Excess Cases Research Articles

Modelling the impact of lockdown-easing measures on cumulative COVID-19 cases and deaths in England

ObjectivesTo assess the potential impacts of successive lockdown-easing measures in England, at a point in the COVID-19 pandemic when community transmission levels were relatively high.DesignWe developed a Bayesian model to...

Thyroid cancer overdiagnosis revisited

BackgroundEvidence has accumulated showing that an increase in thyroid cancer incidence reflects overdiagnosis of clinically unimportant lesions due to the rise in the use of neck ultrasonography. In the manuscript we examine the hypothesis that the rise in thyroid cancer incidence in Russia is largely caused by overdiagnosis. Materials and methodsIncidence and mortality rates of thyroid cancer for Russia overall and its administrative regions were abstracted from the statistical database of the Ministry of Health of Russia. For incidence trends, we calculated the percentage change, linear regression coefficient and p-value. The calculation of excess cases was based on expected age-specific distributions assuming that the incidence of thyroid cancer increases exponentially with age, as predicted by the multistage model of carcinogenesis. FindingsOver the study period (1989–2015) the age standardized incidence of thyroid cancer has tripled in Russian women and doubled in men. Strong support for the hypothesis that the increase in thyroid cancer incidence may be artificial is evident from age-specific incidence trends: increases in incidence in middle age but not in older ages, thereby altering the age curves from the expected exponential shape to an “inverted U” shape. The number of observed cases of thyroid cancer exceeded the expected number by 138, 325 or 70 % of all cases diagnosed with thyroid cancer. We attribute the excess cases to detection by ultrasonography clinically unimportant lesions. This is supported by a very high incidence –to-mortality ratio, low case fatality, high and growing prevalence of thyroid cancer. ConclusionAlthough there is an evidence that exposure to iodine 131 (131I) is an important cause of the increase in incidence of thyroid cancer in high-risk populations, we have shown that this increase could largely be attributed to overdiagnosis associated with ultrasonography screening. Overdiagnosis is the only explanation of the increase in thyroid cancer incidence in low-risk regions.

Excess Invasive Meningococcal Disease Associated With Seasonal Influenza, South Africa, 2003-2018.

BackgroundInvasive meningococcal disease (IMD) is a devastating illness with high mortality rates. Like influenza, endemic IMD is seasonal, peaking in winter. Studies suggest that circulation of influenza virus may influence the timing and magnitude of IMD winter peaks.MethodsThis ecological study used weekly data from 2 nationwide surveillance programs: Viral Watch (proportion of outpatient influenza-positive cases from throat or nasal swab samples) and GERMS-SA (laboratory-confirmed cases of IMD), occurring across South Africa from 2003 through 2018 in all age bands. A bivariate time series analysis using wavelet transform was conducted to determine cocirculation of the diseases and the time lag between the peak seasons. We modeled excess meningococcal disease cases attributable to influenza cocirculation, using univariate regression spline models. Stata and R statistical software packages were used for the analysis.ResultsA total of 5256 laboratory-confirmed IMD cases were reported, with an average annual incidence of 0.23 episodes per 100 000 population and a mean seasonal peak during week 32 (±3 weeks). Forty-two percent of swab samples (10 421 of 24 741) were positive for influenza during the study period. The mean peak for all influenza occurred at week 26 (±4 weeks). There was an average lag time of 5 weeks between annual influenza and IMD seasons. Overall, 5% (1%–9%) of IMD cases can be attributable to influenza cocirculation, with, on average, 17 excess IMD cases per year attributable to influenza.ConclusionsA quantifiable proportion of IMD in South Africa is associated with influenza cocirculation; therefore, seasonal influenza vaccination may have an effect on preventing a small portion of IMD in addition to preventing influenza.

Adverse Cardiovascular Events Following Severe Maternal Morbidity.

Severe maternal morbidity (SMM) affects 50,000 women annually in the United States, but its consequences are not well understood. We aimed to estimate the association between SMM and risk of adverse cardiovascular events during the 2 years postpartum. We analyzed 137,140 deliveries covered by the Pennsylvania Medicaid program (2016-2018), weighted with inverse probability of censoring weights to account for nonrandom loss to follow-up. SMM was defined as any diagnosis on the Centers for Disease Control and Prevention list of SMM diagnoses and procedures and/or intensive care unit admission occurring at any point from conception through 42 days postdelivery. Outcomes included heart failure, ischemic heart disease, and stroke/transient ischemic attack up to 2 years postpartum. We used marginal standardization to estimate average treatment effects. We found that SMM was associated with increased risk of each adverse cardiovascular event across the follow-up period. Per 1,000 deliveries, relative to no SMM, SMM was associated with 12.1 (95% confidence interval (CI): 6.2, 18.0) excess cases of heart failure, 6.4 (95% CI: 1.7, 11.2) excess cases of ischemic heart disease, and 8.2 (95% CI: 3.2, 13.1) excess cases of stroke/transient ischemic attack at 26 months of follow-up. These results suggest that SMM identifies a group of women who are at high risk of adverse cardiovascular events after delivery. Women who survive SMM may benefit from more comprehensive postpartum care linked to well-woman care.

Excess Mortality Probably Attributable to COVID-19 in Tokyo, Japan During August and October 2020

Background: By March, 2021, the COVID-19 outbreak had reached its highest peak at the end of December, 2020. Nevertheless, no remarkable excess mortality attributable to COVID-19 has been observed. Object: We sought to quantify excess mortality in April using the National Institute of Infectious Diseases (NIID) model. Method: We applied the NIID model to deaths of all causes from 1987 through February, 2021 for all of Japan and through October for Tokyo. Results: Results obtained for Japan show very few excess mortality cases in August and October, 2020, estimated respectively as 12 and 104. However, in Tokyo, 595 cases of excess mortality were detected during August and October: they were, respectively, 3.1% and 1.7% of baseline numbers. Discussion and Conclusion: We detected considerable excess mortality in Tokyo but not throughout Japan. Continued careful monitoring of excess mortality of COVID-19 is expected to be important.

Expiring Eviction Moratoriums and COVID-19 Incidence and Mortality.

The coronavirus disease 2019 (COVID-19) pandemic and associated economic crisis have placed millions of US households at risk of eviction. Evictions may accelerate COVID-19 transmission by decreasing individuals’ ability to socially distance. We leveraged variation in the expiration of eviction moratoriums in US states to test for associations between evictions and COVID-19 incidence and mortality. The study included 44 US states that instituted eviction moratoriums, followed from March 13 to September 3, 2020. We modeled associations using a difference-in-difference approach with an event-study specification. Negative binomial regression models of cases and deaths included fixed effects for state and week and controlled for time-varying indicators of testing, stay-at-home orders, school closures, and mask mandates. COVID-19 incidence and mortality increased steadily in states after eviction moratoriums expired, and expiration was associated with a doubling of COVID-19 incidence (incidence rate ratio = 2.1; 95% confidence interval (CI): 1.1, 3.9) and a 5-fold increase in COVID-19 mortality (mortality rate ratio = 5.4; CI: 3.1, 9.3) 16 weeks after moratoriums lapsed. These results imply an estimated 433,700 excess cases (CI: 365,200, 502,200) and 10,700 excess deaths (CI: 8,900, 12,500) nationally by September 3, 2020. The expiration of eviction moratoriums was associated with increased COVID-19 incidence and mortality, supporting the public-health rationale for eviction prevention to limit COVID-19 cases and deaths.

Preventable causes of cancer in Texas by race/ethnicity: tobacco smoking.

OBJECTIVESTobacco smoking is classified as carcinogenic to humans (International Agency for Research on Cancer Group 1). We aimed to estimate the percentage and number of incident cancer cases diagnosed in Texas in 2015 that were attributable to tobacco smoking, and we examined differences in the proportions of smoking-attributable cancers between the major racial/ethnic subgroups of the population.METHODSWe calculated population-attributable fractions for cancers attributable to tobacco smoking using prevalence data from the Texas Behavioral Risk Factor Surveillance System and relative risks associated with smoking status from pooled analyses of cohort studies or meta-analyses. Cancer incidence data were collected from the Texas Cancer Registry.RESULTSWe estimated that 19,000 excess cancer cases or 18.4% of all cancers diagnosed in 2015 in Texans aged ≥ 25 years were caused by tobacco smoking. Males had a higher overall proportion of cancers attributable to tobacco smoking than females (male, 23.3%, 11,993 excess cases; female, 13.5%, 7,006 cases). Approximately 20% of cancer cases in non-Hispanic Whites and non-Hispanic Blacks were attributable to tobacco smoking compared to 12.8% among Hispanics.CONCLUSIONSDespite ongoing public health campaigns combatting tobacco use, this preventable behavior still contributes significantly to cancer incidence in Texas. Racial/ethnic differences in smoking prevalence and smoking-attributable cancer incidence should be considered when designing cancer prevention programs.

Risk assessment of excess mortality attribute to PM_(2.5) exposure in 5 cities in China in 2018

To assess the risk of excess mortality caused by exposure to PM_(2.5) in 5 cities in China. Surveillance data on daily concentration of PM_(2.5), meteorology and death-causes were collected from 2015 to 2018 in Harbin, Xi& apos; an, Nanjing, Chengdu and Guangzhou cities. Generalized additive model(GAM) was used to analyze acute exposure-response coefficients of PM_(2.5) exposure on the mortality. Using daily 24-hour average concentration of PM_(2.5) in 2018 to estimate the exposure levels of the population, with PM_(2.5) 24-hour average concentration limit of the ambient air quality standard(GB 3095-2012) for reference concentration(75 μg/m~3), and applicating the health risk assessment model, the excess deaths attribute to PM_(2.5) exposure in the 5 cities in 2018 was estimated. Attribute to PM_(2.5) exposure, the excess cases of death caused by circulatory system diseases in Harbin and Guangzhou were 35 and 92, the excess cases caused by respiratory diseases in Xi& apos; an was 70, the excess cases of caused by non-accident in Nanjing was 69, and the excess cases caused by non-accidental, respiratory and circulatory diseases in Chengdu were 588, 210 and 134 in 2018. PM_(2.5) exposure could increase the excess mortality risk, which varies among different cities.

Damages Liability of the EU for Harm Caused by Excessive Duration of Court Proceedings

In January 2017, the European Union was ordered to pay damages to two companies because of excessively long court proceedings before the General Court, the first time such an order had been made. At this point, a number of EU Courts’ judgments that address damages liability for excessively long court proceedings can be found. According to the European Court of Justice, a damages claim is an appropriate and effective remedy in a case of a failure to adjudicate within a reasonable time. This contribution systematizes and analyses recent EU level case law regarding the excessive duration of court proceedings with damages as a remedy. A particular emphasis is placed on examining the relevant case law against the backdrop of existing EU damages liability law. We particularly study how the conditions of harm and causation are interpreted and applied in the EU level ‘excessive duration cases’. We discuss and summarize the theoretical and practical implications of the excessive duration liability case law, as well as highlight particularly interesting details from recent judgments. EU Courts, Right to trial within a reasonable time, Excessive duration of court proceedings, Effective remedies, Damages liability of the EU, Economic harm, Non-material harm, Conditions for liability, Requirements for establishing harm and causation, Significance for EU damages liability law

Multilevel modeling of county-level excessive alcohol use, rurality, and COVID-19 case fatality rates in the US.

Reports of disparities in COVID-19 mortality rates are emerging in the public health literature as the pandemic continues to unfold. Alcohol misuse varies across the US and is related to poorer health and comorbidities that likely affect the severity of COVID-19 infection. High levels of pre-pandemic alcohol misuse in some counties may have set the stage for worse COVID-19 outcomes. Furthermore, this relationship may depend on how rural a county is, as access to healthcare in rural communities has lagged behind more urban areas. The objective of this study was to test for associations between county-level COVID-19 mortality, pre-pandemic county-level excessive drinking, and county rurality. We used national COVID-19 data from the New York Times to calculate county-level case fatality rates (n = 3,039 counties and county equivalents; October 1 -December 31, 2020) and other external county-level data sources for indicators of rurality and health. We used beta regression to model case fatality rates, adjusted for several county-level population characteristics. We included a multilevel component to our model and defined state as a random intercept. Our focal predictor was a single variable representing nine possible combinations of low/mid/high alcohol misuse and low/mid/high rurality. The median county-level COVID-19 case fatality rate was 1.57%. Compared to counties with low alcohol misuse and low rurality (referent), counties with high levels of alcohol and mid (β = -0.17, p = 0.008) or high levels of rurality (β = -0.24, p<0.001) demonstrated significantly lower case fatality rates. Our findings highlight the intersecting roles of county-level alcohol consumption, rurality, and COVID-19 mortality.

Covid-19 in end-stage renal disease patients with renal replacement therapies: A systematic review and meta-analysis

The novel coronavirus (COVID-19), caused by SARS-CoV-2, showed various prevalence and case-fatality rates (CFR) among patients with different pre-existing chronic conditions. End-stage renal disease (ESRD) patients with renal replacement therapy (RRT) might have a higher prevalence and CFR due to reduced immune function from uremia and kidney tropism of SARS-CoV-2, but there was a lack of systematic study on the infection and mortality of the SARS-CoV-2 infection in ESRD patients with various RRT. We searched five electronic databases and performed a systematic review and meta-analysis up to June 30, 2020, to evaluate the prevalence and case fatality rate (CFR) of the COVID-19 infection among ESRD patients with RRT. The global COVID-19 data were retrieved from the international database on June 30, 2020, for estimating the prevalence and CFR of the general population as referencing points. Of 3,272 potential studies, 34 were eligible studies consisted of 1,944 COVID-19 confirmed cases in 21,873 ESRD patients with RRT from 12 countries in four WHO regions. The overall pooled prevalence in ESRD patients with RRT was 3.10% [95% confidence interval (CI) 1.25-5.72] which was higher than referencing 0.14% global average prevalence. The overall estimated CFR of COVID-19 in ESRD patients with RRT was 18.06% (95% CI 14.09-22.32) which was higher than the global average at 4.98%. This meta-analysis suggested high COVID-19 prevalence and CFR in ESRD patients with RRT. ESRD patients with RRT should have their specific protocol of COVID-19 prevention and treatment to mitigate excess cases and deaths.

Contribution of common risk variants to multiple sclerosis in Orkney and Shetland

Orkney and Shetland, the population isolates that make up the Northern Isles of Scotland, are of particular interest to multiple sclerosis (MS) research. While MS prevalence is high in Scotland, Orkney has the highest global prevalence, higher than more northerly Shetland. Many hypotheses for the excess of MS cases in Orkney have been investigated, including vitamin D deficiency and homozygosity: neither was found to cause the high prevalence of MS. It is possible that this excess prevalence may be explained through unique genetics. We used polygenic risk scores (PRS) to look at the contribution of common risk variants to MS. Analyses were conducted using ORCADES (97/2118 cases/controls), VIKING (15/2000 cases/controls) and Generation Scotland (30/8708 cases/controls) data sets. However, no evidence of a difference in MS-associated common variant frequencies was found between the three control populations, aside from HLA-DRB1*15:01 tag SNP rs9271069. This SNP had a significantly higher risk allele frequency in Orkney (0.23, p value = 8 × 10–13) and Shetland (0.21, p value = 2.3 × 10–6) than mainland Scotland (0.17). This difference in frequency is estimated to account for 6 (95% CI 3, 8) out of 150 observed excess cases per 100,000 individuals in Shetland and 9 (95% CI 8, 11) of the observed 257 excess cases per 100,000 individuals in Orkney, compared with mainland Scotland. Common variants therefore appear to account for little of the excess burden of MS in the Northern Isles of Scotland.

Sex Difference in the Case Fatality of Older Myocardial Infarction Patients.

BackgroundThe female sex is associated with poorer outcomes after myocardial infarction (MI), although current evidence in older patients is limited and mixed. We sought to evaluate sex-based differences in outcome after MI in older patients.MethodConsecutive older (≥70 years) all-comer patients with out-of-hospital MI admitted to 20 hospitals in Finland between 2005 and 2014 were studied using national registries (n = 40 654, mean age 80 years, 50% women). The outcome of interest was death within 1 year after MI. Differences between sexes (age, baseline features, medication, comorbidities, revascularization, and treating hospital) were balanced by inverse probability weighting.ResultsAdjusted all-cause case fatality was lower in women than in men at 30 days (16.0% vs 19.0%, respectively) and at 1 year (27.7% vs 32.4%, respectively) after MI (hazard ratio: 0.83; confidence interval [CI]: 0.80–0.86; p < .0001). Excess 1-year case fatality after MI compared to the corresponding general population was 22.1% (CI: 21.4%–22.8%) in women and 24.1% (CI: 23.4%–24.9%) in men. Women had a lower adjusted hazard of death after MI in subgroups of patients aged 70–79 years and ≥80 years, patients with and without ST elevation MI, revascularized and non-revascularized patients, patients with and without atrial fibrillation, and patients with and without diabetes. The sex difference in case fatality remained similar during the study period.ConclusionsOlder women were found to have a lower hazard of death after an out-of-hospital MI when compared to older men with similar features and treatments. This finding was consistent in several subgroups.

The Effect of Dust Transport on the Concentration of Chlorophyll-A in the Surface Layer of the Black Sea

This paper focuses on the atmospheric dust transport effect on the changes in chlorophyll-A concentration in the Black Sea surface layer. In order to assess the input of nutrients with atmospheric precipitations at the Crimean coast of the Black Sea, the collected samples were analyzed for the content of inorganic nitrogen, phosphates, and silicon. The samples were taken into a wet-only sampler and into a permanently open one, to assess the effect of dust on the nutrients concentration in dry depositions. Cases of multi-fold excess of the nutrients content in the open sampler collected precipitation over that in the wet-only sampler were identified. For such high concentration cases, the 7-day back-trajectories analyses was carried out using the model of the international network AERONET and the HYSPLIT model. The results of our research showed that the influx of nutrients with the atmospheric depositions can result in increasing of chlorophyll-A concentration in 11–36% in the surface layer of the Black Sea. After atmospheric depositions, concentration of phosphates in the surface layer can increase more than five times compared with the background concentration. The increase of silicon concentration can reach 30%. The influx of atmospheric precipitation containing significant amounts of nutrients into the bay can shifts the Redfield ratio compared with background value up to three times.

Secondary cancer risk from modern external-beam radiotherapy of prostate cancer patients: Impact of fractionation and dose distribution.

Modern radiotherapy (RT) uses altered fractionation, long beam-on time and image-guided procedure. This study aimed to compare secondary cancer risk (SCR) associated with primary field, scatter/leakage radiations and image-guided procedure in prostate treatment using intensity-modulated RT (IMRT), CyberKnife stereotactic body RT (CK-SBRT) in relative to 3-dimensional conformal RT (3D-CRT). Prostate plans were generated for 3D-CRT, IMRT (39 fractions of 2 Gy), and CK-SBRT (five fractions of 7.25 Gy). Excess absolute risk (EAR) was calculated for organs in the primary field using Schneider’s mechanistic model and concept of organ equivalent dose (OED) to account for dose inhomogeneity. Doses from image-guided procedure and scatter/leakage radiations were determined by phantom measurements. The results showed that hypofractionation relative to conventional fractionation yielded lower SCR for organs in primary field (p ≤ 0.0001). SCR was further modulated by dose-volume distribution. For organs near the field edge, like the rectum and pelvic bone, CK-SBRT plan rendered better risk profiles than IMRT and 3D-CRT because of the absence of volume peak in high dose region (relative risk [RR]: 0.65, 0.22, respectively, p ≤ 0.0004). CK-SBRT and IMRT generated more scatter/leakage and imaging doses than 3D-CRT (p ≤ 0.0002). But primary field was the major contributor to SCR. EAR estimates (risk contributions, primary field: scatter/leakage radiations: imaging procedure) were 7.1 excess cases per 104 person–year (PY; 3.64:2.25:1) for CK-SBRT, 9.93 (7.32:2.33:1) for IMRT and 8.24 (15.99:2.35:1) for 3D-CRT (p ≤ 0.0002). We conclude that modern RT added more but small SCR from scatter/leakage and imaging doses. The primary field is a major contributor of risk which can be mitigated by the use of hypofractionation.

Fuzzy modelling of combustion efficiency and control of excess air flow case study: 320-MW steam unit/Isfahan Power Plant/Iran

Abstract One of the most critical factors affecting boiler efficiency and hazardous-gas-emission reduction is the volume of excess air mixed with fuel. A knowledge-based approach is proposed to model the efficiency of a 320-MW natural-gas-fired steam power plant in Isfahan, Iran by applying fuzzy-modelling techniques to control the boiler efficiency. This model is based on fuel and air entering the boiler. First, the fuzzy-model structure is identified by applying the fuzzy rules obtained from an experienced human operator. The proposed method is then optimized using a genetic algorithm to increase the fuzzy-model accuracy. The results indicate that, by applying a genetic algorithm, the precision of the proposed fuzzy model increases. The error between the actual efficiency of the plant and the output efficiency of the proposed model is low. This model is developed by applying the fuzzy rules and modelling-related calculations. Finally, to optimize the efficiency of the boiler, a fuzzy proportional-integral controller is designed. The closed-loop control simulations are run by applying both the proposed controller and the manual controller to demonstrate the influence of the suggested method. The simulation outcomes indicate that the recommended controller adjusts the excess-air percentage correctly and increases the unit efficiency by 0.70%, significantly reducing fuel consumption.

Flood hydrometeorology and gastroenteric infection: The Winter 2015–2016 flood event in the Republic of Ireland

During a 6-week period in November and December 2015, a series of Atlantic Storms swept across the Republic of Ireland (ROI) causing widespread pluvial and fluvial flooding. Flooding was particularly severe in the west and midlands, with rainfall up to 200% above normal in many regions, making it the wettest winter ever recorded. While the infrastructural damage and subsequent costs associated with flood events have, and continue to receive widespread attention, far less coverage is given to the associated adverse human health effects. This is particularly significant in the ROI, which is characterised by the highest crude incidence rates of verotoxigenic E. coli (VTEC) enteritis and cryptosporidiosis in Europe. Accordingly, weekly spatially-referenced infection incidence from July 2015 to June 2016 were employed in concurrence with weekly time-series of cumulative antecedent rainfall, surface water discharge and groundwater level, and high-resolution flood risk mapping. An ensemble of statistical and time-series analyses were used to quantify the influence of flood hydrometeorology on the incidence of confirmed infections. Seasonal decomposition (excluding seasonal patterns and long-term trends) identified a high residual infection peak during April 2016, with space-timing scanning used to identify the location, size and temporal extent of clustering. Excess cases of VTEC enteritis were geographically associated with the midlands, while cryptosporidiosis clusters were widespread. Generalised linear modelling of infection locations show that areas with a surface water body exhibited significantly higher incidence rates for both VTEC (OR: 1.225; p < 0.001) and cryptosporidiosis (OR: 1.363; p < 0.001). ARIMA models show a clear association between rainfall, surface water discharge, groundwater levels and infection incidence, with lagged associations from 16 to 20 weeks particularly strong, thus indicating a link between infection peaks (April 2016) and the flood event which began approximately 18 weeks earlier. All three hydrometeorological variables were associated with the increase in cryptosporidiosis during April 2016, while only surface water discharge was associated with VTEC enteritis. Study findings may be employed for improved risk communication, risk management and surveillance to safeguard public health after large hydrometeorological events.

Social workers' perspectives on barriers and facilitators in responding to intimate partner violence in primary health care in Spain.

To identify the barriers and facilitators of managing intimate partner violence (IPV) cases, from the perspective of primary health care (PHC) social workers. Qualitative study through interviews with 14 social workers working in PHC centres in Spain. A thematic analysis approach was applied to identify barriers and facilitators according to the Tanahashi model. The barriers identified by social workers in providing effective coverage to women suffering from IPV included insufficient practical training, a lack of knowledge from women on social workers' roles, a lack of teamwork, and excess IPV case referrals from other professionals to social workers. The identified facilitators were the existence of electronic protocols and good practices including therapeutic support groups and holistic intervention approaches. An excess of referrals to social workers of identified IPV cases following consultation by other members of the PHC team, alongside the lack of interdisciplinary teamwork, does not enable a comprehensive and holistic approach to this problem. Compulsory, practical, and interdisciplinary training in IPV for all PHC professionals and students must be a priority for health agencies and universities in order to facilitate a comprehensive and quality approach for all women suffering from IPV.

A Population-Based Assessment of Physical Symptoms and Mental Health Outcomes Among Adults Following the Flint Water Crisis.

Little is known about the physical and mental health outcomes of adults in the low-income, predominantly Black city of Flint, Michigan, following the city's water crisis which began in April 2014 after austerity policies led to the city switching its water source. We investigate these dynamics using data from a longitudinal community-based cohort in Flint. Between June and November 2019, surveys were administered at nine public sites across Flint. Nested models were employed to assess relationships between respondent demographics, including race/ethnicity, and self-report of clinician-diagnosed blood lead levels (BLLs) and various physical symptoms and mental health outcomes, including depression/anxiety (PHQ-4) and psychological trauma (PC-PTSD-5). Of the 331 respondents (mean age: 47.9 + 16.5), most were women (58.6%) and Black (57.7%). In total, 10.0% self-reported elevated BLLs, with borderline significantly higher reports among Blacks (p = 0.07). Skin rashes (58.1% vs. 33.9%, p < 0.01), hair loss (45.5% vs. 30.3%, p = 0.01), and nausea (35.6% vs. 20.2%, p = 0.1) were significantly higher among Blacks versus Whites. Additionally, 29.0% and 26.3% of respondents met trauma and depression/anxiety criteria, respectively. Increasing physical symptoms was associated with psychological trauma (OR 2.1, p < 0.01) and depression/anxiety (OR 1.9, p < 0.01). In closing, Flint adults, particularly Blacks, experienced deleterious physical and mental health outcomes following the city's water crisis that appear to represent a substantial burden of excess cases. Further research is needed on how austerity impacts community health in economically distressed urban cities and ways to generate capacity to identify and curb adverse consequences.

Divergences on expected pneumonia cases during the COVID-19 epidemic in Catalonia: a time-series analysis of primary care electronic health records covering about 6 million people

BackgroundPneumonia is one of the complications of COVID-19. Primary care electronic health records (EHR) have shown the utility as a surveillance system. We therefore analyse the trends of pneumonia during two waves of COVID-19 pandemic in order to use it as a clinical surveillance system and an early indicator of severity.MethodsTime series analysis of pneumonia cases, from January 2014 to December 2020. We collected pneumonia diagnoses from primary care EHR, a software system covering > 6 million people in Catalonia (Spain). We compared the trend of pneumonia in the season 2019–2020 with that in the previous years. We estimated the expected pneumonia cases with data from 2014 to 2018 using a time series regression adjusted by seasonality and influenza epidemics.ResultsBetween 4 March and 5 May 2020, 11,704 excess pneumonia cases (95% CI: 9909 to 13,498) were identified. Previously, we identified an excess from January to March 2020 in the population older than 15 years of 20%. We observed another excess pneumonia period from 22 october to 15 november of 1377 excess cases (95% CI: 665 to 2089). In contrast, we observed two great periods with reductions of pneumonia cases in children, accounting for 131 days and 3534 less pneumonia cases (95% CI, 1005 to 6064) from March to July; and 54 days and 1960 less pneumonia cases (95% CI 917 to 3002) from October to December.ConclusionsDiagnoses of pneumonia from the EHR could be used as an early and low cost surveillance system to monitor the spread of COVID-19.