Neighborhood Characteristics and COVID-19 Incidence and Mortality in Southeastern Pennsylvania.

The COVID-19 pandemic has differentially impacted people according to their race/ethnicity, socioeconomic status, and preexisting conditions. Public health surveillance efforts, especially those occurring early in the pandemic, did not gather nor report adequate individual-level demographic information to identify these differences, and thus, neighborhood-level characteristics were used to note striking disparities in the US. We sought to determine whether risk factors associated with COVID-19 incidence and mortality in five Southeastern Pennsylvania counties could be better understood by using neighborhood-level demographic data augmented with health, socioeconomic, and environmental characteristics derived from publicly available sources. Although we found that education level and age of residents were the most salient predictors of COVID-19 incidence and mortality, respectively, neighborhoods exhibited a high degree of segregation with multiple correlated factors, which limits the ability of neighborhood-level analysis to identify actionable factors underlying COVID-19 disparities.

Impact of the COVID-19 pandemic on cancer patients in western Pennsylvania: rural-urban disparities.

PURPOSE: Disparities in cancer care persist between patients living in rural versus urban areas. The COVID-19 pandemic may have impacted concerns related to care and personal health differently in rural cancer patients. Using survey data collected from cancer patients in western Pennsylvania, we examined pandemic-related distress, concerns related to cancer care, impact on personal health, and the extent to which these differed by urban-rural residence. METHODS: Patients filled out an initial survey in August-December 2020; a second survey was completed in March 2021. The following patient concerns related to the pandemic were evaluated: threat of COVID-19 to their health, pandemic-related distress, perceptions of cancer care, and vaccine hesitancy. Multivariable logistic regression models were used to examine relationships between these outcomes and urban-rural residence as well as patient-related factors, including anxiety symptoms and social support. RESULTS: The study sample included 1,980 patients, 17% resided in rural areas. COVID-19 represented a major or catastrophic threat to personal health for 39.7% of rural and 49.0% of urban patients (p = 0.0017). Patients with high general anxiety were 10-times more likely to experience pandemic-related distress (p < 0.001). In the follow-up survey (n = 983), vaccine hesitancy was twice as prevalent among rural patients compared to urban (p = 0.012). CONCLUSIONS: The extent to which perceptions of the threat of COVD-19 to personal health and vaccine hesitancy exacerbates rural-urban disparities in cancer care and prognosis warrants further study. Cancer patients may be vulnerable to heightened anxiety and distress triggered by the pandemic.

Changes in Urologic Cancer Surgical Volume and Length of Stay During the COVID-19 Pandemic in Pennsylvania.

Importance: Disruptions in cancer surgery during the COVID-19 pandemic led to widespread deferrals and cancellations, creating a surgical backlog that presents a challenge for health care institutions moving into the recovery phase of the pandemic. Objective: To describe patterns in surgical volume and postoperative length of stay for major urologic cancer surgery during the COVID-19 pandemic. Design, Setting, and Participants: This cohort study identified 24 001 patients 18 years or older from the Pennsylvania Health Care Cost Containment Council database with kidney cancer, prostate cancer, or bladder cancer who received a radical nephrectomy, partial nephrectomy, radical prostatectomy, or radical cystectomy between the first quarter (Q1) of 2016 and Q2 of 2021. Postoperative length of stay and adjusted surgical volumes were compared before and during the COVID-19 pandemic. Main Outcomes and Measures: The primary outcome was adjusted surgical volume for radical and partial nephrectomy, radical prostatectomy, and radical cystectomy during the COVID-19 pandemic. The secondary outcome was postoperative length of stay. Results: A total of 24 001 patients (mean [SD] age, 63.1 [9.4] years; 3522 women [15%], 19 845 White patients [83%], 17 896 living in urban areas [75%]) received major urologic cancer surgery between Q1 of 2016 and Q2 of 2021. Of these, 4896 radical nephrectomy, 3508 partial nephrectomy, 13 327 radical prostatectomy, and 2270 radical cystectomy surgical procedures were performed. There were no statistically significant differences in patient age, sex, race, ethnicity, insurance status, urban or rural status, or Elixhauser Comorbidity Index scores between patients who received surgery before and patients who received surgery during the pandemic. For partial nephrectomy, a baseline of 168 surgeries per quarter decreased to 137 surgeries per quarter in Q2 and Q3 of 2020. For radical prostatectomy, a baseline of 644 surgeries per quarter decreased to 527 surgeries per quarter in Q2 and Q3 of 2020. However, the likelihood of receiving radical nephrectomy (odds ratio [OR], 1.00; 95% CI, 0.78-1.28), partial nephrectomy (OR, 0.99; 95% CI, 0.77-1.27), radical prostatectomy (OR, 0.85; 95% CI, 0.22-3.22), or radical cystectomy (OR, 0.69; 95% CI, 0.31-1.53) was unchanged. Length of stay for partial nephrectomy decreased from baseline by a mean of 0.7 days (95% CI, -1.2 to -0.2 days) during the pandemic. Conclusions and Relevance: This cohort study suggests that partial nephrectomy and radical prostatectomy surgical volume decreased during the peak waves of COVID-19, as did postoperative length of stay for partial nephrectomy.

Genomic Epidemiology of Severe Acute Respiratory Syndrome Coronavirus 2 Transmission Among University Students in Western Pennsylvania.

BACKGROUND: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) control on college campuses is challenging given communal living and student social dynamics. Understanding SARS-CoV-2 transmission among college students is important for the development of optimal control strategies. METHODS: SARS-CoV-2 nasal swab samples were collected from University of Pittsburgh students for symptomatic testing and asymptomatic surveillance from August 2020 through April 2021 from 3 campuses. Whole-genome sequencing (WGS) was performed on 308 samples, and contact tracing information collected from students was used to identify transmission clusters. RESULTS: We identified 31 Pangolin lineages of SARS-CoV-2, the majority belonging to B.1.1.7 (Alpha) and B.1.2 lineages. Contact tracing identified 142 students (46%) clustering with each other; WGS identified 53 putative transmission clusters involving 216 students (70%). WGS identified transmissions that were missed by contact tracing. However, 84 cases (27%) could not be linked by either WGS or contact tracing. Clusters were most frequently linked to students residing in the same dormitory, off-campus roommates, friends, or athletic activities. CONCLUSIONS: The majority of SARS-CoV-2-positive samples clustered by WGS, indicating significant transmission across campuses. The combination of WGS and contact tracing maximized the identification of SARS-CoV-2 transmission on campus. WGS can be used as a strategy to mitigate, and further prevent transmission among students.

Geographic variations in opioid overdose patterns in Pennsylvania during the COVID-19 pandemic.

The convergence of the opioid epidemic and the COVID-19 pandemic has created new health challenges throughout the United States. Since the onset of the pandemic, media attention and scholarly research have drawn attention to the intersections of addiction and COVID-19. However, there remain few empirical studies that examine the direct impacts of the COVID-19 pandemic for opioid overdose patterns. Even fewer have integrated quantitative and qualitative methods to detail the place-specific dynamics shaping opioid overdose and addiction treatment during the COVID-19 pandemic. This article measures and maps change in the age-adjusted rate of opioid-related overdose incidents at the county level from 2018 to 2020. These analyses are combined with interviews conducted since December 2020 with public health providers in the state of Pennsylvania to identify the key factors influencing opioid misuse and transformations in addiction treatment practices.

Early influenza vaccination rates decline in children during the COVID-19 pandemic.

BACKGROUND: This investigation sought to determine whether early season rates of pediatric influenza vaccination changed in a season when there was a concurrent COVID-19 pandemic. METHODS: This study used cohort and cross sectional data from an academic primary care division in Southcentral Pennsylvania that serves approximately 17,500 patients across 4 practice sites. Early season (prior to November 1) vaccination rates in 2018, 2019 and 2020 were recorded for children, age 6 months to 17 years. To explore the impact of COVID-19 on vaccination, we fit a model with a logit link (estimated via generalized estimating equations to account for clustering by patient over time) on calendar year, adjusted for race, ethnicity, age, and insurance type. We examined interaction effects of demographic covariates with calendar year. RESULTS: Early vaccination rates were lower in 2020 (29.7%) compared with 2018 and 2019 (34.2% and 33.3%). After adjusting for covariates and accounting for clustering over time, the odds of early vaccination in 2020 were 19% lower compared to 2018 (OR 0.81, 95% CI: 0.78-0.85). In 2020, children with private insurance were more likely to receive early vaccination than in 2018 (OR 1.51, 95% CI: 1.04-1.15), whereas children with public insurance were less likely to receive early vaccination in 2020 than in 2018 (OR 0.62, 95% CI: 1.38-1.65). CONCLUSIONS: Early influenza vaccination rates declined in a year with a concurrent COVID-19 pandemic. Modeling that accounts for individual trends and demographic variables identified specific populations with lower odds of early vaccination in 2020. Additional research is needed to investigate whether the COVID-19 pandemic impacted parental intent to obtain the influenza vaccine, or introduced barriers to healthcare access.

Estimated Cases Averted by COVID-19 Digital Exposure Notification, Pennsylvania, USA, November 8, 2020-January 2, 2021.

We combined field-based data with mathematical modeling to estimate the effectiveness of smartphone-enabled COVID-19 exposure notification in Pennsylvania, USA. We estimated that digital notifications potentially averted 7-69 cases/1,000 notifications during November 8, 2020-January 2, 2021. Greater use and increased compliance could increase the effectiveness of digital notifications.

An Examination of US COVID-19 Vaccine Distribution in New Jersey, Pennsylvania, and New York.

COVID-19 quickly spread across the United States (US) while communications and policies at all government levels suffered from inconsistency, misinformation, and lack of coordination. In order to explain the discrepancy between availability and population uptake, a case study was conducted analyzing vaccine rollout plans, social media, and Health Officer/Other Key Informant interviews in New Jersey, New York, and Pennsylvania. Key research questions included, "What were the barriers and facilitators of early COVID vaccine distribution?" and "What mechanisms in the community emerged to alleviate strains in early vaccination?" Findings from this study revealed that pre-existing emergency preparedness infrastructures and plans developed since the 9/11 tragedy were seemingly abandoned. This caused health departments at all levels of government to make impromptu, non-uniform decisions leading to confusion, vaccine hesitancy, and ultimately low uptake. The results indicate that future vaccine rollout best practices must include evidence-based decision-making, coordinated communications, and outreach to high-priority and vulnerable communities.

Shifting Medication Treatment Practices in the COVID-19 Pandemic: A Statewide Survey of Pennsylvania Opioid Treatment Programs.

OBJECTIVES: We sought to understand how opioid treatment programs (OTPs) adapted OTP operations to the COVID-19 pandemic and new federal regulations around methadone and buprenorphine. METHODS: In fall 2020, we conducted an online survey of all 103 OTPs licensed by the Pennsylvania Department of Drug and Alcohol Programs, including clinical directors. Survey domains included changes to methadone take-home and telehealth practices; overdose and diversion prevention tactics; perceptions regarding how such changes influence patient well-being; and financial/operational concerns related to the new policies and practices. We calculated descriptive statistics and conducted Chi-square test to test for differences between not-for-profit versus for-profit and large versus small OTPs. RESULTS: Forty-seven percent (46%) OTPs responded to the survey. 10% and 25%, respectively, endorsed offering telephone and video-based telemedicine buprenorphine induction. Sixty-six percent endorsed extending take-home supplies of methadone, but most indicated that these extensions applied to a minority of their patients. Most respondents agreed that provision of buprenorphine via telehealth and extended take-home methadone reduced patient burden in accessing medications and prevented exposure to COVID-19, while not significantly increasing risk of overdose. We did not find major differences in COVID-19 practice modifications by nonprofit status or size of OTP. CONCLUSIONS: In Pennsylvania, the COVID-19 pandemic led to rapid changes in provision of opioid treatment services. Findings on relatively low uptake of longer methadone take-home regimens and virtual buprenorphine initiation despite general support for these practices imply a need to further develop guidelines for best clinical practices and understand/address barriers to their implementation.

Genomic characterization of SARS-CoV-2 from vaccine breakthrough cases in Allegheny County, Pennsylvania.

We performed whole genome sequencing on SARS-CoV-2 from 59 vaccinated individuals from southwest Pennsylvania who tested positive between February and September, 2021. A comparison of mutations among vaccine breakthrough cases to a time-matched control group identified potential adaptive responses of SARS-CoV-2 to vaccination.

Multiple Introductions of SARS-CoV-2 Alpha and Delta Variants into White-Tailed Deer in Pennsylvania.

The SARS-CoV-2 pandemic began by viral spillover from animals to humans; today multiple animal species are known to be susceptible to infection. White-tailed deer, Odocoileus virginianus, are infected in North America at substantial levels, and genomic data suggests that a variant in deer may have spilled back to humans. Here, we characterize SARS-CoV-2 in deer from Pennsylvania (PA) sampled during fall and winter 2021. Of 123 nasal swab samples analyzed by RT-qPCR, 20 (16.3%) were positive for SARS-CoV-2. Seven whole genome sequences were obtained, together with six more partial spike gene sequences. These annotated as alpha and delta variants, the first reported observations of these lineages in deer, documenting multiple new jumps from humans to deer. The alpha lineage persisted in deer after its displacement by delta in humans, and deer-derived alpha variants diverged significantly from those in humans, consistent with a distinctive evolutionary trajectory in deer. IMPORTANCE Coronaviruses have been documented to replicate in numerous species of vertebrates, and multiple spillovers of coronaviruses from animals into humans have founded human epidemics. The COVID-19 epidemic likely derived from a spillover of SARS-CoV-2 from bats into humans, possibly via an intermediate host. There are now several examples of SARS-CoV-2 jumping from humans into other mammals, including mink and deer, creating the potential for new animal reservoirs from which spillback into humans could occur. For this reason, data on formation of new animal reservoirs is of great importance for understanding possible sources of future infection. Here, we identify extensive infection in white-tailed deer in Pennsylvania, including what appear to be multiple independent transmissions. Data further suggests possible transmission among deer. These data thus help identify a potential new animal reservoir and provide background information relevant to its management.

Hospitalization and mortality in patients with COVID-19 with or at risk of type 2 diabetes: data from five health systems in Pennsylvania and Maryland.

OBJECTIVE: To identify the demographic and clinical characteristics associated with adverse COVID-19 outcomes across a 12-month period in 2020 and 2021. RESEARCH DESIGN AND METHODS: We conducted a retrospective cohort study using electronic health records from five academic health systems in Pennsylvania and Maryland, including patients with COVID-19 with type 2 diabetes or at risk of type 2 diabetes. Patients were classified based on 30-day outcomes: (1) no hospitalization; (2) hospitalization only; or (3) a composite measure including admission to the intensive care unit (ICU), intubation, or death. Analyses were conducted in patients with type 2 diabetes and patients at risk of type 2 diabetes separately. RESULTS: We included 15 725 patients with COVID-19 diagnoses between March 2020 and February 2021. Older age and higher Charlson Comorbidity Index scores were associated with higher odds of adverse outcomes, while COVID-19 diagnoses later in the study period were associated with lower odds of severe outcomes. In patients with type 2 diabetes, individuals on insulin treatment had higher odds for ICU/intubation/death (OR=1.59, 95% CI 1.27 to 1.99), whereas those on metformin had lower odds (OR=0.56, 95% CI 0.45 to 0.71). Compared with non-Hispanic White patients, Hispanic patients had higher odds of hospitalization in patients with type 2 diabetes (OR=1.73, 95% CI 1.36 to 2.19) or at risk of type 2 diabetes (OR=1.77, 95% CI 1.43 to 2.18.) CONCLUSIONS: Adults who were older, in racial minority groups, had multiple chronic conditions or were on insulin treatment had higher risks for severe COVID-19 outcomes. This study reinforced the urgency of preventing COVID-19 and its complications in vulnerable populations. TRIAL REGISTRATION NUMBER: NCT02788903.

Demographics, comorbidities, and laboratory parameters in hospitalized patients with SARS-CoV2 infection at a community hospital in rural Pennsylvania.

INTRODUCTION: Inherent differences as well as health disparities among rural and urban populations warrant further studies focused on the characteristics and outcomes in COVID-19 patients in a rural setting. The aim of this study was to describe these elements in patients infected with SARS-CoV2, hospitalized at a single center in rural Pennsylvania. METHODS: Patients with SARS-CoV2 infections hospitalized between March-December 2020 were studied. Data were obtained from electronic health records generated reports and was retrospectively analyzed. Patients were classified into three groups according to severity. Distribution of variables was studied among these three groups. Using certain variables, we ran logistic regression analysis to study the odds of death and requirement of mechanical ventilation (MV). RESULTS: Among 335 hospitalized patients infected with SARS-CoV2, age more than 65 years increased the severity of clinical status and in-hospital mortality. Gender did not affect odds of death nor need for MV. Hypertension was the most common comorbidity, but diabetes mellitus and chronic obstructive pulmonary disease (COPD) increased the risk of death. In terms of laboratory parameters, our data suggests that maximum LDH marginally increased the risk of death and maximum WBC marginally increased the risk of need for MV and death. CONCLUSION: Through our basic analysis of various characteristics of SARS-CoV2 positive patients admitted in a rural hospital, we have identified certain risk factors associated with severe disease and increased in-hospital mortality. These were found to be largely similar to current literature from studies in urban populations, bolstering the reproducibility and generalizability of existing knowledge. This information lays the foundation for future studies to investigate the role of these factors in morbidity and mortality associated with COVID-19 in depth.

Reducing occupational exposure to SARS-CoV-2: A survey of changes in caseload and controls among medical examiner and coroners' offices in Pennsylvania during 2020.

Like their counterparts in healthcare, workers in medical examiner and coroners' offices are considered essential workers. The frequency and urgency of their work during the coronavirus disease 2019 (COVID-19) pandemic have only become of greater importance. Because of the increased mortality in the general population due to SARS-CoV-2, the virus that causes COVID-19, it is reasonable to assume that the workload and risk of occupational exposure to SARS-CoV-2 have increased for these workers who are required by state law to investigate deaths known or suspected to be due to a contagious disease that constitutes a public hazard. Studies investigating the impact of the COVID-19 pandemic on these workers and their operations have been limited. The objective of this study was to conduct an assessment of routine medical examiner and coroners' office duties (e.g., infectious disease testing and decedent transport) by surveying the 67 county medical examiner and coroners' offices in Pennsylvania to characterize how the rise in infectious disease cases from COVID-19 influenced workload and resource needs. Quantitative results demonstrated an increase in workload and use of personal protective equipment (PPE) while engineering control usage remained the same. Qualitative results revealed various challenges experienced by the offices during the pandemic including limitations in access to PPE, insufficient storage space for increased numbers of decedents, personnel shortage/burnout, and limited or no engagement at the state level for emergency response planning and implementation. These data are valuable to inform the need for additional guidance or supplies and may be used to optimize resource planning and implementation (e.g., personnel, facilities, and supplies) for both routine and surge demand scenarios.

Large university with high COVID-19 incidence is not associated with excess cases in non-student population.

Large US colleges and universities that re-opened campuses in the fall of 2020 and the spring of 2021 experienced high per capita rates of COVID-19. Returns to campus were controversial because they posed a potential risk to surrounding communities. A large university in Pennsylvania that returned to in-person instruction for Fall 2020 and Spring 2021 semesters reported high incidence of COVID-19 among students. However, the co-located non-student resident population in the county experienced fewer COVID-19 cases per capita than reported in neighboring counties. Activity patterns from mobile devices indicate that the non-student resident population near the university restricted their movements during the pandemic more than residents of neighboring counties. Respiratory virus prevention and management in student and non-student populations requires different, specifically targeted strategies.

'Us-Versus-Them': Othering in COVID-19 public health behavior compliance.

OBJECTIVE: We explored public perceptions about the COVID-19 pandemic to learn how those attitudes may affect compliance with health behaviors. METHODS: Participants were Central Pennsylvania adults from diverse backgrounds purposively sampled (based on race, gender, educational attainment, and healthcare worker status) who responded to a mixed methods survey, completed between March 25-31, 2020. Four open-ended questions were analyzed, including: "What worries you most about the COVID-19 pandemic?" We applied a pragmatic, inductive coding process to conduct a qualitative, descriptive content analysis of responses. RESULTS: Of the 5,948 respondents, 538 were sampled for this qualitative analysis. Participants were 58% female, 56% with ≥ bachelor's degree, and 50% from minority racial backgrounds. Qualitative descriptive analysis revealed four themes related to respondents' health and societal concerns: lack of faith in others; fears of illness or death; frustration at perceived slow societal response; and a desire for transparency in communicating local COVID-19 information. An "us-versus-them" subtext emerged; participants attributed non-compliance with COVID-19 behaviors to other groups, setting themselves apart from those Others. CONCLUSION: Our study uncovered Othering undertones in the context of the COVID-19 pandemic, occurring between groups of like-minded individuals with behavioral differences in 'compliance' versus 'non-compliance' with public health recommendations. Addressing the 'us-versus-them' mentality may be important for boosting compliance with recommended health behaviors.

Experiences of New Mothers During the Coronavirus Disease 2019 (COVID-19) Pandemic.

OBJECTIVE: To describe postpartum experiences of women who gave birth during the coronavirus disease 2019 (COVID-19) pandemic, to identify short-term and long-term opportunities to address maternal-child health during this pandemic. METHODS: This qualitative photo-elicitation study asked 30 women between 3 and 10 weeks postpartum to take photographs that encompassed their experience as a new mother during the pandemic. Two trained interviewers elicited elements of this experience using the photos as an anchor during virtual, hour-long interviews. Interview transcripts were analyzed using directed content analysis, including open coding to identify key ideas, codebook development, and codebook refinement. Half of transcripts were team coded to ensure coding accuracy. After coding, the study team organized codes to inform the development of an explanatory model. RESULTS: Interviews identified important stressors new mothers experienced that were worsened during the pandemic, namely fear, child care, older children, loss, isolation, and employment. Interviews also highlighted key support structures (self-care, interpersonal, and structural supports) that were at times helpful in alleviating stressors and at others were inadequate to counter stress and even enhanced stress. CONCLUSION: For postpartum individuals overall, the pandemic resulted in increased strain during an already stressful time. These findings demonstrate inadequacy of support systems for postpartum women and may highlight action items for stakeholders to improve postpartum care during the pandemic and in the future.

Transmission of SARS-CoV-2 from humans to a 16-year-old domestic cat with comorbidities in Pennsylvania, USA.

BACKGROUND AND OBJECTIVES: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), besides causing human infection, has been shown to naturally infect several susceptible animal species including large cats (tigers, lions, pumas, spotted leopards), dogs, cats, ferrets, gorillas and minks. Cats and minks are continuing to be the most reported species with SARS-CoV-2 infections among animals but it needs to be investigated further. METHODS AND RESULTS: We report the detection of SARS-CoV-2 from a domestic cat that exhibited respiratory disease after being exposed to SARS-CoV-2 virus from humans in the same household. SARS-CoV-2 RNA was detected in two oropharyngeal swabs collected at two time points, 11 days apart; the first, when the cat was reported to be sick and the second, before euthanasia due to poor prognosis. The viral nucleic acid detected at two time points showed no genomic variation and resembled the clade GH circulating in humans in the United States. Clinical and pathological findings noted in this 16-year-old cat were consistent with respiratory and cardiac insufficiency. CONCLUSIONS: SARS-CoV-2 viral infection was likely an incidental clinical finding, as the virus was not detected in fixed lungs, heart, or kidney tissues. Only fresh lung tissue collected at necropsy showed the presence of viral nucleic acid, albeit at a very low level. Further research is needed to clarify the clinical course of SARS-CoV-2 in companion animals of advanced age and underlying cardiac disease.

Lifestyle and mental health 1 year into COVID-19.

In previous work, Giuntella et al. (Proc Natl Acad Sci 118:e2016632118, 2021), we documented large disruptions to physical activity, sleep, time use and mental health among young adults at the onset of the COVID-19 pandemic in Spring 2020. This study explores the trends 1 year into COVID-19, as vaccines began to roll out, COVID-19 deaths declined, and social distancing measures eased in the United States. We combine biometric and survey data from multiple cohorts of college students spanning Spring 2019 through Spring 2021 (N = 1179). Our results show persistent impacts of the pandemic on physical activity and mental health. One year into the pandemic, daily steps averaged about 6300 per day compared to about 9800 per day prior to the pandemic, a 35% decline. Almost half of participants were at risk of clinical depression compared to a little over one-third prior to the pandemic, a 36% increase. The impacts on screen time, social interactions and sleep duration at the onset of COVID-19 largely dissipated over the course of the pandemic, though screen time remained significantly higher than pre-pandemic levels. In contrast to the sharp changes in lifestyle and mental health documented as the pandemic emerged in March 2020, we do not find evidence of behavioral changes or improvements in mental well-being over the course of Spring 2021 as the pandemic eased.