H5N1

SARS-CoV-2 elimination, not mitigation, creates best outcomes for health, the economy, and civil liberties

Via The Lancet: SARS-CoV-2 elimination, not mitigation, creates best outcomes for health, the economy, and civil liberties.

The trade-off between different objectives is at the heart of political decision making. Public health, economic growth, democratic solidarity, and civil liberties are important factors when evaluating pandemic responses. There is mounting evidence that these objectives do not need to be in conflict in the COVID-19 response. Countries that consistently aim for elimination—ie, maximum action to control SARS-CoV-2 and stop community transmission as quickly as possible—have generally fared better than countries that opt for mitigation—ie, action increased in a stepwise, targeted way to reduce cases so as not to overwhelm health-care systems. 

We compared COVID-19 deaths, gross domestic product (GDP) growth, and strictness of lockdown measures during the first 12 months of the pandemic for Organisation for Economic Co-operation and Development (OECD) countries that aim for elimination or mitigation (figure). Although all indicators favour elimination, our analysis does not prove a causal connection between varying pandemic response strategies and the different outcome measures. 

COVID-19 deaths per 1 million population in OECD countries that opted for elimination (Australia, Iceland, Japan, New Zealand, and South Korea) have been about 25 times lower than in other OECD countries that favoured mitigation (figure). Mortality is a proxy for a country's broader disease burden. For example, decision makers should also consider the increasing evidence of long-term morbidities after SARS-CoV-2 infection. 

There is also increasing consensus that elimination is preferable to mitigation in relation to a country's economic performance.6 One study quantified the optimal basic reproduction number so that elimination is achieved at minimal economic cost. To this end, consider weekly GDP growth with respect to 2019 for the OECD countries that opted for elimination or mitigation (figure). Elimination is superior to mitigation for GDP growth on average and at almost all time periods. GDP growth returned to pre-pandemic levels in early 2021 in the five countries that opted for elimination, whereas growth is still negative for the other 32 OECD countries. 

Despite its health and economic advantages, an elimination strategy has been criticised for restricting civil liberties. This claim can be challenged by analysing the stringency index developed by researchers at the University of Oxford. This index measures the strictness of lockdown-style policies that primarily restrict people's behaviour by combining eight indicators of containment and closure policies, eight indicators of health system policies, and one indicator of public information campaigns. 

Among OECD countries, liberties were most severely impacted in those that chose mitigation, whereas swift lockdown measures—in line with elimination—were less strict and of shorter duration (figure). Importantly, elimination has been framed as a civic solidarity approach that will restore civil liberties the soonest; this focus on common purpose is frequently neglected in the political debate. 

Evidence suggests that countries that opt for rapid action to eliminate SARS-CoV-2—with the strong support of their inhabitants—also better protect their economies and minimise restrictions on civil liberties compared with those that strive for mitigation. Looking ahead, mass COVID-19 vaccination is key to returning to usual life, but relying solely on COVID-19 vaccines to control the pandemic is risky due to their uneven roll-out and uptake, time-limited immunity, and the emergence of new SARS-CoV-2 variants. 

History shows that vaccination alone can neither single-handedly nor rapidly control a virus and that a combination of public health measures are needed for containment. The eradication of smallpox required concerted, decades-long efforts, including vaccination; communication and public engagement; and test, trace, and isolate measures. Even at the end of vaccination campaigns, such public health measures must be maintained to some extent or new waves of infections might lead to increased morbidity and mortality. 

With the proliferation of new SARS-CoV-2 variants of concern, many scientists are calling for a coordinated international strategy to eliminate SARS-CoV-2. Moreover, the US Department of State declared in April, 2021, that stopping COVID-19 is the Biden–Harris administration's number one priority and highlighted that “this pandemic won't end at home until it ends worldwide”. 

National action alone is insufficient and a clear global plan to exit the pandemic is necessary. Countries that opt to live with the virus will likely pose a threat to other countries, notably those that have less access to COVID-19 vaccines. The uncertainty of lockdown timing, duration, and severity will stifle economic growth as businesses withhold investments and consumer confidence deteriorates. Global trade and travel will continue to be affected. 

Political indecisiveness and partisan policy decisions reduce trust in government. This does not bode well in those countries that have seen a retraction of democracy. Meanwhile, countries opting for elimination are likely to return to near normal: they can restart their economies, allow travel between green zones, and support other countries in their vaccination campaigns and beyond. 

The consequences of varying government COVID-19 responses will be long-lasting and extend beyond the end of the pandemic. Early economic and political gains made by countries aiming to eliminate SARS-CoV-2 will probably pay off in the long run.

A collapse foretold: How Brazil’s Covid-19 outbreak overwhelmed hospitals

Via The New York Times: A Collapse Foretold: How Brazil’s Covid-19 Outbreak Overwhelmed Hospitals. Excerpt:

PORTO ALEGRE, Brazil — The patients began arriving at hospitals in Porto Alegre far sicker and younger than before. Funeral homes were experiencing a steady uptick in business, while exhausted doctors and nurses pleaded in February for a lockdown to save lives. 

But Sebastião Melo, Porto Alegre’s mayor, argued there was a greater imperative. 

“Put your life on the line so that we can save the economy,” Mr. Melo appealed to his constituents in late February. 

Now Porto Alegre, a prosperous city in southern Brazil, is at the heart of a stunning breakdown of the country’s health care system — a crisis foretold. 

More than a year into the pandemic, deaths in Brazil are at their peak and highly contagious variants of the coronavirus are sweeping the nation, enabled by political dysfunction, widespread complacency and conspiracy theories. 

The country, whose leader, President Jair Bolsonaro, has played down the threat of the virus, is now reporting more new cases and deaths per day than any other country in the world.

“We have never seen a failure of the health system of this magnitude,” said Ana de Lemos, the executive director of Doctors Without Borders in Brazil. “And we don’t see a light at the end of the tunnel.” 

On Wednesday, the country surpassed 300,000 Covid-19 deaths, with roughly 125 Brazilians succumbing to the disease every hour. Health officials in public and private hospitals were scrambling to expand critical care units, stock up on dwindling supplies of oxygen and procure scarce intubation sedatives that are being sold at an exponential markup. 

Intensive care units in Brasília, the capital, and 16 of Brazil’s 26 states report dire shortages of available beds, with capacity below 10 percent, and many are experiencing rising contagion (when 90 percent of such beds are full the situation is considered dire.)

In Rio Grande do Sul, the state that includes Porto Alegre, the waiting list for intensive care unit beds doubled over the past two weeks, to 240 critically ill patients. 

 At Hospital Restinga e Extremo Sul, one of the main medical facilities in Porto Alegre, the emergency room has become a crammed Covid ward where many patients received care in chairs, for lack of a free bed. Last week, the military built a tent field hospital outside the main entrance, but hospital officials said the additional bed space is of little use for a medical staff stretched beyond its limit. 

“The entire system is on the verge of collapse,” said Paulo Fernando Scolari, the hospital’s director. “People are coming in with more serious symptoms, lower oxygen levels, in desperate need of treatment.” 

The breakdown is a stark failure for a country that, in past decades, was a model for other developing nations, with a reputation for advancing agile and creative solutions to medical crises, including a surge in H.I.V. infections and the outbreak of Zika. 

Mr. Melo, who campaigned last year on a promise to lift all pandemic restrictions in the city, said a lockdown would cause people to starve. 

“Forty percent of our economy, our labor force, is informal,” he said in an interview. “They’re people who need to go out and work in order to have something to eat at night.” 

President Bolsonaro, who continues to promote ineffective and potentially dangerous drugs to treat the disease, has also said lockdowns are untenable in a country where so many people live in poverty. While several Brazilian states have ordered business shutdowns in recent weeks, there have been no strict lockdowns. 

Some of the president’s supporters in Porto Alegre have protested business shutdowns in recent days, organizing caravans that stop outside of hospitals and blast their horns while inside Covid wards overflow.

Brazil: Harsh letter from bankers and economists criticizes Bolsonaro and offers proposals for the pandemic

Via BBC News Brasil: In full: that says the harsh letter from bankers and economists criticizing Bolsonaro and proposals for a pandemic. Excerpt from the Google translation:

In an open letter, more than 200 economists, bankers, businessmen and former public sector officials criticized the Bolsonaro government's actions in the pandemic, demanded more vaccines, free masks and social distance measures and refuted the "false dilemma between saving lives and guarantee the livelihood of the vulnerable population."

"Preliminary data on deaths and economic performance suggest that the countries with the worst economic performance had more deaths from covid-19", says the document, signed by names such as bankers Roberto Setubal and Pedro Moreira Salles (Itaú), former ministers Pedro Malan and Rubens Ricupero and economists such as Laura Carvalho, Elena Landau and Affonso Celso Pastore, this former president of the Central Bank. 

The almost 2,700-word letter can be divided into two: a diagnosis of the country's alarming health and economic situation today and a defense of four major measures against the spread of the disease. 

"There is no more time to waste on sterile debates and false news. We need to be guided by successful experiences, by low-cost, high-impact actions, by initiatives that can actually reverse the unprecedented situation that the country is experiencing."

In the last three weeks, Brazil has been beating successive records of deaths registered in a 24-hour period every day. Currently, the daily average is 2,255 deaths, but the trend is upward, and some researchers do not rule out that this number may even double soon.

'Falling off a cliff': Pandemic crippling world's most fragile states, finds report

Via The Guardian: 'Falling off a cliff': pandemic crippling world's most fragile states, finds report. Excerpt:

Thousands could starve in the world’s most fragile states as the pandemic comes on top of existing crises, warns a new report today which found aid workers are deeply pessimistic about the coming year. 

The survey of aid workers by the Disaster Emergency Committee (DEC) found that they believed humanitarian conditions were at their worst in a decade. 

The chief executive of the DEC, Saleh Saeed, said reduced funding could force aid providers to prioritise some populations and services over others. 

“People living in places made perilous by conflict, violence and climate disasters are coping with the coronavirus pandemic as best they can, but the odds are stacked against them. The knock-on effects of the pandemic have crippled economies, making the world’s poorest people even poorer,” said Saeed. 

The report focused on Syria, Yemen, Somalia, South Sudan, the Democratic Republic of the Congo and Afghanistan, as well as the Rohingya refugee camps in Bangladesh.

It said there had been a significant economic impact in all of these countries, but that the direct health impact of the coronavirus had also been underestimated because of insufficient testing capacity. 

Ahmed Khalif, country director for the charity Action Against Hunger in Somalia, said livelihoods had been damaged by drops in crucial livestock exports and remittances sent from the diaspora, coming alongside conflict, locust infestations and drought.

African swine fever mutation spreads in China, sparking new control fears

Via Caixin Global: African Swine Fever Mutation Spreads in China, Sparking New Control Fears. Excerpt:

Chinese scientists have discovered a milder but harder-to-detect mutation of the African swine fever virus has been spreading in China, posing new challenges to the prevention and control of the highly infectious disease which swept the country in 2018. 

Researchers from the Harbin Veterinary Institute said they had documented new strains of the disease and warned that the mutations might already be prevalent among pig populations in fields, a report published in the academic journal Science China Life Sciences on Feb. 24. It confirmed a similar report published by the Military Veterinary Institute early last month. 

Compared to pigs infected with classic African swine fever, animals infected with the new strains experience a longer period of disease, milder symptoms and ones which are more easily misdiagnosed. Failure to diagnose contaminated pigs at an early stage can lead to mass infection in farms and irrecoverable loss, multiple pig farming industry insiders said. 

With milder clinical symptoms, the new strains are more difficult to detect in livestock while remaining highly transmissible, making early diagnosis more challenging, they said. While not dangerous to humans, the disease can cause up to 100% fatality in pigs, leading to severe economic losses to the pig sector. 

China consumes more than half of the world's pork production. An estimated 30% of Chinese pork production is by small-scale farmers who may lack the expertise or funds to protect their animals from the disease, according to health experts. 

There are no commercialized vaccines or specialized treatment for the virus. Controlling the pandemic relies on swift diagnosis and extermination of infected animals. A swine fever virus vaccine developed by the Harbin Veterinary Institute is currently in its second stage of clinal trials. 

Multiple industry professionals told Caixin, speaking on condition of anonymity, that although there is no approved vaccine to date, many pig farms have used “underground vaccines” from unknown sources to mitigate losses. Professionals worry that these unregulated vaccines may cause the virus to mutate, thereby exacerbating the crisis.

Priorities for the COVID-19 pandemic at the start of 2021: Statement of the Lancet COVID-19 Commission

Via The Lancet: Priorities for the COVID-19 pandemic at the start of 2021: statement of the Lancet COVID-19 Commission. Excerpt:

The Lancet COVID-19 Commission calls for three urgent actions in the COVID-19 response (our broader overview is available on our website). 

First, all regions with high rates of new COVID-19 cases, including the USA and the European Union (EU), should intensify measures to minimise community transmission alongside rapid deployment of COVID-19 vaccines. 

Second, governments should urgently and fully fund WHO and the Access to COVID-19 Tools (ACT) Accelerator, including COVAX. 

Third, the G20 countries should empower the International Monetary Fund (IMF) and multilateral development banks to increase the scale of financing and debt relief. 

Success on all three priorities—containment of transmission, rapid vaccination, and emergency finance—will require improved global cooperation. The high rates of community transmission (>100 new COVID-19 cases per million per day) in the USA, Europe, South Africa, and other countries show the emergence of new variants of SARS-CoV-2, such as lineage B.1.1.7 in the UK, 501Y.V2 in South Africa, and additional variants emerging in California, USA, and in Brazil. 

New lineages are increasing transmission of infection and raising risks in regions that have been less affected by COVID-19, including in sub-Saharan Africa. Additionally, acquired immunity from earlier COVID-19 infections might be less protective against reinfection with some of the new SARS-CoV-2 variants. Mutant lineages might also reduce the efficacy of COVID-19 vaccines and require adapted vaccines or boosters. 

The numbers of new COVID-19 cases in east Asia and the Pacific (<10 new cases per million per day in most countries) have been consistently below those of Northern America and Europe. The lower numbers of COVID-19 cases in these countries result from the successful implementation of comprehensive containment measures: border restrictions and other limits on movement; behavioural changes including widespread use of face masks and physical distancing; active surveillance by public health systems, including mass testing, backward tracing (to identify the sources of outbreaks), and forward tracing (to identify the contacts of new cases); and the quarantine of all suspected cases and the use of facility-based isolation of confirmed cases of COVID-19. 

The USA and the EU failed to implement such comprehensive measures, and there was generally excessive decentralisation of containment efforts across the 50 US states and 27 EU members in 2020. Lack of centralised coordination undermined control of COVID-19, not least because of interstate travel in the USA and intercountry travel in the EU. Both the USA and EU need to step up more top–down coordination in 2021. 

Stronger health systems that incorporate universal health coverage and community-based health workers are vital in the response to COVID-19. At least half of the world's population lacks access to essential health services. Strengthening community-based and gender-responsive health systems will be essential to implement inclusive and comprehensive COVID-19 immunisation campaigns. 

The global roll-out of COVID-19 vaccines to date is neither inclusive nor adequately planned. COVAX has targeted immunisation coverage of at least 20% of the population in each participating country by the end of 2021, and has contracted for 2 billion doses of COVID-19 vaccines. Yet the timely supply of vaccines to COVAX is in question, as high-income countries (HICs) step to the front of the queue for limited supplies of COVID-19 vaccines. 

As of Feb 9, 2021, 148·08 million COVID-19 vaccine doses had been delivered, of which 115·67 million were delivered in the USA (43·21 million), China (40·52 million), the EU (18·36 million), and the UK (13·58). Other countries in Africa, Latin America and the Caribbean, and Asia (not including China) have received very few vaccine doses or none at all. 

This unequal access to COVID-19 vaccines is partly due to the difficulty of managing the ultracold supply chain needed for the two mRNA vaccines, but it is also due to the vaccine supply deals negotiated by HICs directly with the vaccine producers, rather than through COVAX.

Coronavirus today: Surviving post-COVID-19 medical bills

Via the Los Angeles Times, another reason to be glad we live in Canada: Coronavirus Today: Surviving post-COVID medical bills. Excerpt:

Good evening. I’m Amina Khan, and it’s Tuesday, Feb. 9. Here’s what’s happening with the coronavirus in California and beyond. 

We’re learning a lot about the long-term damage the coronavirus can inflict on victims, including breathing problems and chest pain. As the pandemic rages on, another lasting condition has emerged among COVID-19 survivors: overwhelming medical bills that threaten to cripple them financially just as they’re trying to get back on their feet. 

 Take Patricia Mason, who was rushed to the emergency room by her husband and didn’t see him again for nearly a month. The 51-year-old Vacaville woman was transferred to a different hospital in the middle of the night as her condition deteriorated; two days later, her doctor put her chances of survival at less than a 30%. 

Mason did make it through her ordeal last spring, but she did not emerge unscathed, my colleague Maria L. La Ganga reports. She suffers from brain fog, her joints are swollen and painful, and she takes baby aspirin and a handful of supplements every day. 

And then there’s the bill for saving her life: $1,339,181.94. Mason and her husband are on the hook for $42,184.20 of that total. 

The couple, with five jobs and nine mostly-grown kids between them, knows there’s zero chance of paying it off in full. And they’re not alone. 

“The deck is absolutely stacked against the consumer and the patient,” said Sabrina Corlette, co-director of the Center on Health Insurance Reforms at Georgetown University. She added that “getting answers about why certain things are on the bill is almost impossible.” 

During the Obama administration, the federal government put a cap on the amount most insurance plans can require patients to pay. But not all plans have so-called out-of-pocket maximums. Even when they do, the annual limit for a family was $16,300 last year. That ceiling rose to $17,100 this year, though insurance companies can adopt a lower limit. Regardless, that kind of money is still hard for many families to spare during the worst recession in nearly a century. 

Mason is insured through her husband’s union on a plan administered by Blue Shield of California, but it’s what’s called a self-funded plan that happens to be “grandfathered in” and doesn’t have to abide by federal out-of-pocket maximums. The Kaiser Family Foundation estimates that 61% of Americans who get their insurance through their jobs are covered by these kinds of self-funded plans, though it’s unclear how many are also exempt from the federal out-of-pocket limit. 

Many insurance companies said early in the pandemic that they would waive all out-of-pocket costs for policyholders’ COVID-19 treatment. But most waivers do not include self-funded plans. 

A lot of folks could find themselves in the same boat as Mason. 

“I don’t have $42,000 to spare,” Mason said. “I am lucky enough to be alive, so we take that into consideration. But the reality is I don’t have [the money]. It’s not going to happen.”

COVID-19 in California: A different kind of double jeopardy

Via The Los Angeles Times: Coronavirus Today: A different kind of double jeopardy. Excerpt:

At a time when public officials are practically begging residents to not leave their homes because of COVID-19, the Los Angeles County Superior Court system — the largest in the country — is still requiring people to venture forth for in-person hearings, including eviction proceedings and trials. That’s despite the recent deaths of three court employees from COVID-19, and despite the fact that being in enclosed spaces with other people provides an easy opportunity for the coronavirus to spread. 

In traffic courts, scores of people wait in hallways and courtrooms to contest speeding citations, my colleague Matt Hamilton reports. In criminal courts, shackled defendants sit with masks drooping off their faces, and some lawyers remove their masks when addressing a judge. One judge even allowed a witness to testify without a mask. 

“Every single day the courts are going through procedures without precautions to keep people safe and holding proceedings that result in people getting kicked out onto the street. It’s a public health disaster,” said Adam Murray, executive director of Inner City Law Center. “If you walk into eviction or traffic courtrooms, you are not seeing wealthy or middle-income people. It’s poor people who have to go in and adjudicate their cases in person.” 

Staff and legal groups have pushed for more rigorous methods of screening the public, such as temperature checks. But they haven’t gotten them. 

Although lawmakers instituted some eviction moratoriums, which have reduced the flow of eviction cases, such measures typically require tenants to come to court to demonstrate why the moratorium applies. Often, moratorium is a bit of a misnomer, as the measures don’t necessarily stop landlords from filing eviction lawsuits. 

These practices pose real exposure risks for Angelenos like Juan Garcia, who rode the bus to a downtown L.A. court to contest an eviction. The disabled widower used a cane as he navigated the Stanley Mosk Courthouse, waited among dozens in a hallway for his hearing, then asked a judge for more time to secure low-income housing — at least another month or two. The judge set an eviction trial for April. 

“I don’t know what I’m going to do,” Garcia, 60, said outside the courtroom, wrestling with the prospect of homelessness. 

L.A. Superior Court has taken steps to significantly reduce foot traffic, and officials estimate 65% fewer people circulate in the system’s 38 courthouses than before the pandemic. Roughly 4,500 people appear remotely each day for hearings. And all of the 600 or so courtrooms across the county have the capability to conduct remote proceedings, said court spokeswoman Ann Donlan. 

But many in-person hearings are still taking place, and the criminal courts held nearly 70 jury trials in the final four months of 2020. Sometimes, the parties in a case insist on an in-person hearing. Some litigants lack internet or phone access, or don’t know a remote option is available. And unless a litigant has taken the steps to secure a waiver from the court, each remote appearance comes at a cost: $15 for audio and $23 for video. 

In eviction cases like Garcia’s, where tenants have just five court days to respond and most tenants lack legal representation, attorneys say that judges often require in-person proceedings, jeopardizing the health of lawyers, clients and court staff. 

Court officials say its operations are essential and its services, like providing restraining orders in domestic violence cases and protecting defendants’ due process rights, require keeping courthouses open. But others say many operations can be put off for now. 

“There is no urgency for a person with a traffic citation to be there now,” said Lauren Zack, an attorney with Public Counsel.

One year, 400,000 coronavirus deaths: How the US guaranteed its own failure

Via The New York Times, what journalists like to call a "damning indictment": One Year, 400,000 Coronavirus Deaths: How the U.S. Guaranteed Its Own Failure. Excerpt, with my bolding:

“We will manage the hell out of this operation,” Mr. Biden said on Friday. “Our administration will lead with science and scientists.” 

The strategy signals a shift from the past year, during which the Trump administration largely delegated responsibility for controlling the virus and reopening the economy to 50 governors, fracturing the nation’s response. Interviews with more than 100 health, political and community leaders around the country and a review of emails and other state government records offer a fuller picture of all that went wrong:  

• The severity of the current outbreak can be traced to the rush to reopen last spring. Many governors moved quickly, sometimes acting over the objections of their advisers. The reopenings nationally led to a surge of new infections that grew over time: Never again would the country’s average drop below 20,000 new cases a day.  

• Science was sidelined at every level of government. More than 100 state and local health officials have been fired or have resigned since the beginning of the pandemic. In Florida, leading scientists offered their expertise to the governor’s office but were marginalized, while Gov. Ron DeSantis turned to Dr. Scott W. Atlas, a Trump adviser, and others whose views were embraced in conservative circles but rejected by scores of scientists. 

• While the president publicly downplayed the need for masks, White House officials were privately recommending that certain states with worsening outbreaks require face coverings in public spaces. But records show that at least 26 states ignored recommendations from the White House on masks and other health issues. In South Dakota, Gov. Kristi Noem, boasted to political allies about not requiring masks even as her state was in the midst of an outbreak that became one of the worst in the nation. 

Gov. Jared Polis of Colorado said states had faced difficult choices in balancing the virus — often hearing competing voices on how to do it best — and said Mr. Trump had left them without the political support they needed as they urged the public to accept masks and social distancing. “The single biggest thing that would have made a difference was the clarity of message from the person at the top,” Mr. Polis said in an interview.  

The pandemic indeed came with significant challenges, including record unemployment and a dynamic disease that continued to circle the globe. Without a national strategy from the White House, it is unlikely that any state could have fully stopped the pandemic’s spread.  

But ​the majority of deaths in the United States have come since the strategies needed to contain it were clear to state leaders, who had a range of options, from mask orders to targeted shutdowns and increased testing. Disparities have emerged between states that took restrictions seriously and those that did not.  

America now makes up 4 percent of the world’s population but accounts for about 20 percent of global deaths. While Australia, Japan and South Korea showed it was possible to keep deaths low, the United States — armed with wealth, scientific prowess and global power — became the world leader: it now has one of the highest concentrations of deaths, with nearly twice as many reported fatalities as any other country.

Deaths of despair and the incidence of excess mortality in 2020

Via the National Bureau for Economic Research: Deaths of Despair and the Incidence of Excess Mortality in 2020. The abstract, with my bolding:

Weekly mortality through October 3 is partitioned into normal deaths, COVID, and nonCOVID excess deaths (NCEDs). Before March, the excess is negative for the elderly, likely due to the mild flu season. From March onward, excess deaths are approximately 250,000 of which about 17,000 appear to be a COVID undercount and 30,000 non-COVID. 

Deaths of despair (drug overdose, suicide, alcohol) in 2017 and 2018 are good predictors of the demographic groups with NCEDs in 2020. The NCEDs are disproportionately experienced by men aged 15-55, including men aged 15-25. 

Local data on opioid overdoses further support the hypothesis that the pandemic and recession were associated with a 10 to 60 percent increase in deaths of despair above already high pre-pandemic levels.