Updated Surveillance Metrics and History of the COVID-19 Pandemic (2020-2023) in Latin America and the Caribbean: Longitudinal Trend Analysis.

BACKGROUND: In May 2020, the World Health Organization (WHO) declared Latin America and the Caribbean (LAC) the epicenter of the COVID-19 pandemic, with over 40% of worldwide COVID-19-related deaths at the time. This high disease burden was a result of the unique circumstances in LAC. OBJECTIVE: This study aimed to (1) measure whether the pandemic was expanding or contracting in LAC when the WHO declared the end of COVID-19 as a public health emergency of international concern on May 5, 2023; (2) use dynamic and genomic surveillance methods to describe the history of the pandemic in the region and situate the window of the WHO declaration within the broader history; and (3) provide, with a focus on prevention policies, a historical context for the course of the pandemic in the region. METHODS: In addition to updates of traditional surveillance data and dynamic panel estimates from the original study, we used data on sequenced SARS-CoV-2 variants from the Global Initiative on Sharing All Influenza Data (GISAID) to identify the appearance and duration of variants of concern (VOCs). We used Nextclade nomenclature to collect clade designations from sequences and Pangolin nomenclature for lineage designations of SARS-CoV-2. Additionally, we conducted a 1-sided t test for whether the regional weekly speed (rate of novel COVID-19 transmission) was greater than an outbreak threshold of 10. We ran the test iteratively with 6 months of data across the period from August 2020 to May 2023. RESULTS: The speed of pandemic spread for the region had remained below the outbreak threshold for 6 months by the time of the WHO declaration. Acceleration and jerk were also low and stable. Although the 1- and 7-day persistence coefficients remained statistically significant for the 120-day period ending on the week of May 5, 2023, the coefficients were relatively modest in magnitude (0.457 and 0.491, respectively). Furthermore, the shift parameters for either of the 2 most recent weeks around May 5, 2023, did not indicate any change in this clustering effect of cases on future cases. From December 2021 onward, Omicron was the predominant VOC in sequenced viral samples. The rolling t test of speed=10 became entirely insignificant from January 2023 onward. CONCLUSIONS: Although COVID-19 continues to circulate in LAC, surveillance data suggest COVID-19 is endemic in the region and no longer reaches the threshold of the pandemic definition. However, the region experienced a high COVID-19 burden in the early stages of the pandemic, and prevention policies should be an immediate focus in future pandemics. Ahead of vaccination development, these policies can include widespread testing of individuals and an epidemiological task force with a contact-tracing system.

Middle East and North Africa: Updated Surveillance Metrics and History of the COVID-19 Pandemic (2020-2023)This study updates the COVID-19 pandemic surveillance in the Middle East and North Africa we first conducted in 2020 with two additional years of data for the region.

BACKGROUND: This study updates the COVID-19 pandemic surveillance in the Middle East and North Africa we first conducted in 2020 with two additional years of data for the region. OBJECTIVE: The objective of this study is to determine whether the Middle East and North Africa region meets the criteria for moving from a pandemic to endemic. In doing so, this study considers pandemic trends, dynamic and genomic surveillance methods, and region-specific historical context for the pandemic. These considerations continue through the World Health Organization (WHO) declaration of the end of the public health emergency for the COVID-19 pandemic on May 5, 2023. METHODS: In addition to updates of traditional surveillance data and dynamic panel estimates from the original study Post et al. (2021), this study used data on sequenced SARS-CoV-2 variants from the Global Initiative on Sharing All Influenza Data (GISAID) to identify the appearance and duration of variants of concern. We used Nextclade nomenclature to collect clade designations from sequences and Pangolin nomenclature for lineage designations of SARS-CoV-2. Finally, we conducted a one-sided t-test for whether regional weekly speed of COVID-19 spread was greater than an outbreak threshold of ten. We ran the test iteratively with six months of data from September 4, 2020, to May 12, 2023. RESULTS: The speed of COVID-19 spread for the region had remained below the outbreak threshold for seven continuous months by the time of the WHO declaration. Acceleration and jerk were also low and stable. While the 1- and 7-day persistence coefficients remained statistically significant and positive, the weekly shift parameters suggested the coefficients had most recently turned negative, meaning the clustering effect of new COVID-19 cases became even smaller in the two weeks around the WHO declaration. From December of 2021 onward, Omicron was the predominant variant of concern in sequenced viral samples. The rolling t-test of speed of spread equal to ten became entirely insignificant from October 2022 onward. CONCLUSIONS: The COVID-19 pandemic had far-reaching effects on MENA, impacting healthcare systems, economies, and social well-being. While COVID-19 continues to circulate in the Middle East and North Africa, the rate of transmission remained well below the threshold of an outbreak for over one year ahead of the WHO declaration. COVID-19 is endemic in the region and no longer reaches the threshold of the pandemic definition. Both standard and enhanced surveillance metrics confirm that the pandemic had transitioned to endemic by the time of the WHO declaration.

European Surveillance and History of the COVID-19 Pandemic: Updated Epidemiological Assessment.

BACKGROUND: COVID-19 surveillance plays a crucial role in monitoring the pandemic's progression and comprehending its impact on diverse regions. In this study, we build upon our initial research published in 2020 by incorporating an additional two years of data for Europe. We assess whether COVID-19 had shifted from pandemic to endemic in the region when the World Health Organization (WHO) declared the end of the public health emergency for the COVID-19 pandemic on May 5, 2023. OBJECTIVE: First, we measure whether there was an expansion or contraction in the pandemic in Europe at the time of the WHO declaration. Second, we use dynamic and genomic surveillance methods to describe the history of the pandemic in the region and situate the window of the WHO declaration within the broader history. Third, we provide the historical context for the course of the pandemic in Europe in terms of policy and disease burden at the country and region levels. METHODS: In addition to updates of traditional surveillance data and dynamic panel estimates from the original study Post et al. (2021), this study used data on sequenced SARS-CoV-2 variants from the Global Initiative on Sharing All Influenza Data (GISAID) to identify the appearance and duration of variants of concern. We used Nextclade nomenclature to collect clade designations from sequences and Pangolin nomenclature for lineage designations of SARS-CoV-2. Finally, we conducted a one-sided t-test for whether regional weekly speed was greater than an outbreak threshold of ten. We ran the test iteratively with six months of data across the sample period. RESULTS: Speed for the region had remained below the outbreak threshold for four months by the time of the WHO declaration. Acceleration and jerk were also low and stable. While the 1- and 7-day persistence coefficients remained statistically significant, the coefficients were moderate in magnitude (0.404 and 0.547, respectively). The shift parameters for the two weeks around the WHO declaration were small and insignificant, suggesting little change in the clustering effect of cases on future cases at the time. From December of 2021 onward, Omicron was the predominant variant of concern in sequenced viral samples. The rolling t-test of speed equal to ten became insignificant for the first time in April 2023. CONCLUSIONS: While COVID-19 continues to circulate in Europe, the rate of transmission remained below the threshold of an outbreak for four months ahead of the WHO declaration. The region had previously been in a nearly continuous state of outbreak. The more recent trend suggest COVID-19 was endemic in the region and no longer reached the threshold of the pandemic definition. However, several countries remained in a state of outbreak, and the conclusion that COVID-19 was no longer pandemic in Europe at the time is unclear.

Investigating the 2016 surge in firearm violence in Illinois, USA, through community-based organisations: a qualitative study.

BACKGROUND: Illinois experienced a historic firearm violence surge in 2016 with a decline to baseline rates in 2018. This study aimed to understand this 2016 surge through the direct accounts of violence prevention community-based organisations (CBOs) in Illinois. METHODS: We conducted semistructured interviews with 20 representatives from 13 CBOs from the south and west sides of greater Chicago metropolitan area. Interviews were audio recorded, coded and analysed thematically. RESULTS: We identified lack of government-derived infrastructure and systemic poverty as the central themes of Illinois's 2016 firearm violence surge. Participants highlighted the Illinois Budget Impasse halted funding for violence prevention efforts, leading to 2016's violence. This occurred in the context of a strained relationship with the criminal justice system, where disengagement from police and mistrust in the justice system led victims and families to seek justice outside of the judicial system. Participants emphasised that systemic poverty and the obliteration of community support structures led to overwhelming desperation, which, in turn, increased risky behaviours perceived as necessary for survival. Participants disproportionately identified that this impacted the young people in their communities. CONCLUSIONS: Lack of government-derived infrastructure and systemic poverty were the central themes of the 2016 firearm violence surge. The insights gained from the 2016 surge are applicable to understanding both current and future surges. CBOs focused on violence prevention offer insights into the context and conditions fuelling surges in the epidemic of violence.

Older adult drug overdose: an application of latent class analysis to identify prevention opportunities.

BACKGROUND: Older adult overdose death rates have increased significantly in recent years. However, research for prevention of drug overdose death specific to older adults is limited. Our objective is to identify profiles based on missed intervention points (touchpoints) to inform prevention of future older adult unintentional overdose deaths. METHODS: We used latent class analysis methods to identify profiles of decedents aged 55 + years in the Illinois Statewide Unintentional Drug Overdose Reporting System. This system collects data on 92.6% of all unintentional overdose deaths in Illinois and includes data from death certificates, coroner/medical examiner, toxicology, and autopsy reports. Data include decedent demographics, circumstances leading up to and surrounding the fatal overdose and details regarding the overdose. Variables in the latent class analysis model included sex, race, alcohol test result, social isolation, recent emergency department (ED) visit, chronic pain, and pain treatment. RESULTS: We identified three distinct decent profiles. Class 1 (13% of decedents) included female decedents who were in pain treatment, had physical health problems, and had greater likelihood of a recent ED visit before their death. Class 2 (35% of decedents) decedents were most likely to be socially connected (live with others, employed, had social or family relationships) but less likely to have recent healthcare visits. Class 3 (52% of decedents) decedents had higher social isolation (lived alone, unemployed, unpartnered), were mostly male, had fewer known physical health conditions, and more alcohol positivity at time of death. White decedents are clustered in class 1 while Black decedents are predominant in classes 2 and 3. CONCLUSIONS: These profiles link to potential touchpoint opportunities for substance use disorder screening harm reduction and treatment. Class 1 members were most likely to be reachable in healthcare settings. However, most decedents were members of Classes 2 and 3 with less engagement in the healthcare system, suggesting a need for screening and intervention in different contexts. For Class 2, intervention touchpoints might include education and screening in work or social settings such as senior centers given the higher degree of social connectivity. For Class 3, the most isolated group, touchpoints may occur in the context of harm reduction outreach and social service delivery.

Characteristics of child abuse fatalities: Insights from a statewide violent death reporting system.

BACKGROUND: Child maltreatment fatalities are a significant public health issue. Case level characteristics of abuse-related deaths can increase our understanding of maltreatment fatalities and inform region-specific prevention initiatives. OBJECTIVE: Explore child abuse fatalities in the Illinois Violent Death Reporting System (IVDRS) for commonalities and distinctive features. METHODS, PARTICIPANTS AND SETTING: A mixed methods study was conducted using IVDRS data from 2015 to 2018. All fatalities with a homicide or undetermined manner of death among decedents 10 years old or younger were included. Both discrete and narrative data were analyzed separately for victim, suspect, circumstance, and household characteristics. RESULTS: Of the 106 deaths that met inclusion criteria, 74 % of homicide deaths (64/86) and 50 % of undetermined deaths (10/20) were due to abuse. Psychosocial characteristics most often identified in abusive deaths included family relationship problems, mental illness, and history of substance abuse. Other common characteristics included use of personal weapons or blunt instruments and death due to punishment. Including narrative data rather than discrete data alone identified 148 % more deaths with three characteristics commonly found in abusive deaths: history of abuse, shaken baby syndrome, and family history of violence. CONCLUSION: This study demonstrates the capability of multi-source state-level data to enrich our understanding of child abuse fatalities. Employing the narrative review method in other states using the National Violent Death Reporting System may increase the identification of abuse fatalities. Improved recognition and characterization of abuse fatalities has the potential to help address systemic factors involved and enhance targeted prevention efforts. WHAT IS KNOWN: Child abuse fatalities represent a significant and preventable public health issue in the United States. Case-specific characteristics are limited in national data sets, and their absence curtails prevention opportunities. WHAT THIS STUDY ADDS: State-wide reporting systems of violent deaths offer rich and multisource data regarding child abuse fatalities including detailed victim, suspect, circumstance, and household characteristics. This data can be used to enhance our knowledge of maltreatment fatalities and may inform region-specific public health and prevention initiatives.

Health care and harm reduction provider perspectives on treating older adults who use non-medical opioids: a qualitative study set in Chicago.

BACKGROUND: Opioid overdose death rates are increasing for adults aged 55 and older, with especially high rates in large urban areas. In parallel, admissions to treatment programs for older adults using illicit substances are increasing as well. Despite these trends, there is a lack of information about older adults who use non-medical opioids (NMO) and even less knowledge about their health and service encounters. Conducted in Chicago, Illinois, this qualitative study explores the perspectives of health care and harm reduction service providers who work with older adults using non-medical opioids. METHODS: The study used snowball sampling to locate participants with expertise in working with older adults who use non-medical opioids. In total, we conducted 26 semi-structured interviews from September 2021-August 2022. We explored questions regarding participants' perceptions of older adult opioid use patterns, comorbidities, and involvement in harm reduction outreach and opioid use disorder treatment. RESULTS: Many of the providers we interviewed consider older adults who use NMO as a distinct population that employ unique use behaviors with the intent to protect them from opioid overdose. However, these same unique behaviors may potentiate their risk for overdose in today's climate. Providers report initial encounters that are not care seeking for opioid use and primarily oriented around health conditions. Older adults who use non-medical opioids are seen as complex patients due to the need to diagnostically untangle symptoms of substance use from co-morbidities and conditions associated with aging. Treatment for this population is also viewed as complicated due to the interactions between aging, comorbidities, and substance use. Providers also noted that older adults who use NMO have use behaviors that make them less visible to outreach and treatment service providers, potentially putting them at increased risk for overdose and health conditions associated with opioid use. CONCLUSIONS: Findings from this study are intended to inform future research on care provision for older adults who use non-medical opioids and may be especially applicable to large urban reas with histories of opioid use dating back to earlier drug epidemics of the 1970s, 1980s, and 1990s.

Changes in the Demographic Distribution of Chicago Gun-Homicide Decedents From 2015-2021: Violent Death Surveillance Cross-sectional Study.

BACKGROUND: Homicide is one of the 5 leading causes of death in the United States for persons aged 1 to 44 years. In 2019, 75% of US homicides were by gun. Chicago has a gun-homicide rate 4 times the national average, and 90% of all homicides are by gun. The public health approach to violence prevention calls for a 4-step process, beginning with defining and monitoring the problem. Insight into the characteristics of gun-homicide decedents can help frame next steps, including identifying risk and protective factors, developing prevention and intervention strategies, and scaling effective responses. Although much is known about gun homicide because it is a long-standing, entrenched public health problem, it is useful to monitor trends to update ongoing prevention efforts. OBJECTIVE: This study aimed to use public health surveillance data and methods to describe changes in the race/ethnicity, sex, and age of Chicago gun-homicide decedents from 2015-2021, in the context of year-to-year variation and an overall increase in the city's gun-homicide rate. METHODS: We calculated the distribution of gun-related homicide deaths by 6 race/ethnicity and sex groups (non-Hispanic Black female, non-Hispanic White female, Hispanic female, non-Hispanic Black male, non-Hispanic White male, and Hispanic male), age in years, and age by age group. We used counts, percentages, and rates per 100,000 persons to describe the distribution of deaths among these demographic groups. Comparisons of means and column proportions with tests of significance set at P≤.05 were used to describe changes in the distribution of gun-homicide decedents over time by race-ethnicity-sex and age groups. The comparison of mean age by race-ethnicity-sex group is done using 1-way ANOVA with significance set at P≤.05. RESULTS: The distribution of gun-homicide decedents in Chicago by race/ethnicity and sex groups had been relatively stable from 2015 to 2021 with 2 notable exceptions: a more than doubling of the proportion of gun-homicide decedents who were non-Hispanic Black female (3.6% in 2015 to 8.2% in 2021) and an increase of 3.27 years in the mean age of gun-homicide decedents. The increase in mean age coincided with a decrease in the proportion of non-Hispanic Black male gun-homicide decedents between the ages of 15-19 and 20-24 years and, conversely, an increase in the proportion of non-Hispanic Black male gun-homicide decedents aged 25-34 years. CONCLUSIONS: The annual gun-homicide rate in Chicago had been increasing since 2015 with year-to-year variation. Continued monitoring of trends in the demographic makeup of gun-homicide decedents is necessary to provide the most relevant and timely information to help shape violence prevention efforts. We detected several changes that suggest a need for increased outreach and engagement marketed toward non-Hispanic Black female and non-Hispanic Black male individuals between the ages of 25-34 years.

Prevalence of Alcohol in Unintentional Opioid Overdose Deaths, 2017-2020.

This cross-sectional study investigates the prevalence of alcohol in unintentional opioid overdose deaths in Illinois from 2017 through 2020.

The Association Between Adolescent Active Commuting to School and Parent Walking Behavior: The FLASHE Study.

PURPOSE: To examine the relationship between adolescent active commuting to school (ACS; walking or biking to/from school) and parent walking activity. DESIGN: Cross-sectional. SETTING: US nationwide online surveys. SAMPLE: 1367 parent-adolescent (12-17 years) dyads among the Family Life, Activity, Sun, Health, and Eating (FLASHE) study participants (29.4% response rate). MEASURES: Online surveys asked about adolescent ACS and parent walking activity in the past week. Adolescents who reported ACS at least once in the past week were categorized as engaging in ACS. Parent walking frequency was categorized into 0-2, 3-5, and 6-7 days. ANALYSIS: Logistic regression analysis was conducted to compare the probability of adolescent ACS by parent walking activity, adjusted for sociodemographic factors and adolescent-, parent-, and neighborhood-level covariates. RESULTS: 28.5% of adolescents engaged in ACS at least once in the past week. Compared to 0-2 days/week of parent walking activity, ORs for adolescent ACS for 3-5 and 6-7 days/week of parent walking activity were 1.98 (95% CI=1.38-2.87) and 1.81 (1.23-2.68), respectively. In stratified analyses by parent and adolescent sex, father-son dyads presented the strongest association between adolescent ACS and parent walking 3-5 and 6-7 days/week (ORs=4.17 [1.46-11.91] and 3.95 [1.45-10.77], respectively). CONCLUSIONS: Adolescents with parents who engaged in walking activity ≥3 days/week were more likely to actively commute to school. Parent walking activity may have positive intergenerational effects on adolescent ACS and physical activity.

Disparities by Sex and Race and Ethnicity in Death Rates Due to Opioid Overdose Among Adults 55 Years or Older, 1999 to 2019.

Importance: Rates of opioid overdose deaths are increasing for older adults. Less is known about these deaths compared with those of younger adults. Objective: To analyze rate variation among opioid overdose deaths in older adults by sex and by race and ethnicity over time. Design, Setting, and Participants: This 21-year longitudinal cross-sectional study of adults who died due to opioid overdose at 55 years or older stratified by sex and by race and ethnicity used data from the Multiple Cause of Death database from the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research. The data include all opioid overdose deaths among this age group that occurred between January 1, 1999, and December 31, 2019 (N = 79 893). Exposures: Sex and racial and ethnic groups. Main Outcomes and Measures: Rates of opioid overdose deaths per 100 000 population by sex and by race and ethnicity for persons 55 years or older. Results: During the period 1999 to 2019, 79 893 US residents 55 years or older died due to an opioid overdose. Among these individuals, 79.97% were aged 55 to 64 years, and 58.98% were men. Annual numbers of deaths increased over time from 518 in 1999 to 10 292 in 2019. Annual rates of opioid overdose deaths per 100 000 persons 55 years or older increased over time and ranged from 0.90 in 1999 to 10.70 in 2019. Substantial variation by sex and by race and ethnicity was found. In 2013, rates among non-Hispanic Black men began to diverge from those of other demographic subgroups. By 2019, the opioid overdose fatality rate among non-Hispanic Black men 55 years or older was 40.03 per 100 000 population, 4 times greater than the overall opioid overdose fatality rate of 10.70 per 100 000 for persons of the same age. Conclusions and Relevance: In this longitudinal cross-sectional study of US adults who died due to opioid overdose, the burden of opioid overdose deaths among older adults since 2013 was most concentrated among non-Hispanic Black men. Deaths among non-Hispanic Black men were disproportionality represented in the overall increase in the rate of opioid overdose deaths among older adults. Further research is needed to inform policy and practice.

Association between youth homicides and state spending: a Chicago cross-sectional case study.

OBJECTIVE: To identify contributing factors associated with rapid spikes and declines in Chicago youth homicide from 2009 to 2018. SETTING: City of Chicago, Illinois, US 2009-2018. PARTICIPANTS: Homicide count data come from the National Violent Death Reporting System. The study included information on 2271 homicide decedents between the ages of 15 and 24 who died between 1 January 2009 and 31 December 2018. Of these decedents, 92.9% were male; 79.1% were non-Hispanic black; and 94.9% died from a firearm injury. PRIMARY AND SECONDARY OUTCOME MEASURES: (A) Temporal shifts in monthly homicide rates and (B) temporal associations between social, environmental and economic conditions/events and fluctuations in homicides. RESULTS: We found statistically significant shifts in homicide rates over time: a 77% rise in monthly youth homicide rates per 100 000 persons from 2015 to 2016 (4.3 vs 7.5); dropping back to pre-2015 rates (4.3) by mid-2017. There was a temporal co-occurrence between the rapid rise in youth homicides and absence of a state budget. Conversely, we found a temporal co-occurrence of the sharp decline in homicides with the reinstatement of a state budget. Adjusting for seasonality, we found death rates were greater in the months without a budget compared with months with a budget (1.48, 95% CI 1.29 to 1.70). CONCLUSIONS: Our findings suggest that state funding may be a potential protective factor against youth homicide.

Community Versus Hospital Opioid-Related Overdose Deaths in Illinois.

OBJECTIVE: To better understand approaches to reducing mortality from the opioid epidemic, we analyzed in-hospital versus community opioid-related overdose deaths in Illinois. METHODS: We used data from the Statewide Unintentional Drug Overdose Reporting System (July 2017 through December 2018) to identify deaths that occurred in hospitals and communities (ie, homes or public spaces). We used census tract-level data for 34 Illinois counties to create bivariate mapping by overdose death rates. We used logistic regression to analyze the association of demographic and overdose characteristics with the likelihood of death in a hospital versus a community. RESULTS: During the study period, 2833 opioid-related overdose deaths occurred in 24 Illinois counties, 655 (23.1%) of which occurred in the hospital; of 2178 community deaths, 1888 (86.7%) occurred in the same census tract as the decedent's recorded residence and 1285 (59.0%) occurred in the decedent's home. Non-Hispanic Black people were 1.63 (95% CI, 1.27-2.10) times more likely than non-Hispanic White people to die in a hospital. Decedents from suburban Cook County and other Chicago suburban counties were significantly more likely to die in the hospital than decedents from Chicago or other Illinois counties. Documentation of a previous overdose, history of opioid use, and having bystanders present were significantly associated with hospital deaths. Evidence of a rapid overdose, fentanyl present, or prescription opioids were significantly associated with deaths in a community. CONCLUSIONS: The high number of opioid-related overdose deaths in the community illustrates the need to decriminalize illicit drug use and facilitate treatment seeking. Establishing supervised safe consumption sites may have the biggest effect in reducing the number of opioid-related overdose deaths.

Documentation of Screening for Firearm Access by Healthcare Providers in the Veterans Healthcare System: A Retrospective Study.

INTRODUCTION: Presence of a firearm is associated with increased risk of violence and suicide. United States military veterans are at disproportionate risk of suicide. Routine healthcare provider screening of firearm access may prompt counseling on safe storage and handling of firearms. The objective of this study was to determine the frequency with which Veterans Health Administration (VHA) healthcare providers document firearm access in electronic health record (EHR) clinical notes, and whether this varied by patient characteristics. METHODS: The study sample is a post-9-11 cohort of veterans in their first year of VHA care, with at least one outpatient care visit between 2012-2017 (N = 762,953). Demographic data, veteran military service characteristics, and clinical comorbidities were obtained from VHA EHR. We extracted clinical notes for outpatient visits to primary, urgent, or emergency clinics (total 105,316,004). Natural language processing and machine learning (ML) approaches were used to identify documentation of firearm access. A taxonomy of firearm terms was identified and manually annotated with text anchored by these terms, and then trained the ML algorithm. The random-forest algorithm achieved 81.9% accuracy in identifying documentation of firearm access. RESULTS: The proportion of patients with EHR-documented access to one or more firearms during their first year of care in the VHA was relatively low and varied by patient characteristics. Men had significantly higher documentation of firearms than women (9.8% vs 7.1%; P < .001) and veterans >50 years old had the lowest (6.5%). Among veterans with any firearm term present, only 24.4% were classified as positive for access to a firearm (24.7% of men and 20.9% of women). CONCLUSION: Natural language processing can identify documentation of access to firearms in clinical notes with acceptable accuracy, but there is a need for investigation into facilitators and barriers for providers and veterans to improve a systemwide process of firearm access screening. Screening, regardless of race/ethnicity, gender, and age, provides additional opportunities to protect veterans from self-harm and violence.

The Interplay Between Policy and COVID-19 Outbreaks in South Asia: Longitudinal Trend Analysis of Surveillance Data.

BACKGROUND: COVID-19 transmission rates in South Asia initially were under control when governments implemented health policies aimed at controlling the pandemic such as quarantines, travel bans, and border, business, and school closures. Governments have since relaxed public health restrictions, which resulted in significant outbreaks, shifting the global epicenter of COVID-19 to India. Ongoing systematic public health surveillance of the COVID-19 pandemic is needed to inform disease prevention policy to re-establish control over the pandemic within South Asia. OBJECTIVE: This study aimed to inform public health leaders about the state of the COVID-19 pandemic, how South Asia displays differences within and among countries and other global regions, and where immediate action is needed to control the outbreaks. METHODS: We extracted COVID-19 data spanning 62 days from public health registries and calculated traditional and enhanced surveillance metrics. We use an empirical difference equation to measure the daily number of cases in South Asia as a function of the prior number of cases, the level of testing, and weekly shifts in variables with a dynamic panel model that was estimated using the generalized method of moments approach by implementing the Arellano-Bond estimator in R. RESULTS: Traditional surveillance metrics indicate that South Asian countries have an alarming outbreak, with India leading the region with 310,310 new daily cases in accordance with the 7-day moving average. Enhanced surveillance indicates that while Pakistan and Bangladesh still have a high daily number of new COVID-19 cases (n=4819 and n=3878, respectively), their speed of new infections declined from April 12-25, 2021, from 2.28 to 2.18 and 3.15 to 2.35 daily new infections per 100,000 population, respectively, which suggests that their outbreaks are decreasing and that these countries are headed in the right direction. In contrast, India's speed of new infections per 100,000 population increased by 52% during the same period from 14.79 to 22.49 new cases per day per 100,000 population, which constitutes an increased outbreak. CONCLUSIONS: Relaxation of public health restrictions and the spread of novel variants fueled the second wave of the COVID-19 pandemic in South Asia. Public health surveillance indicates that shifts in policy and the spread of new variants correlate with a drastic expansion in the pandemic, requiring immediate action to mitigate the spread of COVID-19. Surveillance is needed to inform leaders whether policies help control the pandemic.

Using Critical Race Theory to Understand Trial Participation Among Black Individuals With Systemic Lupus Erythematosus: A Qualitative Study of Patients and Caregivers.

OBJECTIVE: Black patients with systemic lupus erythematous (SLE) experience greater disease incidence and severity than White patients, and yet they are underrepresented in SLE clinical trials. We applied Critical Race Theory to qualitatively explore the influence of racism on the underrepresentation of Black patients in SLE clinical trials and to develop a framework for future intervention. METHODS: We conducted focus group sessions in Chicago and Boston with Black adults (ages ≥18 years) with SLE and their caregivers. We queried the participants about their knowledge regarding clinical trials, factors that might motivate or hinder trial participation, and how race and experiences of racism might impact clinical trial participation. Focus group responses were transcribed verbatim and analyzed thematically. RESULTS: We held 4 focus groups (n = 31 participants); 20 participants had SLE, and 11 were caregivers. All participants were Black, 90% were women, and the mean age was 54 years. Qualitative analyses revealed several themes that negatively impact trial participation, including mistrust related to racism, concerns about assignment to placebo groups, strict study exclusion criteria, and SLE-related concerns. Factors that motivated trial participation included recommendations from physicians and reputable institutions, a desire to help the greater good, and culturally sensitive marketing of trials. CONCLUSION: Actions to improve clinical trial participation among Black individuals should focus on reframing how trial information is presented and disseminated and on reevaluating barriers that may restrict trial participation. Additionally, researchers must acknowledge and respond to the presence of racial bias in health care. Community-academic partnerships may help build trust and reduce fears of mistreatment among Black individuals with SLE.

A cross-sectional study of opioid involvement in non-poisoning suicide - risks and prevention opportunities.

OBJECTIVE: To examine prevalence, demographic, and incident factors associated with opioid-positivity in Illinois suicide decedents who died by causes other than poisoning. METHOD: Cross-sectional study of Illinois' suicide decedents occurring between January 2015 and December 2017. Data come from the National Violent Death Reporting System. We used Chi-square tests to compare decedent and incident circumstance characteristics by opioid toxicology screen status. Incident narratives were analyzed to obtain physical and mental health histories and circumstances related to fatal injury events. RESULTS: Of 1007 non-poisoning suicide decedents screened for opioids, 16.4% were opioid-positive. White race, age 75 and over, and widowed or unknown marital status were associated with opioid-positivity. Among opioid-positive decedents, 25% had a history of substance use disorder (SUD), 61% depression, and 19% anxiety. The majority (52%) of opioid-positive decedents died by firearm, a higher percentage than opioid-negative decedents. CONCLUSION: The opioid overdose crisis largely has not overlapped with non-poisoning suicide in this study. Overall, our analyses have not identified additional risk factors for suicide among opioid-positive suicide decedents. However, the overlap between opioid-positivity, SUD, and physical and mental health problems found among decedents in our data suggest several suicide prevention opportunities. These include medication assisted treatment for SUD which has been shown to reduce suicide, screening for opioid/benzodiazepine overlap, and limiting access to lethal means during opioid use. Improved death scene investigations for substances and use of the Prescription Drug Monitoring Program to document prescriptions are needed to further understanding of the role of substances in non-poisoning suicide.