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1.
JAMA Netw Open ; 4(11): e2132548, 2021 11 01.
Article in English | MEDLINE | ID: covidwho-1499192

ABSTRACT

Importance: Compared with the general population, veterans are at high risk for COVID-19 and have a complex relationship with the government. This potentially affects their attitudes toward receiving COVID-19 vaccines. Objective: To assess veterans' attitudes toward and intentions to receive COVID-19 vaccines. Design, Setting, and Participants: This cross-sectional web-based survey study used data from the Department of Veterans Affairs (VA) Survey of Healthcare Experiences of Patients' Veterans Insight Panel, fielded between March 12 and 28, 2021. Of 3420 veterans who were sent a link to complete a 58-item web-based survey, 1178 veterans (34%) completed the survey. Data were analyzed from April 1 to August 25, 2021. Exposures: Veterans eligible for COVID-19 vaccines. Main Outcomes and Measures: The outcomes of interest were veterans' experiences with COVID-19, vaccination status and intention groups, reasons for receiving or not receiving a vaccine, self-reported health status, and trusted and preferred sources of information about COVID-19 vaccines. Reasons for not getting vaccinated were classified into categories of vaccine deliberation, dissent, distrust, indifference, skepticism, and policy and processes. Results: Among 1178 respondents, 974 (83%) were men, 130 (11%) were women, and 141 (12%) were transgender or nonbinary; 58 respondents (5%) were Black, 54 veterans (5%) were Hispanic or Latino, and 987 veterans (84%) were non-Hispanic White. The mean (SD) age of respondents was 66.7 (10.1) years. A total of 817 respondents (71%) self-reported being vaccinated against COVID-19. Of 339 respondents (29%) who were not vaccinated, those unsure of getting vaccinated were more likely to report fair or poor overall health (32 respondents [43%]) and mental health (33 respondents [44%]) than other nonvaccinated groups (overall health: range, 20%-32%; mental health: range, 18%-40%). Top reasons for not being vaccinated were skepticism (120 respondents [36%] were concerned about side effects; 65 respondents [20%] preferred using few medications; 63 respondents [19%] preferred gaining natural immunity), deliberation (74 respondents [22%] preferred to wait because vaccine is new), and distrust (61 respondents [18%] did not trust the health care system). Among respondents who were vaccinated, preventing oneself from getting sick (462 respondents [57%]) and contributing to the end of the COVID-19 pandemic (453 respondents [56%]) were top reasons for getting vaccinated. All veterans reported the VA as 1 of their top trusted sources of information. The proportion of respondents trusting their VA health care practitioner as a source of vaccine information was higher among those unsure about vaccination compared with those who indicated they would definitely not or probably not get vaccinated (18 respondents [26%] vs 15 respondents [15%]). There were no significant associations between vaccine intention groups and age (χ24 = 5.90; P = .21) or gender (χ22 = 3.99; P = .14). Conclusions and Relevance: These findings provide information needed to develop trusted messages used in conversations between VA health care practitioners and veterans addressing specific vaccine hesitancy reasons, as well as those in worse health. Conversations need to emphasize societal reasons for getting vaccinated and benefits to one's own health.


Subject(s)
Attitude , Intention , Vaccination/psychology , Veterans/psychology , Adult , Aged , COVID-19/mortality , COVID-19/prevention & control , COVID-19 Vaccines/immunology , Cross-Sectional Studies , Female , Humans , Male , Middle Aged , Pandemics , SARS-CoV-2 , Surveys and Questionnaires , United States/epidemiology , Vaccination/statistics & numerical data , Veterans/statistics & numerical data
2.
Am J Epidemiol ; 190(11): 2405-2419, 2021 11 02.
Article in English | MEDLINE | ID: covidwho-1493668

ABSTRACT

Hydroxychloroquine (HCQ) was proposed as an early therapy for coronavirus disease 2019 (COVID-19) after in vitro studies indicated possible benefit. Previous in vivo observational studies have presented conflicting results, though recent randomized clinical trials have reported no benefit from HCQ among patients hospitalized with COVID-19. We examined the effects of HCQ alone and in combination with azithromycin in a hospitalized population of US veterans with COVID-19, using a propensity score-adjusted survival analysis with imputation of missing data. According to electronic health record data from the US Department of Veterans Affairs health care system, 64,055 US Veterans were tested for the virus that causes COVID-19 between March 1, 2020 and April 30, 2020. Of the 7,193 veterans who tested positive, 2,809 were hospitalized, and 657 individuals were prescribed HCQ within the first 48-hours of hospitalization for the treatment of COVID-19. There was no apparent benefit associated with HCQ receipt, alone or in combination with azithromycin, and there was an increased risk of intubation when HCQ was used in combination with azithromycin (hazard ratio = 1.55; 95% confidence interval: 1.07, 2.24). In conclusion, we assessed the effectiveness of HCQ with or without azithromycin in treatment of patients hospitalized with COVID-19, using a national sample of the US veteran population. Using rigorous study design and analytic methods to reduce confounding and bias, we found no evidence of a survival benefit from the administration of HCQ.


Subject(s)
Anti-Bacterial Agents/therapeutic use , Azithromycin/therapeutic use , COVID-19/drug therapy , Hospitalization/statistics & numerical data , Hydroxychloroquine/therapeutic use , Veterans/statistics & numerical data , Aged , Aged, 80 and over , Anti-Bacterial Agents/adverse effects , Azithromycin/adverse effects , COVID-19/mortality , Drug Therapy, Combination , Female , Humans , Hydroxychloroquine/adverse effects , Intention to Treat Analysis , Machine Learning , Male , Middle Aged , Pharmacoepidemiology , Retrospective Studies , SARS-CoV-2 , Treatment Outcome , United States/epidemiology
3.
MMWR Morb Mortal Wkly Rep ; 70(37): 1294-1299, 2021 Sep 17.
Article in English | MEDLINE | ID: covidwho-1417367

ABSTRACT

COVID-19 mRNA vaccines (Pfizer-BioNTech and Moderna) have been shown to be highly protective against COVID-19-associated hospitalizations (1-3). Data are limited on the level of protection against hospitalization among disproportionately affected populations in the United States, particularly during periods in which the B.1.617.2 (Delta) variant of SARS-CoV-2, the virus that causes COVID-19, predominates (2). U.S. veterans are older, more racially diverse, and have higher prevalences of underlying medical conditions than persons in the general U.S. population (2,4). CDC assessed the effectiveness of mRNA vaccines against COVID-19-associated hospitalization among 1,175 U.S. veterans aged ≥18 years hospitalized at five Veterans Affairs Medical Centers (VAMCs) during February 1-August 6, 2021. Among these hospitalized persons, 1,093 (93.0%) were men, the median age was 68 years, 574 (48.9%) were non-Hispanic Black (Black), 475 were non-Hispanic White (White), and 522 (44.4%) had a Charlson comorbidity index score of ≥3 (5). Overall adjusted vaccine effectiveness against COVID-19-associated hospitalization was 86.8% (95% confidence interval [CI] = 80.4%-91.1%) and was similar before (February 1-June 30) and during (July 1-August 6) SARS-CoV-2 Delta variant predominance (84.1% versus 89.3%, respectively). Vaccine effectiveness was 79.8% (95% CI = 67.7%-87.4%) among adults aged ≥65 years and 95.1% (95% CI = 89.1%-97.8%) among those aged 18-64 years. COVID-19 mRNA vaccines are highly effective in preventing COVID-19-associated hospitalization in this older, racially diverse population of predominately male U.S. veterans. Additional evaluations of vaccine effectiveness among various age groups are warranted. To prevent COVID-19-related hospitalizations, all eligible persons should receive COVID-19 vaccination.


Subject(s)
COVID-19 Vaccines/administration & dosage , COVID-19/prevention & control , Hospitalization/statistics & numerical data , Veterans/statistics & numerical data , Adolescent , Adult , Aged , COVID-19/epidemiology , COVID-19/therapy , Female , Hospitals, Veterans , Humans , Male , Middle Aged , United States/epidemiology , United States Department of Veterans Affairs , Vaccines, Synthetic , Young Adult
4.
J Am Geriatr Soc ; 69(11): 3044-3050, 2021 11.
Article in English | MEDLINE | ID: covidwho-1398482

ABSTRACT

BACKGROUND: Among nursing home residents, for whom age and frailty can blunt febrile responses to illness, the temperature used to define fever can influence the clinical recognition of COVID-19 symptoms. To assess the potential for differences in the definition of fever to characterize nursing home residents with COVID-19 infections as symptomatic, pre-symptomatic, or asymptomatic, we conducted a retrospective study on a national cohort of Department of Veterans Affairs (VA) Community Living Center (CLC) residents tested for SARS-CoV-2. METHODS: Residents with positive SARS-CoV-2 tests were classified as asymptomatic if they did not experience any symptoms, and as symptomatic or pre-symptomatic if the experienced a fever (>100.4°F) before or following a positive SARS-CoV-2 test, respectively. All-cause 30-day mortality was assessed as was the influence of a lower temperature threshold (>99.0°F) on classification of residents with positive SARS-CoV-2 tests. RESULTS: From March 2020 through November 2020, VA CLCs tested 11,908 residents for SARS-CoV-2 using RT-PCR, with a positivity of rate of 13% (1557). Among residents with positive tests and using >100.4°F, 321 (21%) were symptomatic, 425 (27%) were pre-symptomatic, and 811 (52%) were asymptomatic. All-cause 30-day mortality among residents with symptomatic and pre-symptomatic COVID-19 infections was 24% and 26%, respectively, while those with an asymptomatic infection had mortality rates similar to residents with negative SAR-CoV-2 tests (10% and 5%, respectively). Using >99.0°F would have increased the number of residents categorized as symptomatic at the time of testing from 321 to 773. CONCLUSIONS: All-cause 30-day mortality was similar among VA CLC residents with symptomatic or pre-symptomatic COVID-19 infection, and lower than rates reported in non-VA nursing homes. A lower temperature threshold would increase the number of residents recognized as having symptomatic infection, potentially leading to earlier detection and more rapid implementation of therapeutic interventions and infection prevention and control measures.


Subject(s)
COVID-19 Testing/statistics & numerical data , COVID-19/diagnosis , Fever/diagnosis , Skilled Nursing Facilities , Veterans/statistics & numerical data , Aged , Asymptomatic Infections , COVID-19/complications , Female , Fever/etiology , Humans , Male , Middle Aged , Retrospective Studies
5.
Am J Epidemiol ; 190(11): 2405-2419, 2021 11 02.
Article in English | MEDLINE | ID: covidwho-1393147

ABSTRACT

Hydroxychloroquine (HCQ) was proposed as an early therapy for coronavirus disease 2019 (COVID-19) after in vitro studies indicated possible benefit. Previous in vivo observational studies have presented conflicting results, though recent randomized clinical trials have reported no benefit from HCQ among patients hospitalized with COVID-19. We examined the effects of HCQ alone and in combination with azithromycin in a hospitalized population of US veterans with COVID-19, using a propensity score-adjusted survival analysis with imputation of missing data. According to electronic health record data from the US Department of Veterans Affairs health care system, 64,055 US Veterans were tested for the virus that causes COVID-19 between March 1, 2020 and April 30, 2020. Of the 7,193 veterans who tested positive, 2,809 were hospitalized, and 657 individuals were prescribed HCQ within the first 48-hours of hospitalization for the treatment of COVID-19. There was no apparent benefit associated with HCQ receipt, alone or in combination with azithromycin, and there was an increased risk of intubation when HCQ was used in combination with azithromycin (hazard ratio = 1.55; 95% confidence interval: 1.07, 2.24). In conclusion, we assessed the effectiveness of HCQ with or without azithromycin in treatment of patients hospitalized with COVID-19, using a national sample of the US veteran population. Using rigorous study design and analytic methods to reduce confounding and bias, we found no evidence of a survival benefit from the administration of HCQ.


Subject(s)
Anti-Bacterial Agents/therapeutic use , Azithromycin/therapeutic use , COVID-19/drug therapy , Hospitalization/statistics & numerical data , Hydroxychloroquine/therapeutic use , Veterans/statistics & numerical data , Aged , Aged, 80 and over , Anti-Bacterial Agents/adverse effects , Azithromycin/adverse effects , COVID-19/mortality , Drug Therapy, Combination , Female , Humans , Hydroxychloroquine/adverse effects , Intention to Treat Analysis , Machine Learning , Male , Middle Aged , Pharmacoepidemiology , Retrospective Studies , SARS-CoV-2 , Treatment Outcome , United States/epidemiology
6.
J Am Soc Nephrol ; 32(11): 2851-2862, 2021 11.
Article in English | MEDLINE | ID: covidwho-1394649

ABSTRACT

BACKGROUND: COVID-19 is associated with increased risk of post-acute sequelae involving pulmonary and extrapulmonary organ systems-referred to as long COVID. However, a detailed assessment of kidney outcomes in long COVID is not yet available. METHODS: We built a cohort of 1,726,683 US Veterans identified from March 1, 2020 to March 15, 2021, including 89,216 patients who were 30-day survivors of COVID-19 and 1,637,467 non-infected controls. We examined risks of AKI, eGFR decline, ESKD, and major adverse kidney events (MAKE). MAKE was defined as eGFR decline ≥50%, ESKD, or all-cause mortality. We used inverse probability-weighted survival regression, adjusting for predefined demographic and health characteristics, and algorithmically selected high-dimensional covariates, including diagnoses, medications, and laboratory tests. Linear mixed models characterized intra-individual eGFR trajectory. RESULTS: Beyond the acute illness, 30-day survivors of COVID-19 exhibited a higher risk of AKI (aHR, 1.94; 95% CI, 1.86 to 2.04), eGFR decline ≥30% (aHR, 1.25; 95% CI, 1.14 to 1.37), eGFR decline ≥40% (aHR, 1.44; 95% CI, 1.37 to 1.51), eGFR decline ≥50% (aHR, 1.62; 95% CI, 1.51 to 1.74), ESKD (aHR, 2.96; 95% CI, 2.49 to 3.51), and MAKE (aHR, 1.66; 95% CI, 1.58 to 1.74). Increase in risks of post-acute kidney outcomes was graded according to the severity of the acute infection (whether patients were non-hospitalized, hospitalized, or admitted to intensive care). Compared with non-infected controls, 30-day survivors of COVID-19 exhibited excess eGFR decline (95% CI) of -3.26 (-3.58 to -2.94), -5.20 (-6.24 to -4.16), and -7.69 (-8.27 to -7.12) ml/min per 1.73 m2 per year, respectively, in non-hospitalized, hospitalized, and those admitted to intensive care during the acute phase of COVID-19 infection. CONCLUSIONS: Patients who survived COVID-19 exhibited increased risk of kidney outcomes in the post-acute phase of the disease. Post-acute COVID-19 care should include attention to kidney disease.


Subject(s)
COVID-19/complications , Kidney Diseases/epidemiology , Kidney Diseases/virology , Veterans/statistics & numerical data , Aged , COVID-19/diagnosis , COVID-19/epidemiology , COVID-19/therapy , Case-Control Studies , Cohort Studies , Critical Care , Female , Glomerular Filtration Rate , Hospitalization , Humans , Kidney Diseases/diagnosis , Male , Middle Aged , United States
7.
Hepatology ; 74(1): 322-335, 2021 07.
Article in English | MEDLINE | ID: covidwho-1384170

ABSTRACT

BACKGROUND AND AIMS: Whether patients with cirrhosis have increased risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and the extent to which infection and cirrhosis increase the risk of adverse patient outcomes remain unclear. APPROACH AND RESULTS: We identified 88,747 patients tested for SARS-CoV-2 between March 1, 2020, and May 14, 2020, in the Veterans Affairs (VA) national health care system, including 75,315 with no cirrhosis-SARS-CoV-2-negative (C0-S0), 9,826 with no cirrhosis-SARS-CoV-2-positive (C0-S1), 3,301 with cirrhosis-SARS-CoV-2-negative (C1-S0), and 305 with cirrhosis-SARS-CoV-2-positive (C1-S1). Patients were followed through June 22, 2020. Hospitalization, mechanical ventilation, and death were modeled in time-to-event analyses using Cox proportional hazards regression. Patients with cirrhosis were less likely to test positive than patients without cirrhosis (8.5% vs. 11.5%; adjusted odds ratio, 0.83; 95% CI, 0.69-0.99). Thirty-day mortality and ventilation rates increased progressively from C0-S0 (2.3% and 1.6%) to C1-S0 (5.2% and 3.6%) to C0-S1 (10.6% and 6.5%) and to C1-S1 (17.1% and 13.0%). Among patients with cirrhosis, those who tested positive for SARS-CoV-2 were 4.1 times more likely to undergo mechanical ventilation (adjusted hazard ratio [aHR], 4.12; 95% CI, 2.79-6.10) and 3.5 times more likely to die (aHR, 3.54; 95% CI, 2.55-4.90) than those who tested negative. Among patients with SARS-CoV-2 infection, those with cirrhosis were more likely to be hospitalized (aHR, 1.37; 95% CI, 1.12-1.66), undergo ventilation (aHR, 1.61; 95% CI, 1.05-2.46) or die (aHR, 1.65; 95% CI, 1.18-2.30) than patients without cirrhosis. Among patients with cirrhosis and SARS-CoV-2 infection, the most important predictors of mortality were advanced age, cirrhosis decompensation, and high Model for End-Stage Liver Disease score. CONCLUSIONS: SARS-CoV-2 infection was associated with a 3.5-fold increase in mortality in patients with cirrhosis. Cirrhosis was associated with a 1.7-fold increase in mortality in patients with SARS-CoV-2 infection.


Subject(s)
COVID-19/etiology , Liver Cirrhosis/complications , SARS-CoV-2 , Veterans/statistics & numerical data , Adolescent , Adult , Aged , Aged, 80 and over , COVID-19/epidemiology , COVID-19/mortality , COVID-19/therapy , Female , Hospitalization/statistics & numerical data , Humans , Liver Cirrhosis/virology , Male , Middle Aged , Proportional Hazards Models , Respiration, Artificial/statistics & numerical data , Risk Factors , United States/epidemiology , Young Adult
9.
JAMA Psychiatry ; 78(11): 1218-1227, 2021 11 01.
Article in English | MEDLINE | ID: covidwho-1371312

ABSTRACT

Importance: The COVID-19 pandemic has raised considerable concerns about increased risk for suicidal behavior among US military veterans, who already had elevated rates of suicide before the pandemic. Objective: To examine longitudinal changes in suicidal behavior from before the COVID-19 pandemic to nearly 10 months into the pandemic and identify risk factors and COVID-related variables associated with new-onset suicide ideation (SI). Design, Setting, and Participants: This population-based prospective cohort study used data from the first and second wave of the National Health and Resilience in Veterans Study, conducted from November 18, 2019, to December 19, 2020. Median dates of data collection for the prepandemic and peripandemic assessments were November 21, 2019, and November 14, 2020, nearly 10 months after the start of the COVID-19 public health emergency in the US. A total of 3078 US military veterans aged 22 to 99 years were included in the study. Main Outcomes and Measures: Past-year SI and suicide attempts. Results: In this cohort study of 3078 US veterans (mean [SD] age, 63.2 [14.7] years; 91.6% men; 79.3% non-Hispanic White veterans, 10.3% non-Hispanic Black veterans, and 6.0% Hispanic veterans), 233 (7.8%) reported past-year SI, and 8 (0.3%) reported suicide attempts at the peripandemic assessment. Past-year SI decreased from 10.6% prepandemic (95% CI, 9.6%-11.8%) to 7.8% peripandemic (95% CI, 6.9%-8.8%). A total of 82 veterans (2.6%) developed new-onset SI over the follow-up period. After adjusting for sociodemographic and military characteristics, the strongest risk factors and COVID-19-related variables for new-onset SI were low social support (odds ratio [OR], 2.77; 95% CI, 1.46-5.28), suicide attempt history (OR, 6.31; 95% CI, 2.71-14.67), lifetime posttraumatic stress disorder and/or depression (OR, 2.25; 95% CI, 1.16-4.35), past-year alcohol use disorder severity (OR, 1.06; 95% CI, 1.01-1.12), COVID-19 infection (OR, 2.41; 95% CI, 1.41-5.01), and worsening of social relationships during the pandemic (OR, 1.47; 95% CI, 1.16-1.88). Conclusions and Relevance: The results of this cohort study suggest that despite grim forecasts that the COVID-19 pandemic would exacerbate suicidality among US military veterans, the rate of SI decreased at the population level nearly 10 months into the pandemic. Veterans who were infected with COVID-19 were more than twice as likely to report SI, which suggests the need for future research to examine the potential link between COVID-19 infection and suicidal behavior.


Subject(s)
COVID-19 , Suicidal Ideation , Veterans/statistics & numerical data , Adult , Aged , Female , Humans , Longitudinal Studies , Male , Middle Aged , Prevalence , Risk Factors , United States/epidemiology
10.
Am Heart J ; 240: 46-57, 2021 10.
Article in English | MEDLINE | ID: covidwho-1316364

ABSTRACT

BACKGROUND: Angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB) are known to impact the functional receptor for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The association between chronic therapy with these medications and infection risk remains unclear. OBJECTIVES: The objective was to determine the association between prior ACEI or ARB therapy and SARS-CoV-2 infection among patients with hypertension in the U.S. Veteran's Affairs health system. METHODS: We compared the odds of SARS-CoV-2 infection among three groups: patients treated with ACEI, treated with ARB, or treated with alternate first-line anti-hypertensives without ACEI/ARB. We excluded patients with alternate indications for ACEI or ARB therapy. We performed an augmented inverse propensity weighted analysis with adjustment for demographics, region, comorbidities, vitals, and laboratory values. RESULTS: Among 1,724,723 patients with treated hypertension, 659,180 were treated with ACEI, 310,651 with ARB, and 754,892 with neither. Before weighting, patients treated with ACEI or ARB were more likely to be diabetic and use more anti-hypertensives. There were 13,278 SARS-CoV-2 infections (0.8%) between February 12, 2020 and August 19, 2020. Patients treated with ACEI had lower odds of SARS-CoV-2 infection (odds ratio [OR] 0.93; 95% CI: 0.89-0.97) while those treated with ARB had similar odds (OR 1.02; 95% CI: 0.96-1.07) compared with patients treated with alternate first-line anti-hypertensives without ACEI/ARB. In falsification analyses, patients on ACEI did not have a difference in their odds of unrelated outcomes. CONCLUSIONS: Our results suggest the safety of continuing ACEI and ARB therapy. The association between ACEI therapy and lower odds of SARS-CoV-2 infection requires further investigation.


Subject(s)
Angiotensin Receptor Antagonists/therapeutic use , Angiotensin-Converting Enzyme Inhibitors/therapeutic use , Antihypertensive Agents/therapeutic use , COVID-19/epidemiology , Hypertension/drug therapy , Renin-Angiotensin System/drug effects , Adrenergic beta-Antagonists/therapeutic use , Aged , Angiotensin II Type 2 Receptor Blockers , Calcium Channel Blockers/therapeutic use , Case-Control Studies , Comorbidity , Confidence Intervals , Diabetes Mellitus/epidemiology , Female , Humans , Male , Middle Aged , Odds Ratio , Propensity Score , Receptors, Virus , SARS-CoV-2 , Sodium Chloride Symporter Inhibitors/therapeutic use , United States/epidemiology , United States Department of Veterans Affairs , Veterans/statistics & numerical data
11.
Drug Alcohol Depend ; 225: 108818, 2021 08 01.
Article in English | MEDLINE | ID: covidwho-1275265

ABSTRACT

BACKGROUND: There have been reports of increased alcohol consumption during the COVID-19 pandemic in the general population. However, little is known about the impact of the pandemic on the prevalence of alcohol use disorder (AUD), especially in high-risk samples such as U.S. military veterans. METHODS: Data were analyzed from the 2019-2020 National Health and Resilience in Veterans Study, which surveyed a nationally representative, prospective cohort of 3078 U.S. veterans. Pre-pandemic and 1-year peri-pandemic risk and protective factors associated with incident and chronic probable AUD were examined. RESULTS: A total of 6.9 % (n = 183) of veterans were classified as chronic probable AUD, 3.2 % (n = 85) as remitted from AUD, and 2.7 % (n = 71) as incident probable AUD during the pandemic; the prevalence of probable AUD in the full sample remained stable -10.1 % pre-pandemic and 9.6 % peri-pandemic. Younger age, greater pre-pandemic alcohol use severity, and COVID-related stressors were associated with incident AUD during the pandemic, whereas higher pre-pandemic household income was associated with lower risk of this outcome. Younger age, combat experience, lifetime substance use disorder, greater drug use severity, lower dispositional optimism, and more COVID-related worries and social restriction stress were associated with higher risk of chronic AUD. CONCLUSIONS: Nearly 1-in-10 US veterans screened positive for AUD 1-year into the pandemic; however, the pre- and 1-year peri-pandemic prevalence of probable AUD remained stable. Veterans who are younger, have served in combat roles, endorse more COVID-related stressors, and have fewer socioeconomic resources may be at higher risk for AUD during the pandemic.


Subject(s)
Alcoholism/epidemiology , COVID-19/psychology , Pandemics , Veterans/psychology , Adult , Aged , Aged, 80 and over , COVID-19/epidemiology , Female , Humans , Male , Middle Aged , Prevalence , Prospective Studies , Protective Factors , Risk Factors , United States/epidemiology , Veterans/statistics & numerical data , Young Adult
12.
Hepatology ; 74(1): 322-335, 2021 07.
Article in English | MEDLINE | ID: covidwho-1251985

ABSTRACT

BACKGROUND AND AIMS: Whether patients with cirrhosis have increased risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and the extent to which infection and cirrhosis increase the risk of adverse patient outcomes remain unclear. APPROACH AND RESULTS: We identified 88,747 patients tested for SARS-CoV-2 between March 1, 2020, and May 14, 2020, in the Veterans Affairs (VA) national health care system, including 75,315 with no cirrhosis-SARS-CoV-2-negative (C0-S0), 9,826 with no cirrhosis-SARS-CoV-2-positive (C0-S1), 3,301 with cirrhosis-SARS-CoV-2-negative (C1-S0), and 305 with cirrhosis-SARS-CoV-2-positive (C1-S1). Patients were followed through June 22, 2020. Hospitalization, mechanical ventilation, and death were modeled in time-to-event analyses using Cox proportional hazards regression. Patients with cirrhosis were less likely to test positive than patients without cirrhosis (8.5% vs. 11.5%; adjusted odds ratio, 0.83; 95% CI, 0.69-0.99). Thirty-day mortality and ventilation rates increased progressively from C0-S0 (2.3% and 1.6%) to C1-S0 (5.2% and 3.6%) to C0-S1 (10.6% and 6.5%) and to C1-S1 (17.1% and 13.0%). Among patients with cirrhosis, those who tested positive for SARS-CoV-2 were 4.1 times more likely to undergo mechanical ventilation (adjusted hazard ratio [aHR], 4.12; 95% CI, 2.79-6.10) and 3.5 times more likely to die (aHR, 3.54; 95% CI, 2.55-4.90) than those who tested negative. Among patients with SARS-CoV-2 infection, those with cirrhosis were more likely to be hospitalized (aHR, 1.37; 95% CI, 1.12-1.66), undergo ventilation (aHR, 1.61; 95% CI, 1.05-2.46) or die (aHR, 1.65; 95% CI, 1.18-2.30) than patients without cirrhosis. Among patients with cirrhosis and SARS-CoV-2 infection, the most important predictors of mortality were advanced age, cirrhosis decompensation, and high Model for End-Stage Liver Disease score. CONCLUSIONS: SARS-CoV-2 infection was associated with a 3.5-fold increase in mortality in patients with cirrhosis. Cirrhosis was associated with a 1.7-fold increase in mortality in patients with SARS-CoV-2 infection.


Subject(s)
COVID-19/etiology , Liver Cirrhosis/complications , SARS-CoV-2 , Veterans/statistics & numerical data , Adolescent , Adult , Aged , Aged, 80 and over , COVID-19/epidemiology , COVID-19/mortality , COVID-19/therapy , Female , Hospitalization/statistics & numerical data , Humans , Liver Cirrhosis/virology , Male , Middle Aged , Proportional Hazards Models , Respiration, Artificial/statistics & numerical data , Risk Factors , United States/epidemiology , Young Adult
13.
J Am Geriatr Soc ; 69(8): 2090-2095, 2021 08.
Article in English | MEDLINE | ID: covidwho-1225672

ABSTRACT

BACKGROUND/OBJECTIVES: COVID-19 has caused significant morbidity and mortality in nursing homes. Vaccination against SARS-COV-2 holds promise for reduction in COVID-19. This operational analysis describes the proportion of SARS-COV-2 positive tests before, during, and after vaccination. DESIGN: Retrospective longitudinal cohort analysis from October 1, 2020 until February 14, 2021. SETTING: A total of 130 Department of Veterans Affairs (VA) Community Living Centers (CLC), analogous to nursing homes. INTERVENTION: Vaccination for SARS-CoV-2. MEASUREMENTS: The primary measure is the proportion of SARS-CoV-2 positive tests among CLC residents. In a pooled analysis of weekly testing and vaccine data, the proportion of positive tests was compared for the unvaccinated, first dose, and second dose. For each CLC, we identified the week in which 50% of CLC residents were vaccinated (index week). The analysis aligned the index week for CLCs and examined the proportion of SARS-CoV-2 positive tests at the CLC level before and after. As a reference, we plotted the proportion of positive tests in nursing homes in the same county as the CLC using publicly reported data. RESULTS: Within the pooled VA CLCs, the first SARS-CoV-2 vaccine dose was delivered to 50% of CLC residents within 1 week of availability and second dose within 5 weeks. Relative to the index week, the risk ratio of SARS-CoV-2 positive tests in the vaccinated relative to unvaccinated was significantly lower in Week 4 (relative risk 0.37, 95% confidence interval 0.20-0.68). Throughout the study period, the proportion of SARS-CoV-2 positive tests in community nursing homes was higher compared to VA CLC and also declined after vaccine availability. CONCLUSION: The proportion of SARS-CoV-2 positive tests significantly declined in VA CLCs 4 weeks after vaccine delivery and continued to decline in vaccinated and unvaccinated residents. The results describe the importance of SARS-CoV-2 surveillance and vaccination in VA nursing home residents.


Subject(s)
COVID-19 Testing/statistics & numerical data , COVID-19 Vaccines/administration & dosage , COVID-19/epidemiology , Nursing Homes/statistics & numerical data , Veterans/statistics & numerical data , Aged , Female , Humans , Longitudinal Studies , Male , Retrospective Studies , Vaccination
14.
JAMA Netw Open ; 4(4): e214347, 2021 04 01.
Article in English | MEDLINE | ID: covidwho-1168797

ABSTRACT

Importance: A strategy that prioritizes individuals for SARS-CoV-2 vaccination according to their risk of SARS-CoV-2-related mortality would help minimize deaths during vaccine rollout. Objective: To develop a model that estimates the risk of SARS-CoV-2-related mortality among all enrollees of the US Department of Veterans Affairs (VA) health care system. Design, Setting, and Participants: This prognostic study used data from 7 635 064 individuals enrolled in the VA health care system as of May 21, 2020, to develop and internally validate a logistic regression model (COVIDVax) that predicted SARS-CoV-2-related death (n = 2422) during the observation period (May 21 to November 2, 2020) using baseline characteristics known to be associated with SARS-CoV-2-related mortality, extracted from the VA electronic health records (EHRs). The cohort was split into a training period (May 21 to September 30) and testing period (October 1 to November 2). Main Outcomes and Measures: SARS-CoV-2-related death, defined as death within 30 days of testing positive for SARS-CoV-2. VA EHR data streams were imported on a data integration platform to demonstrate that the model could be executed in real-time to produce dashboards with risk scores for all current VA enrollees. Results: Of 7 635 064 individuals, the mean (SD) age was 66.2 (13.8) years, and most were men (7 051 912 [92.4%]) and White individuals (4 887 338 [64.0%]), with 1 116 435 (14.6%) Black individuals and 399 634 (5.2%) Hispanic individuals. From a starting pool of 16 potential predictors, 10 were included in the final COVIDVax model, as follows: sex, age, race, ethnicity, body mass index, Charlson Comorbidity Index, diabetes, chronic kidney disease, congestive heart failure, and Care Assessment Need score. The model exhibited excellent discrimination with area under the receiver operating characteristic curve (AUROC) of 85.3% (95% CI, 84.6%-86.1%), superior to the AUROC of using age alone to stratify risk (72.6%; 95% CI, 71.6%-73.6%). Assuming vaccination is 90% effective at preventing SARS-CoV-2-related death, using this model to prioritize vaccination was estimated to prevent 63.5% of deaths that would occur by the time 50% of VA enrollees are vaccinated, significantly higher than the estimate for prioritizing vaccination based on age (45.6%) or the US Centers for Disease Control and Prevention phases of vaccine allocation (41.1%). Conclusions and Relevance: In this prognostic study of all VA enrollees, prioritizing vaccination based on the COVIDVax model was estimated to prevent a large proportion of deaths expected to occur during vaccine rollout before sufficient herd immunity is achieved.


Subject(s)
COVID-19 Vaccines/therapeutic use , COVID-19/prevention & control , Health Planning/methods , Health Priorities/statistics & numerical data , Mass Vaccination , Veterans/statistics & numerical data , Aged , Area Under Curve , Comorbidity , Female , Humans , Logistic Models , Male , Middle Aged , Prognosis , ROC Curve , Risk Assessment , Risk Factors , SARS-CoV-2 , United States
16.
J Psychiatr Res ; 137: 351-359, 2021 05.
Article in English | MEDLINE | ID: covidwho-1147075

ABSTRACT

The coronavirus disease 2019 (COVID-19) pandemic has negatively affected the mental health of the general population. However, less is known about its impact on vulnerable populations, such as veterans with pre-existing psychiatric conditions. Data were analyzed from the National Health and Resilience in Veterans Study, which surveyed a nationally representative cohort of U.S. veterans. Pre-pandemic and 1-year peri-pandemic risk and protective factors associated with suicidal ideation (SI) were examined in veterans with pre-existing psychiatric conditions. 19.2% of veterans screened positive for SI peri-pandemic. Relative to veterans without SI, they had lower income, were more likely to have been infected with COVID-19, reported greater COVID-19-related financial and social restriction stress, and increases in psychiatric symptoms and loneliness during the pandemic. A multivariable analysis revealed that older age, greater pre-pandemic psychiatric symptom severity, past-year SI, lifetime suicide attempt, psychosocial difficulties, COVID-19 infection, and past-year increase in psychiatric symptom severity were linked to peri-pandemic SI, while pre-pandemic higher income and purpose in life were protective. Among veterans who were infected with COVID-19, those aged 45 or older and who reported lower purpose in life were more likely to endorse SI. Monitoring for suicide risk and worsening psychiatric symptoms in older veterans who have been infected with COVID-19 may be important. Interventions that enhance purpose in life may help protect against SI in this population.


Subject(s)
COVID-19/epidemiology , Mental Disorders/epidemiology , Pandemics , Protective Factors , Suicidal Ideation , Veterans/psychology , Veterans/statistics & numerical data , Adult , Aged , Aged, 80 and over , Female , Humans , Male , Middle Aged , Prevalence , Risk Factors , Young Adult
17.
Obesity (Silver Spring) ; 29(5): 825-828, 2021 05.
Article in English | MEDLINE | ID: covidwho-1139281

ABSTRACT

OBJECTIVE: The purpose of this study was to assess associations between BMI and severe coronavirus disease 2019 (COVID-19) outcomes: hospitalization, intensive care unit (ICU) admission, and mortality. A secondary aim was to investigate whether associations varied by age. METHODS: The cohort comprised patients in the Veterans Health Administration (VHA) who tested positive for COVID-19 (N = 9,347). For each outcome, we fit piecewise logistic regression models with restricted cubic splines (knots at BMI of 23, 30, and 39), adjusting for age, sex, comorbidities, VHA nursing home residence, and race/ethnicity. Supplemental analyses included age-by-BMI interaction terms (α = 0.05). RESULTS: We found evidence of a nonlinear J-curve association between BMI and likelihood of hospitalization and mortality. BMI was associated with increased odds for hospitalization, ICU admission, and mortality among patients with BMI 30 to 39 but decreased odds of hospitalization and mortality for patients with BMI 23 to 30. Patients under age 75 with BMI between 30 and 39 had increased odds for mortality with increasing BMI. CONCLUSIONS: Odds for severe outcomes with COVID-19 infection increased with increasing BMI for people with, but not without, obesity. This nonlinear relationship should be tested in future research. COVID-19 public health messages in VHA, and broadly, should incorporate information about risks associated with all classes of obesity, particularly for those under age 75.


Subject(s)
Body Mass Index , COVID-19/epidemiology , Veterans/statistics & numerical data , Aged , Cohort Studies , Comorbidity , Female , Hospitalization , Humans , Intensive Care Units , Logistic Models , Male , Middle Aged , Obesity/complications , Risk Factors , United States/epidemiology , Veterans Health , Veterans Health Services
18.
Obesity (Silver Spring) ; 29(5): 900-908, 2021 05.
Article in English | MEDLINE | ID: covidwho-1139280

ABSTRACT

OBJECTIVE: The purpose of this study is to examine the associations of BMI with testing positive for severe acute respiratory coronavirus 2 (SARS-CoV-2) and risk of adverse outcomes in a cohort of Veterans Affairs enrollees. METHOD: Adjusted relative risks/hazard ratios (HRs) were calculated for the associations between BMI category (underweight, normal weight, overweight, class 1 obesity, class 2 obesity, and class 3 obesity) and testing positive for SARS-CoV-2 or experiencing hospitalization, intensive care unit admission, mechanical ventilation, and death among those testing positive. RESULTS: Higher BMI categories were associated with higher risk of a positive SARS-CoV-2 test compared with the normal weight category (class 3 obesity adjusted relative risk: 1.34, 95% CI: 1.28-1.42). Among 25,952 patients who tested positive for SARS-CoV-2, class 3 obesity was associated with higher risk of mechanical ventilation (adjusted HR [aHR]: 1.77, 95% CI: 1.35-2.32) and mortality (aHR: 1.42, 95% CI: 1.12-1.78) compared with normal weight individuals. These associations were present primarily in patients younger than 65 and were attenuated or absent in older age groups (interaction P < 0.05). CONCLUSION: Veterans Affairs enrollees with higher BMI were more likely to test positive for SARS-CoV-2 and were more likely to be mechanically ventilated or die if infected with SARS-CoV-2. Higher BMI contributed relatively more to the risk of death in those younger than 65 years of age as compared with other age categories.


Subject(s)
Body Mass Index , COVID-19/epidemiology , Obesity/complications , Veterans/statistics & numerical data , Adolescent , Adult , Aged , Aged, 80 and over , COVID-19/complications , COVID-19/mortality , Cohort Studies , Female , Hospitalization , Humans , Intensive Care Units , Male , Middle Aged , Proportional Hazards Models , Respiration, Artificial , Risk Factors , Young Adult
19.
Addict Behav ; 113: 106692, 2021 02.
Article in English | MEDLINE | ID: covidwho-1064696

ABSTRACT

Despite a growing body of research examining correlates and consequences of COVID-19, few findings have been published among military veterans. This limitation is particularly concerning as preliminary data indicate that veterans may experience a higher rate of mortality compared to their civilian counterparts. One factor that may contribute to increased rates of death among veterans with COVID-19 is tobacco use. Indeed, findings from a recent meta-analysis highlight the association between lifetime smoking status and COVID-19 progression to more severe or critical conditions including death. Notably, prevalence rates of tobacco use are higher among veterans than civilians. Thus, the purpose of the current study was to examine demographic and medical variables that may contribute to likelihood of death among veterans testing positive for SARS-CoV-2. Additionally, we examined the unique influence of lifetime tobacco use on veteran mortality when added to the complete model. Retrospective chart reviews were conducted on 440 veterans (80.5% African American/Black) who tested positive for SARS-CoV-2 (7.3% deceased) at a large, southeastern Veterans Affairs (VA) hospital between March 11, 2020 and April 23, 2020, with data analysis occurring from May 26, 2020 to June 5, 2020. Older age, male gender, immunodeficiency, endocrine, and pulmonary diseases were positively related to the relative risk of death among SARS-CoV-2 positive veterans, with lifetime tobacco use predicting veteran mortality above and beyond these variables. Findings highlight the importance of assessing for lifetime tobacco use among SARS-CoV-2 positive patients and the relative importance of lifetime tobacco use as a risk factor for increased mortality.


Subject(s)
COVID-19/mortality , Endocrine System Diseases/epidemiology , Immunologic Deficiency Syndromes/epidemiology , Lung Diseases/epidemiology , Smoking/epidemiology , Veterans/statistics & numerical data , African Americans/statistics & numerical data , Age Factors , Aged , Female , Hospitals, Veterans , Humans , Male , Middle Aged , Retrospective Studies , Risk Factors , Sex Factors , Tobacco Use/epidemiology , United States/epidemiology , /statistics & numerical data
20.
Am J Phys Med Rehabil ; 100(1): 34-38, 2021 01 01.
Article in English | MEDLINE | ID: covidwho-1066487

ABSTRACT

OBJECTIVE: The aim of this study was to examine the impact of demographics, preexisting medical conditions, and in-hospital complications of COVID-19 infection on functional status at discharge. DESIGN AND PARTICIPANTS: A retrospective chart review was conducted on 119 patients hospitalized for COVID-19 infection between March 1, 2020, and April 20, 2020. Demographics, preexisting medical conditions, and newly diagnosed COVID-19 complications were collected from electronic medical records and entered in a deidentified database. MAIN OUTCOME: The primary outcome was functional status at discharge, as measured by independence in activities of daily living. RESULTS: Older age, respiratory failure, cardiac conditions, and thromboembolic complications all made a statistically significant contribution to functional dependence at discharge, with thromboembolic complications evincing the strongest association (odds ratio, 25.58). CONCLUSION AND RELEVANCE: New diagnosis of thrombosis during COVID-19 hospitalization, a measure of COVID-19 disease severity, was the factor most associated with dependence in activities of daily living at discharge. Interestingly, preexisting conditions including hypertension, severe obesity, lung disease, and diabetes did not correlate with dependent functional status at discharge.


Subject(s)
Activities of Daily Living , COVID-19/epidemiology , Cardiovascular Diseases/epidemiology , Functional Status , Patient Discharge/statistics & numerical data , Veterans/statistics & numerical data , Adult , Age Factors , Aged , COVID-19/therapy , Cardiovascular Diseases/therapy , Comorbidity , Female , Health Status , Humans , Male , Middle Aged , Retrospective Studies , Risk Factors
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