBs, were associated with a significant lower risk of hospitalization in the Medicare group (HR, 0.61 [0.41, 0.93], P = 0.02), but not the commercially insured group (HR: 2.14 [0.82, 5.60], P = 0.12; P-interaction 0.09). In the inpatient study, 14.2% died, 59.5% survived to discharge, and 26.3% had an ongoing hospitalization. In propensity score-matched analyses, neither use of ACE inhibitor (0.97 [0.81, 1.16]; P = 0.74) nor ARB (1.15 [0.95, 1.38]; P = 0.15) was associated with risk of in-hospital mortality, in total or in the stratified analyses. ConclusionsThe use of ACE inhibitors and ARBs was not associated with the risk of hospitalization or mortality among those infected with SARS-CoV-2. However, there was a nearly 40% lower risk of hospitalization with the use of ACE inhibitors in the Medicare population. This finding merits a clinical trial to evaluate the potential role of ACE inhibitors in reducing the risk of hospitalization among older individuals, who are at an elevated risk of adverse outcomes with the infection.

Evaluation of the Anticipated Burden of COVID-19 on Hospital-Based Healthcare Services Across the United States (preprint)

Background: Coronavirus disease-19 (COVID-19) is a global pandemic, with the potential to infect nearly 60% of the population. The anticipated spread of the virus requires an urgent appraisal of the capacity of US healthcare services and the identification of states most vulnerable to exceeding their capacity Methods: In the American Hospital Association survey for 2018, a database of US community hospitals, we identified total inpatient beds, adult intensive care unit (ICU) beds, and airborne isolation rooms across all hospitals in each state of continental US. The burden of COVID-19 hospitalizations was estimated based on a median hospitalization duration of 12 days and was evaluated for a 30-day reporting period. Results: At 5155 US community hospitals across 48 states in the contiguous US and Washington DC, there were a total of 788,032 inpatient beds, 68,280 adult ICU beds, and 44,222 isolation rooms. The median daily bed occupancy was 62.8% (IQR 58.1%, 66.6%) across states. Nationally, for every 10,000 individuals, there are 24.2 inpatient beds, 2.8 adult ICU beds, and 1.4 isolation beds. There is a 3-fold variation in the number of inpatient beds available across the US, ranging from 16.4 per 10,000 in Oregon to 47 per 10,000 in South Dakota. There was also a similar 3-fold variation in available or non-occupied beds, ranging from 4.7 per 10,000 in Connecticut through 18.3 per 10,000 in North Dakota. The availability of ICU beds is low nationally, ranging from 1.4 per 10,000 in Nevada to 4.7 per 10000 in Washington DC. Hospitalizations for COVID-19 in a median 0.2% (IQR 0.2 %, 0.3%) of state population, or 1.4% of state's older adults (1.0%, 1.9%) will require all non-occupied beds. Further, a median 0.6% (0.5%, 0.8%) of state population, or 3.9% (3.1%, 4.6%) of older individuals would require 100% of inpatient beds. Conclusion: The COVID-19 pandemic is likely to overwhelm the limited number of inpatient and ICU beds for the US population. Hospitals in half of US states would exceed capacity if less than 0.2% of the state population requires hospitalization in any given month.