H5N1

Association of social and economic inequality with COVID-19 incidence and mortality across US counties

Via JAMA Network: Association of Social and Economic Inequality With Coronavirus Disease 2019 Incidence and Mortality Across US Counties. The key points and abstract:

Key Points 

Question  Are racial/ethnic population composition and economic inequality associated with coronavirus disease 2019 (COVID-19) incidence and mortality?  

Findings  This cross-sectional ecological analysis of cumulative COVID-19 incidence and mortality rates for the first 200 days of the pandemic in 3141 US counties confirmed positive associations of incidence and mortality rates with racial/ethnic composition and with income inequality well as a joint association of incidence and mortality with both structural factors.  

Meaning  This study suggests that COVID-19 surveillance systems should take into account county-level income inequality to better understand the social patterning of COVID-19. 

Abstract 

Importance  It is now established that across the United States, minoritized populations have borne a disproportionate burden from coronavirus disease 2019 (COVID-19). However, little is known about the interaction among a county’s racial/ethnic composition, its level of income inequality, political factors, and COVID-19 outcomes in the population. 

Objective  To quantify the association of economic inequality, racial/ethnic composition, political factors, and state health care policy with the incidence and mortality burden associated with COVID-19. 

Design, Setting, and Participants  This cross-sectional study used data from the 3142 counties in the 50 US states and for Washington, DC. Data on the first 200 days of the COVID-19 pandemic, from the first confirmed US case on January 22 to August 8, 2020, were gathered from the Centers for Disease Control and Prevention and USAFacts.org, the US Census Bureau, the American Community Survey, GitHub, the Kaiser Family Foundation, the Council of State Governments, and the National Governors Association.  

Exposures  Racial/ethnic composition was determined as percentage of the population that is Black or Hispanic; income inequality, using the Gini index; politics, political affiliation and sex of the state governor, gubernatorial term limits, and percentage of the county’s population that voted Republican in 2016; and state health care policy, participation in the expansion of Medicaid under the Affordable Care Act. Six additional covariates were assessed. 

Main Outcomes and Measures  Cumulative COVID-19 incidence and mortality rates for US counties during the first 200 days of the pandemic. Main measures include percentage Black and Hispanic population composition, income inequality, and a set of additional covariates. 

Results  This study included 3141 of 3142 US counties. The mean Black population was 9.365% (range, 0-86.593%); the mean Hispanic population was 9.754% (range, 0.648%-96.353%); the mean Gini ratio was 44.538 (range, 25.670-66.470); the proportion of counties within states that implemented Medicaid expansion was 0.577 (range, 0-1); the mean number of confirmed COVID-19 cases per 100 000 population was 1093.882 (range, 0-14 019.852); and the mean number of COVID-19–related deaths per 100 000 population was 26.173 (range, 0-413.858). 

A 1.0% increase in a county’s income inequality corresponded to an adjusted risk ratio (RR) of 1.020 (95% CI, 1.012-1.027) for COVID-19 incidence and adjusted RR of 1.030 (95% CI, 1.012-1.047) for COVID-19 mortality. Inequality compounded the association of racial/ethnic composition through interaction, with higher income inequality raising the intercepts of the incidence curve RR by a factor of 1.041 (95% CI, 1.031-1.051) and that of the mortality curve RR by a factor of 1.068 (95% CI, 1.042-1.094) but slightly lowering their curvatures, especially for Hispanic composition. 

When state-level specificities were controlled, none of the state political factors were associated with COVID-19 incidence or mortality. However, a county in a state with Medicaid expansion implemented would see the incidence rate RR decreased by a multiplicative factor of 0.678 (95% CI, 0.501-0.918).  

Conclusions and Relevance  This county-level ecological analysis suggests that COVID-19 surveillance systems should account for county-level income inequality to better understand the social patterning of COVID-19 incidence and mortality. High levels of income inequality may harm population health irrespective of racial/ethnic composition.

Children's role in transmission of UK variant needs investigation, expert says

Via Yle Uutiset: Children's role in transmission of UK variant needs investigation, expert says.

As health authorities across Europe closely monitor the mutated UK's coronavirus strain, concern is growing about the potential that the new variant could be more virulent among children.  

Researchers have estimated that the UK variant is around 50 to 70 percent more contagious than the more commonly seen form of the virus.  

The variant has spread rapidly in Ireland and there are also indications that it is in circulation in Denmark, for example, according to epidemiologist Pasi Penttinen, a leading expert at the European Centre for Disease Prevention and Control (ECDC). 

"There are no signs [the variant] causes more serious illness. However, the first results of a study suggest that [current] vaccines will work against the UK variant," Penttinen said. 

The epidemiologist said a major question that needs to be answered is the new variant's virulence as well as the role that children might have in its spread, noting the risk that possible changes to the virus' structure could also cause changes in which population groups might become infected by it. 

Penttinen said that there have been slight indications of this possibility in early stages of research on the topic. 

"Fortunately, the data in the past few days show that there may be no change to the previous [variant], but this is still the subject of rigorous research. I believe that more detailed information will be available in the coming days or weeks," he said. 

Until very recently, it was thought that the role of children in spreading coronavirus was not as significant as, for example, in the spread of influenza or respiratory syncytial (RS) virus. 

Situation serious in Europe 

If it is found that the mutated variant spreads more easily through children, it would potentially have far-reaching implications for the governments' coronavirus policies, such as the possibility of shutting down schools and daycare centres. 

"Some very difficult discussions have been going on in many European countries about the role of school closures in tackling the pandemic, and many countries have kept primary schools and daycare centres open. That is the first thing to consider, if it's found that children play a more significant role in the spread of the disease, regarding the new variants," he said. 

Due to a slower than anticipated rollout, coronavirus vaccines haven't yet made much progress in fighting the disease in Europe or Finland. Penttinen said the situation is very difficult in some parts of Europe, adding that he thinks the fight against Covid-19 will continue for another year but that some progress has been made. 

"It is a very positive development that we are getting the high risk groups vaccinated, so in the coming months we will certainly reduce the risk of people getting seriously ill and we will reduce the fatal consequences at the European level," he said. 

However, inoculating the elderly and other risk groups will not be enough to get the overall epidemic under control, Penttinen warned, adding that virtually everyone over the age of 40 who gets Covid is at a degree of risk of being hospitalised, requiring ICU treatment or even dying from the disease.  

"Even though the vaccine is being distributed and it will reduce serious consequences at the European level in the short term, the disease will not go away in the coming months. We must have the readiness and perseverance to continue restrictive measures until an adequate vaccine coverage is reached among the adult population," Penttinen said.

Sweden failed to protect elderly in COVID-19 pandemic, commission finds

Via Reuters: Sweden failed to protect elderly in COVID pandemic, commission finds. Excerpt:

STOCKHOLM (Reuters) - Sweden failed to protect elderly people during the pandemic with the high level of community spread likely the biggest factor as the coronavirus ravaged ill-prepared nursing homes, an initial report by an official commission said on Tuesday. 

Sweden’s pandemic strategy, shunning lockdowns and masks, has stood out internationally. It left schools, restaurants and businesses largely open while appealing to people to socially distance and maintain good hygiene. 

When announced during the spring, the strategy was coupled with a goal to “ring-fence” the elderly from COVID-19. But as deaths mounted, above all at nursing homes, the commission was appointed to asses the response. 

In the commission’s first findings, it said the overall spread and previously known structural problems within the elderly care system, for which the current and previous governments were ultimately responsible, were to blame for the many deaths.    

“These shortcomings meant that elderly care was unprepared and ill-equipped to deal with a pandemic,” the commission said in a statement. “The employees in elderly care were largely left alone to handle the crisis situation.”  

The strategy has been called reckless and cruel but also won praise from people seeing it as more sustainable and business-friendly. Just under half of Sweden’s almost 7,700 deaths have been nursing home residents. 

The commission also said measures by the government and governmental agencies to protect the elderly during the spring had come too late. “We also assess that the measures were insufficient in several respects,” it added.

European COVID-19 cases are surging but the death rates remain low – for now

Via The Globe and Mail, Eric Reguly writes: European COVID-19 cases are surging but the death rates remain low – for now. Excerpt:

Cases of COVID-19 are climbing across Europe but some scientists and doctors are hesitant to call it a full-blown second wave even though a few countries are seeing record or near-record daily infections. 

The reason: The fatality rates – so far – are not nearly as high as they were during the peak of the pandemic, in March and April, when most of the continent was in tight lockdown for fear that hundreds of thousands, even millions, of people would lose their lives to the deadly novel coronavirus. 

“I’m hesitant to call it a second wave,” said Martin McKee, professor of European public health at the London School of Hygiene and Tropical Medicine. “A better term might be resurgence.”  

There is no doubt a resurgence is under way. In June and into July, new cases in the big European countries fell to several hundred a day, or less. Since then, the caseloads have steadily increased, triggering a new round of restrictions ranging from mandatory mask use once you leave the house, as the Italian government has ordered, to the partial lockdowns of Madrid and other cities where the health authorities are trying to keep the hospitals from being overwhelmed with COVID-19 patients.  

Italy on Friday topped 5,000 new cases for the first time since March. They rose to 5,901 on Tuesday. Italy has been praised by the World Health Organization for keeping its new caseload relatively low, though the rising numbers suggest the country still faces a formidable challenge to control the pandemic.  

On Saturday, France reported almost 27,000 new cases, a record daily high. Britain has often recorded 15,000 or more new cases a day in recent weeks. Britain is at a “tipping point,” Jonathan Van-Tam, the country’s deputy chief medical officer, said on Sunday.  

While the relentless rise in caseloads has made many fearful of new national lockdowns, which would plunge already reeling economies back into deep recession, the number of fatalities suggests that worst-case scenario – tens of thousand of new deaths a day or worse – might be avoided. 

Italy, for instance, was recording between 500 and 900 new deaths a day from late March to late April. In recent weeks, the daily death count has been running in the low double digits, even as the infections have climbed. On Tuesday, Italy saw 41 pandemic deaths, a recent high. 

France has fared somewhat worse, with 50 to 150 new deaths a day in recent weeks, though they are well short of the record 1,437 deaths seen on April 15. The European worry spot is Spain, where the numbers are triggering anxiety among health authorities. There, new deaths have reached 250 or more on some days since early September. Still, they are a quarter or less of the levels seen in March and April.

Horton: COVID-19 is not a pandemic

In The Lancet, editor Richard Horton makes an important point: Offline: COVID-19 is not a pandemic.

As the world approaches 1 million deaths from COVID-19, we must confront the fact that we are taking a far too narrow approach to managing this outbreak of a new coronavirus. We have viewed the cause of this crisis as an infectious disease. All of our interventions have focused on cutting lines of viral transmission, thereby controlling the spread of the pathogen. The “science” that has guided governments has been driven mostly by epidemic modellers and infectious disease specialists, who understandably frame the present health emergency in centuries-old terms of plague. 

But what we have learned so far tells us that the story of COVID-19 is not so simple. Two categories of disease are interacting within specific populations—infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and an array of non-communicable diseases (NCDs). These conditions are clustering within social groups according to patterns of inequality deeply embedded in our societies. The aggregation of these diseases on a background of social and economic disparity exacerbates the adverse effects of each separate disease. 

COVID-19 is not a pandemic. It is a syndemic. The syndemic nature of the threat we face means that a more nuanced approach is needed if we are to protect the health of our communities. 

The notion of a syndemic was first conceived by Merrill Singer, an American medical anthropologist, in the 1990s. Writing in The Lancet in 2017, together with Emily Mendenhall and colleagues, Singer argued that a syndemic approach reveals biological and social interactions that are important for prognosis, treatment, and health policy. Limiting the harm caused by SARS-CoV-2 will demand far greater attention to NCDs and socioeconomic inequality than has hitherto been admitted. 

A syndemic is not merely a comorbidity. Syndemics are characterised by biological and social interactions between conditions and states, interactions that increase a person's susceptibility to harm or worsen their health outcomes. In the case of COVID-19, attacking NCDs will be a prerequisite for successful containment. As our recently published NCD Countdown 2030 showed, although premature mortality from NCDs is falling, the pace of change is too slow. The total number of people living with chronic diseases is growing. Addressing COVID-19 means addressing hypertension, obesity, diabetes, cardiovascular and chronic respiratory diseases, and cancer. 

Paying greater attention to NCDs is not an agenda only for richer nations. NCDs are a neglected cause of ill-health in poorer countries too. In their Lancet Commission, published last week, Gene Bukhman and Ana Mocumbi described an entity they called NCDI Poverty, adding injuries to a range of NCDs—conditions such as snake bites, epilepsy, renal disease, and sickle cell disease. For the poorest billion people in the world today, NCDIs make up over a third of their burden of disease. The Commission described how the availability of affordable, cost-effective interventions over the next decade could avert almost 5 million deaths among the world's poorest people. And that is without considering the reduced risks of dying from COVID-19.

The most important consequence of seeing COVID-19 as a syndemic is to underline its social origins. The vulnerability of older citizens; Black, Asian, and minority ethnic communities; and key workers who are commonly poorly paid with fewer welfare protections points to a truth so far barely acknowledged—namely, that no matter how effective a treatment or protective a vaccine, the pursuit of a purely biomedical solution to COVID-19 will fail. 

Unless governments devise policies and programmes to reverse profound disparities, our societies will never be truly COVID-19 secure. As Singer and colleagues wrote in 2017, “A syndemic approach provides a very different orientation to clinical medicine and public health by showing how an integrated approach to understanding and treating diseases can be far more successful than simply controlling epidemic disease or treating individual patients.” 

I would add one further advantage. Our societies need hope. The economic crisis that is advancing towards us will not be solved by a drug or a vaccine. Nothing less than national revival is needed. 

Approaching COVID-19 as a syndemic will invite a larger vision, one encompassing education, employment, housing, food, and environment. Viewing COVID-19 only as a pandemic excludes such a broader but necessary prospectus.

Prevalence of SARS-CoV-2 antibodies in a large nationwide sample of patients on dialysis in the USA: A cross-sectional study

Via The Lancet: Prevalence of SARS-CoV-2 antibodies in a large nationwide sample of patients on dialysis in the USA: a cross-sectional study. The summary:

Background 

Many patients receiving dialysis in the USA share the socioeconomic characteristics of underserved communities, and undergo routine monthly laboratory testing, facilitating a practical, unbiased, and repeatable assessment of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) seroprevalence. 

Methods 

For this cross-sectional study, in partnership with a central laboratory that receives samples from approximately 1300 dialysis facilities across the USA, we tested the remainder plasma of 28 503 randomly selected adult patients receiving dialysis in July, 2020, using a spike protein receptor binding domain total antibody chemiluminescence assay (100% sensitivity, 99·8% specificity). 

We extracted data on age, sex, race and ethnicity, and residence and facility ZIP codes from the anonymised electronic health records, linking patient-level residence data with cumulative and daily cases and deaths per 100 000 population and with nasal swab test positivity rates. 

We standardised prevalence estimates according to the overall US dialysis and adult population, and present estimates for four prespecified strata (age, sex, region, and race and ethnicity). 

Findings 

The sampled population had similar age, sex, and race and ethnicity distribution to the US dialysis population, with a higher proportion of older people, men, and people living in majority Black and Hispanic neighbourhoods than in the US adult population. Seroprevalence of SARS-CoV-2 was 8·0% (95% CI 7·7–8·4) in the sample, 8·3% (8·0–8·6) when standardised to the US dialysis population, and 9·3% (8·8–9·9) when standardised to the US adult population. 

When standardised to the US dialysis population, seroprevalence ranged from 3·5% (3·1–3·9) in the west to 27·2% (25·9–28·5) in the northeast. Comparing seroprevalent and case counts per 100 000 population, we found that 9·2% (8·7–9·8) of seropositive patients were diagnosed. When compared with other measures of SARS-CoV-2 spread, seroprevalence correlated best with deaths per 100 000 population (Spearman's ρ=0·77). 

Residents of non-Hispanic Black and Hispanic neighbourhoods experienced higher odds of seropositivity (odds ratio 3·9 [95% CI 3·4–4·6] and 2·3 [1·9–2·6], respectively) compared with residents of predominantly non-Hispanic white neighbourhoods. Residents of neighbourhoods in the highest population density quintile experienced increased odds of seropositivity (10·3 [8·7–12·2]) compared with residents of the lowest density quintile. County mobility restrictions that reduced workplace visits by at least 5% in early March, 2020, were associated with lower odds of seropositivity in July, 2020 (0·4 [0·3–0·5]) when compared with a reduction of less than 5%. 

Interpretation 

During the first wave of the COVID-19 pandemic, fewer than 10% of the US adult population formed antibodies against SARS-CoV-2, and fewer than 10% of those with antibodies were diagnosed. Public health efforts to limit SARS-CoV-2 spread need to especially target racial and ethnic minority and densely populated communities.

See also this Washington Post report on the study.

Changing age distribution of the COVID-19 pandemic — United States, May–August 2020

Via MMWR: Changing Age Distribution of the COVID-19 Pandemic — United States, May–August 2020. The summary:

What is already known about this topic?  

Early in the pandemic, COVID-19 incidence was highest among older adults. 

What is added by this report?  

During June–August 2020, COVID-19 incidence was highest in persons aged 20–29 years, who accounted for >20% of all confirmed cases. Younger adults likely contribute to community transmission of COVID-19. Across the southern United States in June 2020, increases in percentage of positive SARS-CoV-2 test results among adults aged 20–39 years preceded increases among those aged ≥60 years by 4–15 days.  

What are the implications for public health practice? 

Strict adherence to community mitigation strategies and personal preventive behaviors by younger adults is needed to help reduce infection and subsequent transmission to persons at higher risk for severe illness.

Dutch COVID-19 infections jump to highest level since April

Via Reuters: Dutch coronavirus infections jump to highest level since April.

AMSTERDAM (Reuters) - The number of new coronavirus infections in the Netherlands jumped 51% last week to their highest level since the end of April, Dutch health authorities said on Tuesday. 

Newly confirmed infections increased to 5,427 in the week to Tuesday, up from 3,597 in the previous week, while the total number of tests rose 10% to little over 180,000.  

Coronavirus cases in the Netherlands had been stable at about 3,500 per week in recent weeks, after the easing of lockdown measures in July was followed by a steady rise to over 4,000 in early August. 

The largest increase of infections last week was among people aged 20 to 24, the health authorities said, while most of the newly infected were found to have contracted the virus at home.

COVID-19 cases in Europe back to March level: ECDC

Via Reuters: COVID-19 cases in Europe back to March level, EU health body says. Excerpt:

BRUSSELS (Reuters) - COVID-19 infections in Europe are back to levels seen in March when the outbreak began its peak phase there, the head of the European Union’s public health agency said on Wednesday, noting however school reopenings did not necessarily pose new risks.

“The virus has not been sleeping over the summer. It did not take vacation,” Andrea Ammon, head of the European Centre for Disease Prevention and Control (ECDC), told EU lawmakers in a regular hearing.  

She said this week’s data showed that across Europe there were 46 cases per 100,000 people. “We are almost back to numbers that we have seen in March,” Ammon said. 

Infections in March in Europe began growing steadily to about 40 per 100,000 people at the end of the month, according to ECDC data, and kept increasing to around 70 per 100,000 by the end of April. 

The current increase of cases was due in part to more testing.  

New cases also concern largely younger people, she said, a new pattern that had resulted in stable hospitalization numbers, as the illness is more serious for older people who were hit hard in March and April.  

However, Ammon said hospitalizations were now growing again, signaling spikes in cases also among the elderly.

COVID-19 in Indonesia

Via the Indonesian Medical Association: “Preliminary Study of the Department of Clinicial Microbiology: 8 out of 100 medical personnel, only 2 in 10 without symptoms, 4 out of 10 patients with moderate and severe symptoms, age range 2-85 years”. Excerpt from the Google translation:

A preliminary study on the description of COVID-19 cases in Indonesia conducted by a number of staff from the Department of Clinical Microbiology, Faculty of Medicine, University of Indonesia (FKUI), was successfully published as a letter to editor in the international journal New Microbes and New Infections in September 2020. 

The staff involved in making this preliminary study are dr. Fera Ibrahim, M.Sc., Ph.D., Sp.MK (K); Prof. dr. Pratiwi Sudarmono, Ph.D., Sp.MK (K); dr. Yulia Rosa Saharman, Sp.MK (K); and dr. A. Natasha.  

The Clinical Microbiology Laboratory of the Faculty of Medicine, University of Indonesia, as one of the reference laboratories for COVID-19 specimens officially appointed by the government, has received 4167 specimens between March-April 2020 with 582 specimens showing positive results so it can be concluded that the positivity rate is 12.6%.  

Based on demographic data, the average age of patients who are positive for COVID-19 is 44.5 years with an age range of 2-85 years and 59% of patients are male. Approximately 17% of patients had comorbids (comorbidities), most of which were cardiovascular disease (58%) and diabetes (37%). The mean age of COVID-19 positive patients found in this study resembled the case data from Singapore (42.5 years), but was younger than the data from Wuhan (55.5 years). However, the findings that male gender and cardiovascular disease are co-morbidities of COVID-19 are in line with reports from other countries. In addition, 8% of COVID-19 positive patients work as health workers.  

Another interesting finding from this study is that about 22% of COVID-19 positive patients were asymptomatic or asymptomatic and 34% had mild symptoms. The remaining 44% had moderate to severe symptoms. 

This study also shows that, although respiratory symptoms are identical to COVID-19 cases (found in 73% of cases), it does not rule out the possibility of COVID-19 patients coming with non-specific symptoms, such as gastrointestinal complaints, lethargy and headaches. This certainly deserves attention because it relates to transmission risk.