H5N1

Madrid orders partial lockdown after surge in Covid-19 infections

Via France24: Madrid orders partial lockdown after surge in Covid-19 infections.

The regional government of the Spanish capital Madrid ordered a lockdown from Monday in some of the poorer areas of the city and its outskirts that are home to about 850,000 people, after a surge in coronavirus infections there. 

Regional leader Isabel Diaz Ayuso said on Friday movement between and within areas in six districts would be restricted, but people would be able to go to work in Spain's hardest-hit region. 

Residents in Madrid's poorer districts had said earlier they felt abandoned, stigmatised and feared new restrictions would deprive them of income. 

After the announcement, a few hundred protestors gathered in front of the offices of Madrid's regional government to demand Ayuso quit. 

"The health centres are saturated in the south of the city and they have not done anything about it," said protester Rosa Baras, 65. 

Ayuso, who attracted criticism for saying this week "the way of life of immigrants" was partly to blame for the rise in cases, said the areas had been chosen because contagion levels there exceeded 1,000 per 100,000 people. 

"We need to avoid lockdown, we need to avoid economic disaster," Ayuso told a news conference. "We don't think it's time to restrict all citizens, but rather to apply measures in areas we have perfectly identified."  

Access to parks and public areas will be restricted, gatherings will be limited to six people and commercial establishments will have to close by 10 p.m. in the areas. 

Inequality gap  

The gap between poorer and richer areas is at the heart of a debate over how to curb an increase in new cases.  

Restrictions will affect Vallecas, a southern district with a lower average income and higher immigrant population, which has one of the highest infection rates in Madrid. It is almost six times higher than in Chamberi, one of the wealthier, northern districts.  

The health system "is more paralysed here, they have us out here waiting, crowded, queues everywhere," retiree Mari Paz Gonzalez said. "We are abandoned... They left us in the hands of God."

Suboptimal US response to COVID-19 despite robust capabilities and resources

Via JAMA Network: Suboptimal US Response to COVID-19 Despite Robust Capabilities and Resources. Excerpt:

Several factors may help explain why the US has struggled more than many other countries to suppress COVID-19, and the GHS Index may provide some possible insights. Despite its top overall ranking on the index, the US received a low score on a key factor that can determine how well a country is able to react to a pandemic: public confidence in the government. 

The US is one of only a small number of high-income countries in the Index that received the lowest possible score on public confidence in the government. Poor confidence in the government can undermine the public’s adherence with disease-control measures, such as wearing masks or stay-at-home recommendations, and has been reported among the existing challenges to the US COVID-19 response.  

In addition, the US received low scores on important indicators pertaining to the strength of its health system and the ability of its people to access health care without barriers. For example, among the 60 high-income countries in the GHS Index, the US ranked 38th for its number of physicians per capita and 40th for its number of hospital beds per capita. On access to health care, the US was ranked 175th globally due to its absence of laws mandating universal health care coverage and large numbers of underinsured and uninsured individuals. A lack of guaranteed access to health care for all citizens leaves many individuals vulnerable during times of emergency. In 2020, the US Congress passed legislation to remove cost barriers for SARS-CoV-2 testing, but testing costs remain and have been cited as a barrier to expanding the number of tests performed in the US.  

Overall, the US was well poised to respond to COVID-19, but it has lacked strength in key areas. Although the US established a national stockpile of medicines, personal protective equipment, and ventilators, when signs of a new outbreak surfaced, calls by federal officials to replenish and augment these supplies were ignored. 

The US also failed to harness its own technical expertise, such as that within the CDC. Although the US has a world-class network of public health and clinical laboratories that had the capacity to develop their own assays to test for SARS-CoV-2, federal restrictions initially prevented these laboratories from doing so. This severely constrained the number of tests the US could conduct (and likely allowed the virus to spread around the country undetected) until these restrictions were eventually lifted. Even now, the lack of a national testing strategy and unaddressed shortages in testing supplies continue to limit the country’s ability to suppress SARS-CoV-2. 

What is most puzzling is that the US has been significantly involved in helping other countries to amass their own capacities to prepare for events like COVID-19. During the Obama administration, the US launched the Global Health Security Agenda and has contributed financial and technical support to help countries develop public health capacities to prevent, detect, and respond to infectious disease outbreaks. Thailand’s epidemiological capabilities were developed with large contributions of funding and expertise from the US. Even though the US lacks a national strategy for testing and conducting surveillance for COVID-19, it has previously helped other countries develop such strategies for other diseases. 

International experts agree that the COVID-19 pandemic as a test case of the capacities as assessed by the GHS Index remains highly relevant. However, going forward, the Index should include new or stronger metrics about additional capacities, such as medical supply chains and a better understanding of national leadership. The strength of a country’s leadership and the confidence of its people in their government and their leaders is just as important (if not more important) than technical capacities. Future versions of the Index will give greater weight to these factors.  

During the years to come, the US undoubtedly will undergo national-level reviews to understand how its strong capabilities were squandered when the country needed them the most. In the meantime, the country’s health and economic security will continue to be adversely affected until national leaders change course.

Prevalence of depression symptoms in US adults before and during the COVID-19 pandemic

Via JAMA Network: Prevalence of Depression Symptoms in US Adults Before and During the COVID-19 Pandemic. The key points and abstract:

Key Points

Question  What is the burden of depression symptoms among US adults during the coronavirus disease 2019 (COVID-19) pandemic compared with before COVID-19, and what are the risk factors associated with depression symptoms?  

Findings  In this survey study that included 1441 respondents from during the COVID-19 pandemic and 5065 respondents from before the pandemic, depression symptom prevalence was more than 3-fold higher during the COVID-19 pandemic than before. Lower income, having less than $5000 in savings, and having exposure to more stressors were associated with greater risk of depression symptoms during COVID-19.  

Meaning  These findings suggest that there is a high burden of depression symptoms in the US associated with the COVID-19 pandemic and that this burden falls disproportionately on individuals who are already at increased risk.  

Abstract 

Importance  The coronavirus disease 2019 (COVID-19) pandemic and the policies to contain it have been a near ubiquitous exposure in the US with unknown effects on depression symptoms. 

Objective  To estimate the prevalence of and risk factors associated with depression symptoms among US adults during vs before the COVID-19 pandemic. 

Design, Setting, and Participants  This nationally representative survey study used 2 population-based surveys of US adults aged 18 or older. During COVID-19, estimates were derived from the COVID-19 and Life Stressors Impact on Mental Health and Well-being study, conducted from March 31, 2020, to April 13, 2020. Before COVID-19 estimates were derived from the National Health and Nutrition Examination Survey, conducted from 2017 to 2018. Data were analyzed from April 15 to 20, 2020. 

Exposures  The COVID-19 pandemic and outcomes associated with the measures to mitigate it.  

Main Outcomes and Measures  Depression symptoms, defined using the Patient Health Questionnaire-9 cutoff of 10 or higher. Categories of depression symptoms were defined as none (score, 0-4), mild (score, 5-9), moderate (score, 10-14), moderately severe (score, 15-19), and severe (score, ≥20). 

Results  A total of 1470 participants completed the COVID-19 and Life Stressors Impact on Mental Health and Well-being survey (completion rate, 64.3%), and after removing those with missing data, the final during–COVID-19 sample included 1441 participants (619 participants [43.0%] aged 18-39 years; 723 [50.2%] men; 933 [64.7%] non-Hispanic White). The pre–COVID-19 sample included 5065 participants (1704 participants [37.8%] aged 18-39 years; 2588 [51.4%] women; 1790 [62.9%] non-Hispanic White). 

Depression symptom prevalence was higher in every category during COVID-19 compared with before (mild: 24.6% [95% CI, 21.8%-27.7%] vs 16.2% [95% CI, 15.1%-17.4%]; moderate: 14.8% [95% CI, 12.6%-17.4%] vs 5.7% [95% CI, 4.8%-6.9%]; moderately severe: 7.9% [95% CI, 6.3%-9.8%] vs 2.1% [95% CI, 1.6%-2.8%]; severe: 5.1% [95% CI, 3.8%-6.9%] vs 0.7% [95% CI, 0.5%-0.9%]). 

Higher risk of depression symptoms during COVID-19 was associated with having lower income (odds ratio, 2.37 [95% CI, 1.26-4.43]), having less than $5000 in savings (odds ratio, 1.52 [95% CI, 1.02-2.26]), and exposure to more stressors (odds ratio, 3.05 [95% CI, 1.95-4.77]). 

Conclusions and Relevance  These findings suggest that prevalence of depression symptoms in the US was more than 3-fold higher during COVID-19 compared with before the COVID-19 pandemic. 

Individuals with lower social resources, lower economic resources, and greater exposure to stressors (eg, job loss) reported a greater burden of depression symptoms. Post–COVID-19 plans should account for the probable increase in mental illness to come, particularly among at-risk populations.

Assessment of COVID-19 hospitalizations by race/ethnicity in 12 states

Via JAMA, a research letter: Assessment of COVID-19 Hospitalizations by Race/Ethnicity in 12 States.

Given the reported health disparities in coronavirus disease 2019 (COVID-19) infection and mortality by race/ethnicity, there is an immediate need for increased assessment of the prevalence of COVID-19 across racial/ethnic subgroups of the population in the US. We examined the racial/ethnic prevalence of cumulative COVID-19 hospitalizations in the 12 states that report such data and compared how this prevalence differs from the racial/ethnic composition of each state’s population. 

Methods 

Using data extracted from the University of Minnesota COVID-19 Hospitalization Tracking Project, we identified the 12 states that reported the race/ethnicity of individuals hospitalized with COVID-19 between April 30 and June 24, 2020. We calculated the percentage of cumulative hospitalizations by racial/ethnic categories averaged over the study period and then calculated the difference between the percentage of cumulative hospitalizations for each subgroup and the corresponding percentage of the state’s population for each racial/ethnic subgroup as reported in the US Census. 

The race/ethnicity categories included were White, Black, American Indian and/or Alaskan Native, Asian, and Hispanic. Descriptive statistical analyses were conducted using Stata/MP, version 14 (Stata Corp). The University of Minnesota Institutional Review Board reviewed the study data and deemed it exempt from review and informed consent requirements because the study was not human subjects research. 

Results 

This analysis of COVID-19 hospitalizations in 12 US states during nearly a 2-month period represented a total of 48 788 cumulative hospitalizations among a total population of 66 796 666 individuals in 12 US states by the end of the study period on June 24, 2020. The share of the hospitalizations of White patients was substantially smaller vs their share of state population in all 12 states (Table and Figure). For example, in Minnesota, the share of hospitalizations of White patients was 52.9%, whereas their share of the state population was 84.1%. 

Conversely, the percentage of hospitalizations among Black patients exceeded the percentage of their representative proportion of the state population in all 12 states. Differences between the cumulative percentage of hospitalizations and the state population of Black individuals were greatest in Ohio (31.8% vs 13.0%), Minnesota (24.9% vs 6.8%), Indiana (28.1% vs 9.8%), and Kansas (22.0% vs 6.1%). 

Eleven states reported the number of COVID-19 hospitalizations for Hispanic individuals, and in 10 states, the percentage of hospitalizations for Hispanic individuals was higher than their representative proportion of the state population. The disparity among Hispanic individuals was most pronounced in Virginia (36.2% of hospitalizations vs 9.6% of population), Utah (35.3% of hospitalizations vs 14.2% of population), and Rhode Island (33.0% of hospitalizations vs 15.9% of population).  

The pattern was largely reversed for the Asian population. In 6 of 10 states that reported data for this subgroup, the proportion of hospitalizations was lower compared with their population representation. In Massachusetts, for example, the Asian population comprised 7.0% of the population but only 4.0% of the COVID-19 hospitalizations. 

Hospitalization data for American Indian and Alaskan Native populations were only reported by 8 states. However, the disparity was substantial in select states. In Arizona, the American Indian and Alaskan Native population accounted for 15.7% of the hospitalizations but only 4.0% of the state’s population. Similarly, in Utah, this subgroup accounted for 5.0% of the hospitalizations in contrast with 0.9% representation of the state population.  

Discussion 

This analysis identified considerable disparities in the prevalence of COVID-19 across racial/ethnic subgroups of the population in 12 US states. These findings are consistent with an earlier Centers for Disease Control and Prevention analysis of 580 hospitalizations between March 1 and March 30, 2020, that found disproportionately high COVID-19 hospitalizations for the Black population. 

Similarly, a study of 1052 confirmed COVID-19 cases between January 1 and April 8, 2020, at a California health system reported higher odds of hospitalization in non-Hispanic Black individuals compared with non-Hispanic White individuals. In addition, we observed high hospitalization rates for Hispanic individuals in most of the states analyzed and high hospitalization rates for American Indian and Alaskan Native populations in select states.  

These findings highlight the need for increased data reporting and consistency within and across all states. Only 12 of 50 US states have consistently reported hospitalizations by race/ethnicity during our study period. New Jersey and Florida recently started reporting data on COVID-19 hospitalizations by race/ethnicity. The present study is limited in that there was no adjustment for age, sex, comorbidities, and socioeconomic factors within each racial/ethnic group that are likely to be associated with COVID-19 hospitalizations. 

A large body of research has identified racial/ethnic health disparities in the risk of infection associated with a higher prevalence of comorbidities, less access to health care, adverse economic conditions, and service-related occupations. The unique clinical, financial, and social implications of COVID-19 for racial/ethnic populations that are often systematically marginalized in society must be well understood to design and establish effective and equitable infrastructure solutions.

COVID-19 today: Challenge upon challenge

Via The Los Angeles Times, today's edition of the paper's Coronavirus Today newsletter: Coronavirus Today: Challenge upon challenge. Excerpt:

Good evening. I’m Diya Chacko, and it’s Wednesday, Aug. 19. Here’s what’s happening with the coronavirus in California and beyond. 

When the pandemic began, the city of Los Angeles opened up more than two dozen of its gyms and recreation centers to homeless people in order to help prevent coronavirus transmission among those living on the street. By May, however, the facilities stopped taking in new admissions — and now, there are just seven sites still open. 

Local outreach workers and activists said they felt left in the dark about why so many had stopped serving as shelters, and they’ve been left to worry where homeless people would land. “We are in the middle of a viral pandemic,” said one homeless advocate. “This pulls people away from the medical care and support they were getting.” 

It’s a vivid example of the gaps in infrastructure made glaringly obvious by the pandemic — especially now, as California struggles with extreme heat, massive wildfires and power shortages. Homeless workers have pivoted to providing immediate aid such as food and water delivery and testing stations for COVID-19. One worker told Times columnist Steve Lopez he had never put in longer hours or dealt with more stressful challenges. 

As Lopez writes, “Los Angeles had a big enough challenge as it was, trying to address the needs of a growing population of homeless people. It did not need the coronavirus on top of that, nor did it need this wretched, blistering heat wave.” 

And the situation could soon get much worse. In less than two weeks, courts in California will resume processing eviction and foreclosure cases after a months-long pause. The most recent episode of “Gimme Shelter,” The Times’ podcast on the housing crisis, features a discussion of the ways elected officials are trying to avert what’s been called an “eviction cliff” that could result in millions of California tenants losing their homes over the next few months. Here’s where you can listen.  

By the numbers 

California cases and deaths as of 5:31 p.m. PDT Wednesday: 

(Compiled by L.A. Times Graphics)  

Across California 

Almost two dozen major wildfires are raging across the state, forcing evacuations in Northern California and stretching resources at a time when they’re already burdened by the pandemic. The threat posed by the virus is requiring the state to reconfigure emergency evacuation centers and fire camps to lessen the risk of spread — and then there’s the additional problem of the power outages affecting hundreds of thousands of people. “We’ve put out every resource we have,” Gov. Gavin Newsom said Wednesday.  

Bottlenecks in Sacramento’s coronavirus testing system have dramatically reduced testing capacity and slowed results. Amid the surge of cases earlier in the summer, appointment time slots filled quickly, five testing sites run by the county temporarily closed, and some healthcare providers limited testing to patients who were visibly sick. The heavy burden on commercial labs that processed tests dramatically delayed the return of results. “Results should come in 24 to 48 hours, ideally,” said the county’s public health officer. “It impacts our ability to take action and do contact investigations.”

Southeast LA County now the epicenter of COVID-19

Via The Los Angeles Times: Southeast L.A. County now the epicenter of coronavirus. Excerpt:

Southeast Los Angeles County has become the epicenter for the resurgence of the coronavirus, according to a Times analysis of county health data that found infections skyrocketing in its mostly working-class Latino communities.  

The sharp increase since the economy reopened around Memorial Day shows the virus is spreading rapidly through factories, stores and other workplaces and into communities with higher rates of poverty, more crowding and many essential workers who make the economy tick. Hit hard by job losses during the shutdown, they are increasingly suffering from the virus itself.  

The region reported more than 27,000 new COVID-19 cases over the last two months, the most in the county. The area now accounts for 19% of new infections, although it comprises just 12% of the countywide population, the Times analysis shows. That vaulted its once-modest infection rate into one of the highest in the county, and just below the already hard-hit Eastside and South L.A. areas, according to the Times analysis through Aug. 2 

The trend is part of a statewide spike in infections among Latinos, both in rural, farm-working communities and urban areas. It’s only the latest burden for a corner of Southern California long beset by pollution from nearby industry, a lack of access to healthcare and a host of other ills. 

The southeast region, with 1.2 million people living in more than a dozen communities along the 710 and 605 freeways, has seen infection rates jump to some of the highest in the county, including Maywood, Huntington Park, South Gate, Cudahy and Lynwood. The area is home to many low-wage, front-line workers, and residents there are more likely to live in overcrowded, multigenerational households — key risk factors in the accelerating spread of the virus, according to experts. 

By contrast, the more affluent and majority-white Westside — which early in the outbreak reported higher infection rates because of travel abroad and better access to testing — recorded about 3,000 new cases and showed a much slower increase, the Times analysis found.

COVID-19: A viral epidemic splintering into deadly pieces

Via The New York Times: A Viral Epidemic Splintering Into Deadly Pieces. Excerpt:

Once again, the coronavirus is ascendant. As infections mount across the country, it is dawning on Americans that the epidemic is now unstoppable, and that no corner of the nation will be left untouched.  

As of Tuesday, the pathogen had infected at least 4.3 million Americans, killing almost 150,000. Many experts fear the virus could kill 200,000 or even 300,000 by year’s end. Even President Trump has donned a mask, after resisting for months, and has canceled the Republican National Convention celebrations in Florida.  

Each state, each city has its own crisis driven by its own risk factors: vacation crowds in one, bars reopened too soon in another, a revolt against masks in a third.  

“We are in a worse place than we were in March,” when the virus coursed through New York, said Dr. Leana S. Wen, a former Baltimore health commissioner. “Back then we had one epicenter. Now we have lots.”

To assess where the country is heading now, The New York Times interviewed 20 public health experts — not just clinicians and epidemiologists, but also historians and sociologists, because the spread of the virus is now influenced as much by human behavior as it is by the pathogen itself.  

Not only are American cities in the South and West facing deadly outbreaks like those that struck Northeastern cities in the spring, but rural areas are being hurt, too. In every region, people of color will continue to suffer disproportionately, experts said. 

While there may be no appetite for a national lockdown, local restrictions must be tightened when required, the researchers said, and governors and mayors must have identical goals. Testing must become more targeted. 

In most states, contact tracing is now moot — there are simply too many cases to track. And while progress has been made on vaccines, none is expected to arrive this winter in time to stave off what many fear will be a new wave of deaths. 

Overall, the scientists conveyed a pervasive sense of sadness and exhaustion. Where once there was defiance, and then a growing sense of dread, now there seems to be sorrow and frustration, a feeling that so many funerals never had to happen and that nothing is going well. The United States is a wounded giant, while much of Europe, which was hit first, is recovering and reopening — although not to us.

“We’re all incredibly depressed and in shock at how out of control the virus is in the U.S.,” said Dr. Michele Barry, the director of the Center for Innovation in Global Health at Stanford University.

With so much wealth and medical talent, they asked, how could we have done so poorly? How did we fare not just worse than autocratic China and isolated New Zealand, but also worse than tiny, much poorer nations like Vietnam and Rwanda?

“National hubris and belief in American exceptionalism have served us badly,” said Martha L. Lincoln, a medical anthropologist and historian at San Francisco State University. “We were not prepared to see the risk of failure.”

'The hotspot of a hotspot of a hotspot': COVID-19 takes heavy toll in south Texas

Via The Guardian: 'The hotspot of a hotspot of a hotspot': coronavirus takes heavy toll in south Texas. Excerpt:

Seventy-two death notices sprawled across an entire page of the Monitor newspaper in Hidalgo county recently. 

The small-print entries, stacked in five tidy columns, didn’t mention Covid-19. But 27 residents of the south Texas community had died from the virus that day, 22 the day before, and 35 the day before that.

“I’ve never seen that ever in my life,” recalled John M Kreidler, a local funeral director, whose family has run Kreidler Funeral Home in McAllen for over a century. 

That was earlier this month, but things have worsened since. The coronavirus pandemic haunts almost everything in this part of the Rio Grande valley, where more than 92% of the almost 900,000 strong population identifies as Hispanic or Latino. 

Hand-sanitizing machines and big bins with masks and gloves surround shoppers at the regional grocery store. Outside of Nomad Shrine Club, a rundown event space turned drive-thru pop-up, residents join a long line of people in cars in search of a Covid-19 test with rapid results. Even Tex Mex, a gentlemen’s club, has a somber message for patrons: “Clothed Again.”  

“The Rio Grande Valley has become the hotspot of a hotspot of a hotspot,” said Ivan Melendez, Hidalgo county’s health authority and a practicing clinician. “We’re at the epicenter of the coronavirus in the United States.”  

Melendez recalled recently encountering a critically ill patient with an alarmingly low pulse. He tried to warn someone, but nurses informed him that a different doctor had already decided not to intervene because they “didn’t expect for [the patient] to survive”. 

In the United States, where the prevailing mantra for physicians is “do no harm”, that kind of ruthless calculation strikes deep, especially when so many of the lives at stake are medically vulnerable and easily exploited. 

In Hidalgo county – “a poor, fat, diabetic population”, Melendez said bluntly – nearly one in three people under age 65 lack health insurance. Thirty percent live in poverty, and a 2020 WalletHub report found that three local cities hold the distinction as the “fattest” metropolitan area in the nation.  

Type 2 diabetes and obesity are among the pre-existing conditions listed by the Centers for Disease Control and Prevention as risk factors for “severe illness” related to Covid-19. Meanwhile, concern over exorbitant hospital bills deters some who don’t have insurance from seeking medical care. These and other socioeconomic factors have caused the virus’ greatest tragedies to disproportionately impact minorities in the US, with Latinos hospitalized at more than four times the rate of their white counterparts. 

Hidalgo county also sits along the US-Mexico border, and an estimated 102,000 unauthorized immigrants who may be afraid to seek care exist within its margins. Large families serve as an ideal vector for the virus, as do those who still flock to beaches and flea markets on weekends.  

Already, 467 members of the community have died from Covid-19, according to the county, most of them since Texas reopened in May. But the state government has actively thwarted efforts to go back into lockdown, prioritizing economic vitality even as the death toll skyrockets.  

Leonardo Tremari worries about going to his job inside a Walmart supercenter in McAllen, but he – and countless other employees – still have to work. “I don’t have a choice,” he told the Guardian, laughing tensely.

Racial and ethnic disparities in COVID-19: Evidence from six large cities

Via the National Bureau of Economic Research: Racial and Ethnic Disparities in COVID-19: Evidence from Six Large Cities. The abstract:

As of June 2020, the coronavirus pandemic has led to more than 2.3 million confirmed infections and 121 thousand fatalities in the United States, with starkly different incidence by race and ethnicity. Our study examines racial and ethnic disparities in confirmed COVID-19 cases across six diverse cities – Atlanta, Baltimore, Chicago, New York City, San Diego, and St. Louis – at the ZIP code level (covering 436 “neighborhoods” with a population of 17.7 million). 

Our analysis links these outcomes to six separate data sources to control for demographics; housing; socioeconomic status; occupation; transportation modes; health care access; long-run opportunity, as measured by income mobility and incarceration rates; human mobility; and underlying population health. 

We find that the proportions of black and Hispanic residents in a ZIP code are both positively and statistically significantly associated with COVID-19 cases per capita. The magnitudes are sizeable for both black and Hispanic, but even larger for Hispanic. Although some of these disparities can be explained by differences in long-run opportunity, human mobility, and demographics, most of the disparities remain unexplained even after including an extensive list of covariates related to possible mechanisms. 

For two cities – Chicago and New York – we also examine COVID-19 fatalities, finding that differences in confirmed COVID-19 cases explain the majority of the observed disparities in fatalities. In other words, the higher death toll of COVID-19 in predominantly black and Hispanic communities mostly reflects higher case rates, rather than higher fatality rates for confirmed cases.

COVID-19: From a PHEIC to a public mental health crisis?

An editorial in The Lancet Public Health: COVID-19: from a PHEIC to a public mental health crisis?

On Jan 30, 2020, the WHO declared the outbreak of COVID-19 a public health emergency of international concern (PHEIC). 6 months later, more than 14 million confirmed cases, more than 600 000 deaths, and unprecedented public health measures are impacting the lives of billions of individuals around the world and all aspects of society. While the focus has been—understandably—on the physical health crisis, the direct and indirect psychological and social effects of the pandemic could be all-pervading. Will the public health emergency of international concern morph into a public mental health crisis? 

Several surveys are capturing the immediate mental health impacts of the pandemic. Findings from the University College London revealed that of 44 000 people surveyed, 18% reported thoughts of self-harm or suicide during lockdown. Matthias Pierce and colleagues' large survey of UK households in The Lancet Psychiatry showed that mental health declined substantially after the first month of COVID-19 lockdown. More than one quarter reported clinically relevant levels of mental distress in late April, 2020, compared with one in five before the lockdown. Women, young people, and those living with pre-school children were the most affected. 

The COVID-19 and the nation's mental health: forecasting needs and risks in the UK report from the Centre for Mental Health released on July 17, lays out the need to prepare for a rising tide of mental health difficulties in the coming months. This follows the Centre's previous briefing, which projected that about half a million people in the UK could experience a mental health difficulty over the next year as a result of the pandemic. The Centre's latest assessment reviews the evidence on the impact of COVID-19 on mental health. In particular, the report identifies that children and young adults are at high risk and that the impact of the pandemic on children and young people's mental health is greater in areas and communities hardest hit by the virus and by lockdowns. 

Children from low-income families, from Black, Asian, and minority ethnic communities, and young carers are all more likely to experience poor mental health. Children's wellbeing has been affected by large and sustained disruptions to their education and environment. For young adults, the deterioration of the economy is of particular concern. Youth unemployment has both short-term and long-term consequences for mental health and there is a high risk that young people will be particularly affected by the economic recession. The economic consequences of COVID-19 could further exacerbate and entrench inequalities. 

Moreover, the impact of loneliness and isolation on the mental health and morbidity of the elderly should also be a source of concern. A survey from the Office of National Statistics showed that more than 70% of people aged over 70 years in the UK are concerned about the impact of COVID-19 on their lives and 20% said that their mental health had been affected. 

Crucially for health-care workers and the social care workforce, data from previous pandemics show clear mental health effects and early reports of frontline health-care workers experiencing a variety of mental health challenges, especially burnout and fear, are emerging. 

Some will dispute the use of mental health to discuss an understandable response to stressors such as isolation and poverty. What is important, however, is the accurate monitoring of the distress and the loss of function that individuals experience in the wake of COVID-19, and the provision of appropriate support. If health professionals, as well as individuals with lived experience, can help the population as a whole, this should be facilitated by policymakers. 

The COVID-19 pandemic presents a public mental health challenge. As Jonathan Campion and colleagues noted in The Lancet Psychiatry, it will be key for countries to prevent an increase in mental issues and a reduction in mental wellbeing across populations, as well as to provide appropriate public mental health interventions. Despite the existence of effective public mental health interventions, implementation is far from adequate. Public mental health interventions will need to be proportionately targeted to groups at a high risk of mental disorder and poor mental wellbeing. 

The unequal impacts of COVID-19, the lockdown, and its socioeconomics consequences are putting greater pressure on groups whose mental health was already more precarious before the pandemic. The COVID-19 pandemic is a public mental health emergency that could exacerbate inequalities in mental health—unless concerted actions are urgently taken.