Estimates of SARS-CoV-2 Omicron BA.2 Subvariant Severity in New England.

Importance: The SARS-CoV-2 Omicron subvariant, BA.2, may be less severe than previous variants; however, confounding factors make interpreting the intrinsic severity challenging. Objective: To compare the adjusted risks of mortality, hospitalization, intensive care unit admission, and invasive ventilation between the BA.2 subvariant and the Omicron and Delta variants, after accounting for multiple confounders. Design, Setting, and Participants: This was a retrospective cohort study that applied an entropy balancing approach. Patients in a multicenter inpatient and outpatient system in New England with COVID-19 between March 3, 2020, and June 20, 2022, were identified. Exposures: Cases were assigned as being exposed to the Delta (B.1.617.2) variant, the Omicron (B.1.1.529) variant, or the Omicron BA.2 lineage subvariants. Main Outcomes and Measures: The primary study outcome planned before analysis was risk of 30-day mortality. Secondary outcomes included the risks of hospitalization, invasive ventilation, and intensive care unit admissions. Results: Of 102 315 confirmed COVID-19 cases (mean [SD] age, 44.2 [21.6] years; 63 482 women [62.0%]), 20 770 were labeled as Delta variants, 52 605 were labeled as the Omicron B.1.1.529 variant, and 28 940 were labeled as Omicron BA.2 subvariants. Patient cases were excluded if they occurred outside the prespecified temporal windows associated with the variants or had minimal longitudinal data in the Mass General Brigham system before COVID-19. Mortality rates were 0.7% for Delta (B.1.617.2), 0.4% for Omicron (B.1.1.529), and 0.3% for Omicron (BA.2). The adjusted odds ratio of mortality from the Delta variant compared with the Omicron BA.2 subvariants was 2.07 (95% CI, 1.04-4.10) and that of the original Omicron variant compared with the Omicron BA.2 subvariant was 2.20 (95% CI, 1.56-3.11). For all outcomes, the Omicron BA.2 subvariants were significantly less severe than that of the Omicron and Delta variants. Conclusions and Relevance: In this cohort study, after having accounted for a variety of confounding factors associated with SARS-CoV-2 outcomes, the Omicron BA.2 subvariant was found to be intrinsically less severe than both the Delta and Omicron variants. With respect to these variants, the severity profile of SARS-CoV-2 appears to be diminishing after taking into account various factors including therapeutics, vaccinations, and prior infections.

The Impact of the COVID-19 Pandemic on Food Insecurity in Northern New England Primary and Prenatal Care Settings.

INTRODUCTION AND OBJECTIVE: Food insecurity (FI) is associated with adverse health outcomes across the lifespan. Primary care and prenatal practices can identify and address FI among patients through screening and interventions. It is unclear how practices and communities responded to FI during the COVID-19 pandemic, and how the pandemic may have impacted practices' FI strategies. We aimed to understand how practices providing primary care or prenatal care in northern New England experienced changes in FI during the COVID-19 pandemic. METHODS: We conducted a web-based survey of clinicians and staff from 43 unique practices providing primary care or prenatal care in northern New England. RESULTS: Most practices (59.5%) reported at least 1 new food program in the practice or community since the pandemic began. Practices reporting new practice- or community-based food programs were more likely to be rural, federally qualified health centers, and have greater confidence in practice and community capacity to address FI (chi-square tests, P < .05). CONCLUSION: Results suggest that practices and surrounding communities in northern New England responded to FI during the pandemic by increasing food support programs. Future work is needed to examine the impact of food programs initiated during the pandemic and determine optimal strategies for practices to address FI among patients.

COVID-19's Perceived Impact on Primary Care in New England: A Qualitative Study.

BACKGROUND: COVID-19 impacted primary care delivery, as clinicians and practices implemented changes to respond to the pandemic while safely caring for patients. This study aimed to understand clinicians' perceptions of the positive and negative impacts of COVID-19 on primary care in New England. METHODS: This qualitative interview study was conducted from October through December 2020. Participants included 22 physicians and 2 nurse practitioners practicing primary care in New England. Data were thematically coded and analyzed deductively and inductively using content analysis. RESULTS: Through qualitative content analysis, 4 areas were identified in which clinicians perceived that COVID-19 impacted primary care: 1) bureaucracy, 2) leadership, 3) telemedicine and patient care, and 4) clinician work-life. Our findings suggest that the positive impacts of COVID-19 included changes in primary care delivery, new leadership opportunities for clinicians, flexible access to care for patients via telemedicine, and a better work-life balance for clinicians. Respondents identified negative impacts related to sustaining pandemic-inspired changes, the inability for some populations to access care via telemedicine, and the rapid implementation of telemedicine causing frustration for clinicians. CONCLUSIONS: Understanding clinician perspectives on how primary care transformed to respond to COVID-19 helps to identify beneficial pandemic-related changes that should be sustained and ideas for improvement that will support patient care and clinician engagement.

Comparative transmissibility of SARS-CoV-2 variants Delta and Alpha in New England, USA.

The SARS-CoV-2 Delta variant rose to dominance in mid-2021, likely propelled by an estimated 40%-80% increased transmissibility over Alpha. To investigate if this ostensible difference in transmissibility is uniform across populations, we partner with public health programs from all six states in New England in the United States. We compare logistic growth rates during each variant's respective emergence period, finding that Delta emerged 1.37-2.63 times faster than Alpha (range across states). We compute variant-specific effective reproductive numbers, estimating that Delta is 63%-167% more transmissible than Alpha (range across states). Finally, we estimate that Delta infections generate on average 6.2 (95% CI 3.1-10.9) times more viral RNA copies per milliliter than Alpha infections during their respective emergence. Overall, our evidence suggests that Delta's enhanced transmissibility can be attributed to its innate ability to increase infectiousness, but its epidemiological dynamics may vary depending on underlying population attributes and sequencing data availability.

Traumatic Injury Under COVID-19 Stay-at-Home Advisory: Experience of a New England Trauma Center.

BACKGROUND: With the onset of the COVID-19 pandemic and subsequent widespread stay-at-home advisories throughout early 2020, hospitals have noticed a decrease in illnesses unrelated to COVID-19. However, the impact on traumatic injury is relatively unknown. This study aims to characterize patterns of trauma during the COVID-19 pandemic at a Level I Trauma Center. MATERIALS & METHODS: A retrospective review was performed of adult trauma patients from March to June, in the years 2018 through 2020. Primary outcome was the number of trauma activations (volume). Secondary outcomes included activation level, mechanism of injury, mortality rate, and length of stay, and other demographic background. Trauma patterns of the 2018 and 2019 periods were combined as historical control, and compared to patterns of the biweekly-matched period of 2020. RESULTS: A total of 2,187 patients were included in analysis (Pre-COVID n = 1,572; COVID n = 615). Results were significant for decreased trauma volume but longer length of stay during COVID cohort, and for an increased proportion of males. No significant difference was found for other demographic variables, trauma mechanisms, or severity. Trauma volume patterns mirrored COVID rates in the state. CONCLUSIONS: Despite a decline in trauma volume, other trauma patterns including severity and mechanism remained unchanged during the COVID-19 period. The decreased volume was not associated with a markedly lower clinical workload, change in team structure, or provider coverage re-distribution. Our data suggests that trauma volume and severity remained high enough during COVID-19 peak to necessitate full staffing, which may provide guidance in the event of a pandemic resurgence.

A New England COVID-19 Registry of Patients With CNS Demyelinating Disease: A Pilot Analysis.

BACKGROUND AND OBJECTIVES: We sought to define the risk of severe coronavirus disease 2019 (COVID-19) infection requiring hospitalization in patients with CNS demyelinating diseases such as MS and the factors that increase the risk for severe infection to guide decisions regarding patient care during the COVID-19 pandemic. METHODS: A pilot cohort of 91 patients with confirmed or suspected COVID-19 infection from the Northeastern United States was analyzed to characterize patient risk factors and factors associated with an increased severity of COVID-19 infection. Univariate analysis of variance was performed using the Mann-Whitney U test or analysis of variance for continuous variables and the χ2 or Fisher exact test for nominal variables. Univariate and stepwise multivariate logistic regression identified clinical characteristics or symptoms associated with hospitalization. RESULTS: Our cohort demonstrated a 27.5% hospitalization rate and a 4.4% case fatality rate. Performance on Timed 25-Foot Walk before COVID-19 infection, age, number of comorbidities, and presenting symptoms of nausea/vomiting and neurologic symptoms (e.g., paresthesia or weakness) were independent risk factors for hospitalization, whereas headache predicted a milder course without hospitalization. An absolute lymphocyte count was lower in hospitalized patients during COVID-19 infection. Use of disease-modifying therapy did not increase the risk of hospitalization but was associated with an increased need for respiratory support. DISCUSSION: The case fatality and hospitalization rates in our cohort were similar to those found in MS and general population COVID-19 cohorts within the region. Hospitalization was associated with increased disability, age, and comorbidities but not disease-modifying therapy use.

Measuring Discharge Outcomes, Length of Stay, and Functional ADL Score During COVID-19 in Inpatient Rehabilitation Hospitals.

OBJECTIVE: To measure discharge disposition, length of stay (LOS), and functional activities of daily living (ADL) scores for patients admitted to acute inpatient rehabilitation hospitals (IRHs) during the coronavirus disease 2019 (COVID-19) pandemic and to compare these parameters with a period prior to the pandemic. DESIGN: Retrospective cohort study via systematic retrospective chart review of consecutive patients admitted to IRHs from January 1-February 19, 2020 (pre-COVID-19T), and COVID-19 time period/patients admitted from April 1, 2020-May 9, 2020 (COVID-19T). SETTING: System of 3 IRHs in the Northeastern United States. PARTICIPANTS: Pre-COVID-19T, n=739; COVID-19T, n=335, of whom n=139 were positive for COVID-19 (COVID+) and n=196 were negative (COVID-) (N=1074). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Discharge disposition, LOS, and functional ADL scores. RESULTS: COVID-19T patients were younger (P=.03) and less likely to be White (P=.03). These patients also had a higher case mix index (CMI; P<.01), longer acute care LOS (P<.01), and longer IRH LOS (P<.01). Patients who were COVID+ (during COVID-19T) were less likely to be White (P<.01), had lower CMI (P<.01), had higher admission and discharge functional ADL scores (P=.02, P<.01), and had longer acute care LOS compared with those who were COVID- (P<.01). There were no differences in discharge outcomes between pre-COVID-19T and COVID-19T cohorts (P=.75), including when stratified for COVID-19 status (P=.74). Functional ADL scores on admission and discharge were lower in COVID-19T than in pre-COVID-19T (P=.01), including when stratified for COVID-19 status though not significant (P=.06). CONCLUSIONS: There were no differences in discharge outcomes for any group. IRH LOS was significantly increased during the pandemic, but there were no statistically significant differences between the COVID+ and COVID- cohorts within COVID-19T. Functional ADL scores were significantly lower during COVID-19T, but COVID status was not a significant predictor. This suggests that COVID+ status was not a barrier to discharge or functional outcomes. This supports the importance of IRHs to restore function and discharge patients to home, even with a more medically complex COVID-19 pandemic population.

It's Not All Smoke and Mirrors: The Role of Social Norms, Alcohol Use, and Pandemic Partying in e-Cigarette Use During COVID-19.

BACKGROUND: E-cigarette use among college students is increasing. In the era of COVID-19, such usage is especially dangerous given that the virus can be deadly for those with impaired respiratory systems. A small but growing body of research suggests that social norms may predict e-cigarette use. However, one's perception of e-cigarette use behaviors (descriptive norms) and approval by peers (injunctive norms) have yet to be studied in college students. The overarching purpose of this study is to determine whether descriptive and injunctive norms for e-cigarette use contribute unique variance to past 30-day e-cigarette use. Methods: Using a sample of 191 students (138 women) surveyed from introductory-level courses at a university in the northeastern United States, we explored the relationships between student demographic characteristics, alcohol use, binge drinking, COVID-19 non-compliant party attendance on and off campus, and social norms with past 30-day e-cigarette use using sequential regression. Two models were utilized to determine if descriptive and injunctive e-cigarette use norms predicted e-cigarette use after controlling for demographic characteristics in the social norms model, and above and beyond demographics and COVID-19 noncompliant party attendance, alcohol use, and binge drinking in the party behaviors model. Results: The results demonstrated that descriptive and injunctive norms for e-cigarette use significantly predicted e-cigarette use in both models, controlling for all covariates. Conclusions/Importance: Findings highlight the importance of social norms in predicting e-cigarette use during the COVID-19 pandemic, identifying areas for prevention and intervention for public health officials and higher education administrators.

Secondary Use of COVID-19 Symptom Incidence Among Hospital Employees as an Example of Syndromic Surveillance of Hospital Admissions Within 7 Days.

Importance: Alternative methods for hospital occupancy forecasting, essential information in hospital crisis planning, are necessary in a novel pandemic when traditional data sources such as disease testing are limited. Objective: To determine whether mandatory daily employee symptom attestation data can be used as syndromic surveillance to estimate COVID-19 hospitalizations in the communities where employees live. Design, Setting, and Participants: This cohort study was conducted from April 2, 2020, to November 4, 2020, at a large academic hospital network of 10 hospitals accounting for a total of 2384 beds and 136 000 discharges in New England. The participants included 6841 employees who worked on-site at hospital 1 and lived in the 10 hospitals' service areas. Exposure: Daily employee self-reported symptoms were collected using an automated text messaging system from a single hospital. Main Outcomes and Measures: Mean absolute error (MAE) and weighted mean absolute percentage error (MAPE) of 7-day forecasts of daily COVID-19 hospital census at each hospital. Results: Among 6841 employees living within the 10 hospitals' service areas, 5120 (74.8%) were female individuals and 3884 (56.8%) were White individuals; the mean (SD) age was 40.8 (13.6) years, and the mean (SD) time of service was 8.8 (10.4) years. The study model had a MAE of 6.9 patients with COVID-19 and a weighted MAPE of 1.5% for hospitalizations for the entire hospital network. The individual hospitals had an MAE that ranged from 0.9 to 4.5 patients (weighted MAPE ranged from 2.1% to 16.1%). For context, the mean network all-cause occupancy was 1286 during this period, so an error of 6.9 is only 0.5% of the network mean occupancy. Operationally, this level of error was negligible to the incident command center. At hospital 1, a doubling of the number of employees reporting symptoms (which corresponded to 4 additional employees reporting symptoms at the mean for hospital 1) was associated with a 5% increase in COVID-19 hospitalizations at hospital 1 in 7 days (regression coefficient, 0.05; 95% CI, 0.02-0.07; P < .001). Conclusions and Relevance: This cohort study found that a real-time employee health attestation tool used at a single hospital could be used to estimate subsequent hospitalizations in 7 days at hospitals throughout a larger hospital network in New England.

Assessing the immediate impact of COVID-19 on surgical oncology practice: Experience from an NCI-designated Comprehensive Cancer Center in the Northeastern United States.

BACKGROUND: The effects of the coronavirus disease 2019 (COVID-19) pandemic on surgical oncology practice are not yet quantified. The aim of this study was to measure the immediate impact of COVID-19 on surgical oncology practice volume. METHODS: A retrospective study of patients treated at an NCI-Comprehensive Cancer Center was performed. "Pre-COVID" era was defined as January-February 2020 and "COVID" as March-April 2020. Primary outcomes were clinic visits and operative volume by surgical oncology subspecialty. RESULTS: Abouyt 907 new patient visits, 3897 follow-up visits, and 644 operations occurred during the study period. All subspecialties experienced significant decreases in new patient visits during COVID, though soft tissue oncology (Mel/Sarc), gynecologic oncology (Gyn/Onc), and endocrine were disproportionately affected. Telehealth visits increased to 11.4% of all visits by April. Mel/Sarc, Gyn/Onc, and Breast experienced significant operative volume decreases during COVID (25.8%, p = 0.012, 43.6% p < 0.001, and 41.9%, p < 0.001, respectively), while endocrine had no change and gastrointestinal oncology had a slight increase (p = 0.823) in the number of cases performed. CONCLUSIONS: The effects of the COVID-19 pandemic are wide-ranging within surgical oncology subspecialties. The addition of telehealth is a viable avenue for cancer patient care and should be considered in surgical oncology practice.

Regional Changes in Patterns of Stroke Presentation During the COVID-19 Pandemic.

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A Peer-Based Strategy to Overcome HPV Vaccination Inequities in Rural Communities: A Physical Distancing-Compliant Approach.

The human papilloma virus (HPV) vaccine is the world's first proven and effective vaccine to prevent cancers in males and females when administered pre-exposure. Like most of the US, barely half of Vermont teens are up-to-date with the vaccination, with comparable deficits in New Hampshire and Maine. The rates for HPV vaccine initiation and completion are as low as 33% in rural New England. Consequently, there is a compelling responsibility to communicate its importance to unvaccinated teenagers before their risk for infection increases. Messaging in rural areas promoting HPV vaccination is compromised by community-based characteristics that include access to appropriate medical care, poor media coverage, parental and peer influence, and skepticism of science and medicine. Current strategies are predominantly passive access to literature and Internet-based information. Evidence indicates that performance-based messaging can clarify the importance of HPV vaccination to teenagers and their parents in rural areas. Increased HPV vaccination will significantly contribute to the prevention of a broadening spectrum of cancers. Reducing rurality-based inequities is a public health priority. Development of a performance-based peer-communication intervention can capture a window of opportunity to provide increasingly effective and sustained HPV protection. An effective approach can be partnering rural schools and regional health teams with a program that is nimble and scalable to respond to public health policies and practices compliant with COVID-19 pandemic-related modifications on physical distancing and interacting in the foreseeable future.

Impacts of the COVID-19 pandemic on healthcare access among patients receiving medication for opioid use disorder.

BACKGROUND: The COVID-19 pandemic significantly altered treatment delivery for opioid treatment programs (OTPs) dispensing medications for opioid use disorder (MOUD). We aimed to identify patterns of substance use among MOUD patients and examine whether COVID-19-related impacts on access to healthcare varied across subgroups. METHODS: This analysis was embedded within a type 3 hybrid trial that enrolled patients across eight OTPs at the start of the pandemic. Enrolled patients reported on past-30 day use of multiple substances during their baseline assessment. Participants re-contacted in May-July 2020 completed a survey about COVID-19-related impacts on various life domains. Using latent class analysis we identified patient subgroups, and then examined group differences on a set of negative and positive COVID-19 impacts related to healthcare access. RESULTS: Of the 188 trial participants, 135 (72 %) completed the survey. Latent class analysis identified three MOUD patient subgroups: minimal use (class probability: 0.25); opioid use (class probability: 0.34); and polysubstance use (class probability: 0.41). Compared to the minimal use group, the polysubstance use group reported increased substance use and difficulty accessing sterile needles, naloxone, and preferred substance. The opioid use group reported increased substance use and difficulty accessing their preferred substance. There were no significant group differences related to accessing routine or specialized healthcare or medication; or paying attention to their health. CONCLUSIONS: During COVID-19, many MOUD patients reported challenges accessing care, particularly harm reduction services for patients with polysubstance use. Additional efforts, like providing wraparound support, may be necessary to serve the needs of MOUD patients.

Volunteerism during COVID-19.

Health care workers have been asked to do their part to make a difference and give back to their community. This personal reflection is a result of an experience as a medical reserve corps nurse volunteer for a local health department in the northeastern United States. Volunteering resulted in positive social and personal benefits for me. It inspired a sense of pride in helping others and knowing that someone's well-being may be enhanced. The individuals whom I spoke with via the phone appreciated the concern for their health, and some individuals seemed to enjoy the interaction with another person, possibly due to their isolation. Descriptions of interactions via phone calls with coronavirus positive individuals are provided that support the benefits of volunteering. Volunteerism has personal value in its ability to inspire someone to continue to make an impact. Volunteerism allowed me to give to others and to gain a sense of purpose.