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1.
Ann Intern Med ; 175(3): 352-361, 2022 Mar.
Article in English | MEDLINE | ID: covidwho-1742919

ABSTRACT

BACKGROUND: Little is known about real-world COVID-19 vaccine effectiveness (VE) in racially and ethnically diverse, elderly populations with high comorbidity burden. OBJECTIVE: To determine the effectiveness of messenger RNA COVID-19 vaccines. DESIGN: Target trial emulation study comparing newly vaccinated persons with matched unvaccinated controls. SETTING: U.S. Department of Veterans Affairs health care system. PARTICIPANTS: Among persons receiving care in the Veterans Affairs health care system (n = 5 766 638), those who received at least 1 dose of the Moderna or Pfizer-BioNTech COVID-19 vaccine from 11 December 2020 to 25 March 2021 (n = 2 099 871) were matched to unvaccinated controls in a 1:1 ratio according to demographic, clinical, and geographic characteristics. INTERVENTION: Follow-up for SARS-CoV-2 infection or SARS-CoV-2-related death, defined as death within 30 days of infection, began after the vaccination date or an identical index date for the matched unvaccinated controls and continued until up to 30 June 2021. MEASUREMENTS: Vaccine effectiveness against SARS-CoV-2 infection or SARS-CoV-2-related death. RESULTS: Vaccinated and unvaccinated groups were well matched; both were predominantly male (92.9% vs. 93.4%), had advanced age (mean, 68.7 years in both groups), had diverse racial and ethnic distribution (for example, Black: 17.3% vs. 17.0%, Hispanic: 6.5% vs. 6.1%), and had substantial comorbidity burden. Vaccine effectiveness 7 or more days after the second vaccine dose was 69% (95% CI, 67% to 70%) against SARS-CoV-2 infection and 86% (CI, 82% to 89%) against SARS-CoV-2-related death and was similar when follow-up was extended to 31 March versus 30 June. Vaccine effectiveness against infection decreased with increasing age and comorbidity burden. LIMITATION: Predominantly male population and lack of data on SARS-CoV-2 variants. CONCLUSION: In an elderly, diverse, high-comorbidity population, COVID-19 VE against infection was substantially lower than previously reported, but VE against death was high. Complementary infection mitigation efforts remain important for pandemic control, even with vaccination. PRIMARY FUNDING SOURCE: U.S. Department of Veterans Affairs.


Subject(s)
COVID-19 , SARS-CoV-2 , Aged , COVID-19/epidemiology , COVID-19/prevention & control , COVID-19 Vaccines , Delivery of Health Care , Female , Humans , Male , Vaccination
2.
American Journal of Public Health ; 112:S36-S38, 2022.
Article in English | ProQuest Central | ID: covidwho-1695673

ABSTRACT

CAUSE OF DEATH REPORTING Even if immediate and underlying CODs are entered accurately according to these standards, important information is lost in the process that leads to the "leading causes of death" reported by the Centers for Disease Control and Prevention (CDC). [...]when regional vital statistics offices share death certificate data with the CDC, the CDC's computerized algorithm selects one diagnosis as the underlying COD, and this is the diagnosis that is reported in CDC mortality statistics.4 Other diagnoses appear in separate COD fields in mortality databases but in no particular order, and they are not included in the vast majority of mortality statistics. [...]in this example, the death might be attributed to cancer orto something else entirely. Another recent study of opioidrelated deaths among "cancer survivors" (which the authors did not explicitly define, but they cited an article that Included In Its definition Individuals with active disease and those with a more remote history of cancer) highlights the potential for loss of data on acute events when a serious Illness and an acute event coexist at the time of death.6 The authors found that decedents with opioid-related primary CODs were less likely to have a cancer diagnosis Included as a contributing COD than would be expected.

3.
PLoS Med ; 18(10): e1003807, 2021 10.
Article in English | MEDLINE | ID: covidwho-1484840

ABSTRACT

BACKGROUND: We examined whether key sociodemographic and clinical risk factors for Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection and mortality changed over time in a population-based cohort study. METHODS AND FINDINGS: In a cohort of 9,127,673 persons enrolled in the United States Veterans Affairs (VA) healthcare system, we evaluated the independent associations of sociodemographic and clinical characteristics with SARS-CoV-2 infection (n = 216,046), SARS-CoV-2-related mortality (n = 10,230), and case fatality at monthly intervals between February 1, 2020 and March 31, 2021. VA enrollees had a mean age of 61 years (SD 17.7) and were predominantly male (90.9%) and White (64.5%), with 14.6% of Black race and 6.3% of Hispanic ethnicity. Black (versus White) race was strongly associated with SARS-CoV-2 infection (adjusted odds ratio [AOR] 5.10, [95% CI 4.65 to 5.59], p-value <0.001), mortality (AOR 3.85 [95% CI 3.30 to 4.50], p-value < 0.001), and case fatality (AOR 2.56, 95% CI 2.23 to 2.93, p-value < 0.001) in February to March 2020, but these associations were attenuated and not statistically significant by November 2020 for infection (AOR 1.03 [95% CI 1.00 to 1.07] p-value = 0.05) and mortality (AOR 1.08 [95% CI 0.96 to 1.20], p-value = 0.21) and were reversed for case fatality (AOR 0.86, 95% CI 0.78 to 0.95, p-value = 0.005). American Indian/Alaska Native (AI/AN versus White) race was associated with higher risk of SARS-CoV-2 infection in April and May 2020; this association declined over time and reversed by March 2021 (AOR 0.66 [95% CI 0.51 to 0.85] p-value = 0.004). Hispanic (versus non-Hispanic) ethnicity was associated with higher risk of SARS-CoV-2 infection and mortality during almost every time period, with no evidence of attenuation over time. Urban (versus rural) residence was associated with higher risk of infection (AOR 2.02, [95% CI 1.83 to 2.22], p-value < 0.001), mortality (AOR 2.48 [95% CI 2.08 to 2.96], p-value < 0.001), and case fatality (AOR 2.24, 95% CI 1.93 to 2.60, p-value < 0.001) in February to April 2020, but these associations attenuated over time and reversed by September 2020 (AOR 0.85, 95% CI 0.81 to 0.89, p-value < 0.001 for infection, AOR 0.72, 95% CI 0.62 to 0.83, p-value < 0.001 for mortality and AOR 0.81, 95% CI 0.71 to 0.93, p-value = 0.006 for case fatality). Throughout the observation period, high comorbidity burden, younger age, and obesity were consistently associated with infection, while high comorbidity burden, older age, and male sex were consistently associated with mortality. Limitations of the study include that changes over time in the associations of some risk factors may be affected by changes in the likelihood of testing for SARS-CoV-2 according to those risk factors; also, study results apply directly to VA enrollees who are predominantly male and have comprehensive healthcare and need to be confirmed in other populations. CONCLUSIONS: In this study, we found that strongly positive associations of Black and AI/AN (versus White) race and urban (versus rural) residence with SARS-CoV-2 infection, mortality, and case fatality observed early in the pandemic were ameliorated or reversed by March 2021.


Subject(s)
COVID-19/mortality , Population Surveillance , Rural Population/trends , United States Department of Veterans Affairs/trends , Urban Population/trends , Aged , COVID-19/diagnosis , COVID-19/economics , Cohort Studies , Female , Humans , Male , Middle Aged , Mortality/trends , Population Surveillance/methods , Risk Factors , Socioeconomic Factors , United States/epidemiology
4.
J Subst Abuse Treat ; 133: 108492, 2022 02.
Article in English | MEDLINE | ID: covidwho-1253265

ABSTRACT

BACKGROUND: Telemedicine-delivered buprenorphine (tele-buprenorphine) can potentially increase access to buprenorphine for patients with opioid use disorder (OUD), especially during the COVID-19 pandemic, but we know little about use in clinical care. METHODS: This study was a retrospective national cohort study of veterans diagnosed with opioid use disorder (OUD) receiving buprenorphine treatment from the Veterans Health Administration (VHA) in fiscal years 2012-2019. The study examined trends in use of tele-buprenorphine and compared demographic and clinical characteristics in patients who received tele-buprenorphine versus those who received in-person treatment only. RESULTS: Utilization of tele-buprenorphine increased from 2.29% of buprenorphine patients in FY2012 (n = 187) to 7.96% (n = 1352) in FY2019 in VHA veterans nationally. Compared to patients receiving only in-person care, tele-buprenorphine patients were less likely to be male (AOR = 0.85, 95% CI: 0.73-0.98) or Black (AOR = 0.54, 95% CI: 0.45-0.65). Tele-buprenorphine patients were more likely to be treated in community-based outpatient clinics rather than large medical centers (AOR = 2.91, 95% CI: 2.67-3.17) and to live in rural areas (AOR = 2.12, 95% CI:1.92-2.35). The median days supplied of buprenorphine treatment was 722 (interquartile range: 322-1459) among the tele-buprenorphine patients compared to 295 (interquartile range: 67-854) among patients who received treatment in-person. CONCLUSIONS: Use of telemedicine to deliver buprenorphine treatment in VHA increased 3.5-fold between 2012 and 2019, though overall use remained low prior to COVID-19. Tele-buprenorphine is a promising modality especially when treatment access is limited. However, we must continue to understand how practitioners and patient are using telemedicine and how these patients' outcomes compare to those using in-person care.


Subject(s)
Buprenorphine , COVID-19 , Opioid-Related Disorders , Telemedicine , Veterans , Buprenorphine/therapeutic use , Cohort Studies , Humans , Male , Opiate Substitution Treatment , Opioid-Related Disorders/drug therapy , Pandemics , Retrospective Studies , SARS-CoV-2
5.
EClinicalMedicine ; 32: 100741, 2021 Feb.
Article in English | MEDLINE | ID: covidwho-1071273

ABSTRACT

BACKGROUND: Suicides by any method, plus 'nonsuicide' fatalities from drug self-intoxication (estimated from selected forensically undetermined and 'accidental' deaths), together represent self-injury mortality (SIM)-fatalities due to mental disorders or distress. SIM is especially important to examine given frequent undercounting of suicides amongst drug overdose deaths. We report suicide and SIM trends in the United States of America (US) during 1999-2018, portray interstate rate trends, and examine spatiotemporal (spacetime) diffusion or spread of the drug self-intoxication component of SIM, with attention to potential for differential suicide misclassification. METHODS: For this state-based, cross-sectional, panel time series, we used de-identified manner and underlying cause-of-death data for the 50 states and District of Columbia (DC) from CDC's Wide-ranging Online Data for Epidemiologic Research. Procedures comprised joinpoint regression to describe national trends; Spearman's rank-order correlation coefficient to assess interstate SIM and suicide rate congruence; and spacetime hierarchical modelling of the 'nonsuicide' SIM component. FINDINGS: The national annual average percentage change over the observation period in the SIM rate was 4.3% (95% CI: 3.3%, 5.4%; p<0.001) versus 1.8% (95% CI: 1.6%, 2.0%; p<0.001) for the suicide rate. By 2017/2018, all states except Nebraska (19.9) posted a SIM rate of at least 21.0 deaths per 100,000 population-the floor of the rate range for the top 5 ranking states in 1999/2000. The rank-order correlation coefficient for SIM and suicide rates was 0.82 (p<0.001) in 1999/2000 versus 0.34 (p = 0.02) by 2017/2018. Seven states in the West posted a ≥ 5.0% reduction in their standardised mortality ratios of 'nonsuicide' drug fatalities, relative to the national ratio, and 6 states from the other 3 major regions a >6.0% increase (p<0.05). INTERPRETATION: Depiction of rising SIM trends across states and major regions unmasks a burgeoning national mental health crisis. Geographic variation is plausibly a partial product of local heterogeneity in toxic drug availability and the quality of medicolegal death investigations. Like COVID-19, the nation will only be able to prevent SIM by responding with collective, comprehensive, systemic approaches. Injury surveillance and prevention, mental health, and societal well-being are poorly served by the continuing segregation of substance use disorders from other mental disorders in clinical medicine and public health practice. FUNDING: This study was partially funded by the National Centre for Injury Prevention and Control, US Centers for Disease Control and Prevention (R49CE002093) and the US National Institute on Drug Abuse (1UM1DA049412-01; 1R21DA046521-01A1).

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