Washington State Department Of Health Research Articles

Cannabis Use Among Students in Grades 8, 10, and 12, by Sex - King County, Washington, 2008-2021.

Cannabis use during adolescence is associated with poor outcomes, including cognitive impairment, cannabis use disorder, and impaired driving. To guide prevention and use reduction strategies, Public Health - Seattle & King County described recent trends in cannabis use by sex among King County, Washington students in grades 8, 10, and 12 and examined trends in sex-based differences. Data collected during seven 2008-2021 survey periods by the Healthy Youth Survey (administered by the Washington State Department of Health) and restricted to King County students in grades 8, 10, and 12 (range=33,439-39,391 students per cycle) were analyzed. Prevalence estimates were generated and sex-based prevalence differences (PDs) in current use (≥1 day during the previous 30 days) and frequent use (≥6 days during the previous 30 days) were assessed. PD models used weighted generalized linear regression with an interaction between sex and survey year. During 2008-2021, cannabis use declined among both male and female students. During 2008-2014, cannabis use was higher among male students than among female students (e.g., PD in 2008=4.8%) and not significantly different during 2014-2016; however, in 2021, current-use prevalence was lower among male students than among female students for the first time (PD=-1.3%). Frequent-use prevalence was similar among males and females. By grade levels, the highest prevalence of both current and frequent cannabis use was observed among 12th grade students, followed by 10th and 8th graders. Sex-specific differences by grade mirrored overall patterns. Developing tailored interventions that consider potential differences in risk and protective factors by sex or gender identity could promote equity in youth (grades 8, 10, and 12) cannabis use reduction measures.

Coping with COVID-19: Standing up a comprehensive behavioral health response to the pandemic.

Integrating behavioral health (BH) into disaster preparedness and response is essential to mitigate and address the BH impacts of disasters, support incident response personnel well-being, and to integrate disaster BH concepts into response strategies and communications. This article describes the development, implementation, and lessons learned from a statewide BH response to this disaster by the COVID-19 Behavioral Health Group (COVID-19 BHG). Operating within the Washington State Department of Health (WA DOH), the BHG is comprised of psychologists and psychiatrists with expertise in disaster BH and response, BH epidemiologists, data analysts, systems specialists, emergency managers, and other DOH staff. The wide array of expertise on the team allowed the COVID-19 BHG to build response functions to match the demands created by the pandemic. This included an Impact & Capacity Assessment function, which developed and distributed monthly impact forecasts and weekly BH situational reports. A Training and Guidance team then collaborated with partners to develop and deliver trainings, resource documents, and public messaging. Additionally, the COVID-19 BHG worked closely with the Health Care Authority (HCA) and BH organizations statewide to maintain the ability of the BH system to deliver care and expand services to meet additional needs. This article describes the development and deployment of an innovative and unique statewide BH response, within the WA DOH during the COVID-19 pandemic.

Innovative Strategies to Address Systemic Inequities in Youth Sexual Health Programs: A Preliminary Program Evaluation.

Disparities in sexual health outcomes between racial and ethnic groups throughout the state of Washington suggest the presence of systemic inequities impeding young people's experience with and access to sexual health care and education. Emerging innovations in sexual health look to center young people, particularly those who have been historically excluded, in the design and implementation of programs that aim to serve them. The Washington Youth Sexual Health Innovation and Impact Network (WYSHIIN) and 11 grant-funded partners engaged communities of youth across the state of Washington, including Two Spirit, lesbian, gay, bisexual, transgender, queer, questioning, intersex, and/or asexual (2SLGBTQIA+) and Black, Indigenous, and People of Color (BIPOC) youth, with the goal of equitably engaging participants and stakeholders to broaden services in schools and community settings. Evaluation staff from the Washington State Department of Health conducted virtual interviews with community partners for preliminary program evaluation purposes and identified 6 strategies for engaging youth. WYSHIIN partners highlighted strategies for centering youth voice and needs at all levels of program development and implementation, embracing holistic and culturally relevant approaches, and 2SLGBTQIA+ inclusion. These themes, reflective of wisdom across multiple Washington communities, offer strategies to address systemic issues that negatively impact youth access to and experience with sexual health care.

Tuberculosis Outbreak in a State Prison System - Washington, 2021-2022.

During 2014-2020, no tuberculosis (TB) cases were reported within the Washington state prison system. However, during July 2021-June 2022, 25 TB cases were reported among persons incarcerated or formerly incarcerated in two Washington state prisons. Phylogenetic analyses of whole genome sequencing data indicated that Mycobacterium tuberculosis isolates from all 11 patients with culture-confirmed TB were closely related, suggesting that these cases represented a single outbreak. The median infectious period for 12 patients who were considered likely contagious was 170 days. As of November 15, 2022, the Washington State Department of Corrections (WADOC) and Washington State Department of Health (WADOH), with technical assistance from CDC, had identified 3,075 contacts among incarcerated residents and staff members at five state prisons, and 244 contacts without a known TB history received a diagnosis of latent TB infection (LTBI). Persons who were evaluated for TB disease were isolated; those receiving a diagnosis of TB then initiated antituberculosis therapy. Persons with LTBI were offered treatment to prevent progression to TB disease. This ongoing TB outbreak is the largest in Washington in 20 years. Suspension of annual TB screening while limited resources were redirected toward the COVID-19 response resulted in delayed case detection that facilitated TB transmission. In addition, fear of isolation might discourage residents and staff members from reporting symptoms, which likely also leads to delayed TB diagnoses. Continued close collaboration between WADOC and WADOH is needed to end this outbreak and prevent future outbreaks.

Sentinel Surveillance System Implementation and Evaluation for SARS-CoV-2 Genomic Data, Washington, USA, 2020-2021.

Genomic data provides useful information for public health practice, particularly when combined with epidemiologic data. However, sampling bias is a concern because inferences from nonrandom data can be misleading. In March 2021, the Washington State Department of Health, USA, partnered with submitting and sequencing laboratories to establish sentinel surveillance for SARS-CoV-2 genomic data. We analyzed available genomic and epidemiologic data during presentinel and sentinel periods to assess representativeness and timeliness of availability. Genomic data during the presentinel period was largely unrepresentative of all COVID-19 cases. Data available during the sentinel period improved representativeness for age, death from COVID-19, outbreak association, long-term care facility-affiliated status, and geographic coverage; timeliness of data availability and captured viral diversity also improved. Hospitalized cases were underrepresented, indicating a need to increase inpatient sampling. Our analysis emphasizes the need to understand and quantify sampling bias in phylogenetic studies and continue evaluation and improvement of public health surveillance systems.

Prospective Case-control Study of Contact Tracing Speed for Emergency Department-based Contact Tracers.

IntroductionIn Snohomish County, WA, the time from obtaining a positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) test and initiating contact tracing is 4–6 days. We tested whether emergency department (ED)-based contact tracing reduces time to initiation and completion of contact tracing investigations.MethodsAll eligible coronavirus disease 2019 (COVID-19)-positive patients were offered enrollment in this prospective case-control study. Contact tracers were present in the ED from 7 AM to 2 AM for 60 consecutive days. Tracers conducted interviews using the Washington State Department of Health’s extended COVID-19 reporting form, which is also used by the Snohomish Health District (SHD).ResultsEighty-one eligible SARS-CoV-2 positive patients were identified and 71 (88%) consented for the study. The mean time between positive COVID-19 test result and initiation of contact tracing investigation was 111 minutes with a median of 32 minutes (range: 1–1,203 minutes). The mean time from positive test result and completion of ED-based contact tracing investigation was 244 minutes with a median of 132 minutes (range: 23–1,233 minutes). In 100% of the enrolled cases, contact tracing was completed within 24 hours of a positive COVID-19 test result. For comparison, during this same period, SHD was able to complete contact tracing in 64% of positive cases within 24 hours of notification of a positive test result (P < 0.001). In the ED, each case identified a mean of 2.8 contacts as compared to 1.4 contacts identified by SHD-interviewed cases. There was no statistically significant difference between the percentage of contacts reached through ED contact tracing (82%) when compared to the usual practice (78%) (P = 0.16).ConclusionWhen contact tracing investigations occur at the point of diagnoses, the time to initiation and completion are reduced, there is higher enrollment, and more contacts are identified.

One Vax Two Lives: a social media campaign and research program to address COVID-19 vaccine hesitancy in pregnancy

The COVID-19 pandemic has disproportionately affected pregnant people by increasing health risks of maternal morbidity and mortality, stillbirth, and preterm birth. Although numerous studies have supported the safety and efficacy of COVID-19 vaccination in pregnancy in preventing or mitigating the risk for these adverse outcomes, many pregnant people remain hesitant. Approximately half of US adults regularly consume news from social media platforms, which are a fertile ground for the spread of vaccine disinformation. The lack of information regarding COVID-19 vaccine safety early in the pandemic fueled vaccine myths targeting the fears of pregnant people about vaccination risks. Saddened by the spike in maternal deaths of unvaccinated individuals during the COVID-19 Delta variant surge in the fall of 2021, we created a social media campaign to promote scientific communication regarding the risks of COVID-19 disease in pregnancy and the benefits of vaccination. We called the campaign “One Vax Two Lives,” which refers to the ability of 1 maternal vaccine to benefit the health and lives of both the pregnant individual and their fetus. We present a blueprint of how we leveraged a large, interdisciplinary student workforce to create a social media campaign and research program studying vaccine hesitancy, which can be replicated by other groups. Community engagement and partnerships with key stakeholders, such as the Washington State Department of Health, were essential for amplifying the campaign and providing our team with feedback on content and approach. We present the analytics of our social media advertisements, web articles, and video content that helped inform the iterative design process of the multimedia content. Moving forward, we are launching collaborative research programs to study vaccine hesitancy and inform the development of new social media content designed for pregnant individuals who are: (1) Spanish-speaking Hispanic/Latina/x, (2) Black or Afro-Latinx, and (3) residents of rural communities in the State of Washington. Data from these mixed methods studies will inform new communication campaigns to reach vaccine-hesitant individuals. Finally, we discuss lessons learned and how the most impactful elements of the campaign can be translated to related areas of maternal public health.

Investigation of Fentanyl Usage in the Seattle Area.

Fentanyl was developed in the 1960s as an alternative to morphine, but quickly became a drug of abuse due to its potency, inexpensiveness, and ease of synthesis. One source of exposure is mixing fentanyl into other drugs of abuse (e.g., heroin), but users also actively seek out this potent opioid. While monitoring for pain medication compliance and office-based opioid treatment, we noticed increasing fentanyl use. We sought to investigate this increase in the local population, and see if this reflected the regional health, morbidity, and mortality statistics. This data review was determined not to involve "human subjects" as defined by federal regulations by the University of Washington (UW) Human Subjects Division (STUDY00014988). Local data were extracted from the laboratory information system and analyzed. Data from the King County Medical Examiner's Office derives from cases sent to the Washington State Toxicology Laboratory. The Addictions, Drug, and Alcohol Institute (ADAI) at the UW compiled data from the Washington State Department of Health, the Forensic Laboratory Services Bureau, Washington State Patrol, and the state Office of Financial Management. We found a significant increase in fentanyl positivity in clinical LC-MS/MS assays, an increase in deaths due to fentanyl, and an increase in the fentanyl usage documented by the public health laboratory. Clinical data from community toxicology testing performed at academic medical centers can reflect trends in society at large, and as such, there may be a compelling reason to publish and use these data to inform public health approaches.

Deaths associated with opioids, race and ethnicity, and years of potential life lost in Washington State

IntroductionThis study examined disparities in years of potential life lost (YPLL) related to opioid use among racial and ethnic groups adjusting for individual- and neighborhood-level characteristics. MethodsThe study obtained data on 5265 geocoded death records associated with opioid use from the Washington State Department of Health. Death certificates included information on race and ethnicity, sex, marital status, and educational attainment. We linked these records to neighborhood-level indicators of rurality, area deprivation, and access to opioid treatment programs. Generalized linear mixed models tested associations between racial and ethnic identity and YPLL controlling for other individual and neighborhood characteristics. ResultsAmong all decedents from opioid-related causes, the study found that racial and ethnic minorities—including Black, American Indian/Alaska Native, Asian, Native Hawaiian or other Pacific Islander—multiracial, or Hispanic adults died at younger ages than did White adults (33 to 44 vs 45). In the fully adjusted models, the estimated mean for YPLL was higher for Asian or Native Hawaiian or other Pacific Islander, multiracial, and Hispanic adults compared to White adults. Accounting for educational attainment and marital status substantially reduced YPLL differences between groups, by as much as 40% in some cases. ConclusionsThe study observed striking differences in YPLL related to opioid causes among racial and ethnic minorities. Accounting for social determinants of health greatly reduced YPLL across all groups but racial and ethnic disparities in YPLL remained significant. Understanding and alleviating additional causes of disparities in YPLL is warranted to abate the epidemic of opioid related deaths in the United States.

Breathing Uneasy: Fit-Tested N95 Respirator Access in Washington State Long-Term Care Facilities

Long-term care facilities (LTCF) have been disproportionately impacted by illness and death from COVID-19. Shortages of respirators for staff, especially Particulate Filtering Facepiece Respirators (N95), have limited LTCFs ability to follow public health recommendations for preventing COVID-19 transmission. Use of N95 respirators was infrequent in Washington State (WA) LTCFs prior to May 2020. N95 respirators must be individually fit tested to provide intended protection; a fit test is a procedure that tests the seal between the N95 respirator and the wearer’s face. The WA Department of Health (WA DOH), collaborated with stakeholders to survey LTCFs in November 2020 regarding needs for fit tested respirators and analyzed responses (n=384). Responses by facility type: 8.3% nursing homes, 17.7% assisted living, 62.8% adult family home, 11.2% other. In WA, adult family homes (AFH) are licensed for six or fewer residents. 23.70% of LTCFs indicated they did not have any N95 respirators in stock at their facility; 96.7% of these were AFH. In August 2020 WA DOH surveyed AFH owners and received 110 responses; 9.76% reported having at least one staff member fit tested for respirators. Smaller facilities may experience increased burden in accessing N95 respirators and fit testing due to lack of established relationships with suppliers and small volumes being purchased. WA DOH used federal COVID funding to contract with mobile fit testing providers and prioritized AFHs for this service. Between December 1, 2020-February 28, 2021, staff at 290 LTCFs were fit tested. The project will continue throughout 2021.

Disparities in Access to Radiation Oncology Facilities Among American Indian/Alaska Natives and Hispanics in Metro and Non-Metro Washington State

Racial and ethnic minorities in Washington State (WA) experience higher cancer mortality relative to whites. We sought to characterize differences in travel distance as a marker for access to radiation therapy (RT) facilities in WA and one possible contributing factor to cancer disparities.Geocoded mortality data from the WA Department of Health (2011-2018) were used to identify decedents with mortality related to all causes, all cancers, and cancers likely requiring access to RT (defined as estimated RT usage rate > 50% by anatomical subsite corresponding to ICD-9 or 10 code). Race was defined per US Office of Management and Budget 1997 standard and ethnicity as Hispanic or non-Hispanic. RT facility locations were identified from the Directory of Radiotherapy Centers and validated by internet search or phone calls. Road network distance from decedent's residence to nearest RT facility was calculated on a geographic information platform. Generalized mixed models were used for statistical analysis.We identified 109,134 cancer-related deaths of which 60,973 likely required RT. Among decedents with cancers likely requiring RT, non-Hispanic (NH) American Indian/Alaskan Native (AI/AN) decedents would have had to travel 1.16 times (95% CI 1.09-1.24) farther to reach the nearest treatment facility compared to NH whites. This association existed in metro counties but was more pronounced in non-metro and rural counties, where NH AI/ANs would have had to travel 1.39 times farther compared to NH whites (95% CI 1.22 - 1.58). This translated to an average of 83 miles (SD = 22) for NH AI/AN in rural areas to travel to RT centers whereas NH Whites in rural areas would have had to travel on average 59 miles (SD = 28). Hispanics would have had to travel 1.11 times farther to reach the nearest facility compared to NH whites (95% CI 1.06 - 1.16), primarily due to differences in urban areas. NH African American, NH Asian, and NH Native Hawaiian decedents lived closer to RT facilities compared to the NH white decedents. Based on our findings, we estimated that expanding the federal "safe harbor" restrictions on health systems providing transportation from 50 to 75 miles could open up needed services for 96% of rural NH AI/ANs.NH AI/ANs and rural decedents experience stark disparities in access to RT facilities in WA state. The findings call for creative initiatives to improve access to critical cancer treatment services to combat racial, ethnic and rural disparities in cancer deaths. In depth analysis of local barriers to access for minority communities is necessary to devising practical solutions such as advocating for policy change for "safe harbor" restrictions.

Navigating the Storm of COVID-19 Literature Through Academic-Practice Partnership in Washington State: The COVID-19 Literature Situation Report.

Shortly after the first COVID-19 case in the United States was identified in Washington, the Washington State Department of Health (WA DOH) determined that real-time knowledge of scientific findings related to SARS-CoV-2 was critical for an effective response. Epidemiologists at the WA DOH established the Daily Literature Situation Report (Lit Rep), within the agency's incident management team, to support public health and state leaders in evidence-based decision making. However, from January to May, the scale of the pandemic response and daily volume of emerging information grew beyond the capacity of the WA DOH epidemiology team tasked with gathering, reviewing, summarizing, and disseminating it daily. To ensure public health leaders maintained awareness of the rapidly evolving scientific literature during the pandemic to support evidence-based practice. The WA DOH contracted the University of Washington (UW) Alliance for Pandemic Preparedness to assemble a team of faculty and students to continue producing the Lit Rep. In addition to the daily Lit Rep, the UW team developed in-depth reports addressing questions from public health leadership and further evolved the methodology for the daily reports to support long-term sustainability and broader accessibility. Throughout its existence, the Lit Rep had summarized more than 4300 articles from more than 150 000 citations and had more than 5600 subscribers from public health practice, academia, and the general public, both domestic and international. The flexible Lit Rep model sets a standard for responding to emerging public health threats and communicating complex scientific information to government leaders, public health staff, and other interested parties. The WA DOH and the UW have exemplified how a mutually beneficial partnership can be established to support more effective public health practice based on real-time evidence both during a crisis and potentially for future public health challenges.

Determining the DNA Fingerprinting Profiles of Salmonella Isolates from Raw Poultry Meats and Human Clinical Samples from the Same Geographic Area Using Pulsed-Field Gel Electrophoresis

Foods of animal origin, such as poultry, eggs, and pork, are recognized sources of Salmonella infections, but determination of the proportion of foodborne infections associated with various food sources has been challenging. In the present study, 141 Salmonella isolates recovered from 1,322 poultry product samples purchased over a 1-year period from retail stores across Seattle, WA were subtyped by pulsed-field gel electrophoresis (PFGE) using restriction enzyme XbaI. The objectives of the study were (i) to analyze the longitudinal distribution of Salmonella PFGE profiles throughout the sampling period and their clonality within and between poultry processing establishments, (ii) to determine the association between PFGE profiles of Salmonella isolates from locally distributed poultry products and those of clinical isolates submitted to the Washington State Department of Health (WA-DOH) laboratories, and (iii) to compare the PFGE profiles of Salmonella isolates from the National Antimicrobial Resistance Monitoring System (NARMS) retail meats program. During the 1-year sampling period, multiple indistinguishable PFGE patterns were found across multiple poultry processing establishments. Twelve of the 30 unique PFGE profiles of Salmonella isolates from locally purchased poultry products were indistinguishable from the PFGE profiles of clinical Salmonella isolates submitted to the WA-DOH. When the PFGE profiles from the poultry samples were compared with those found in the NARMS database, eight indistinguishable PFGE matches were found with isolates recovered from chicken breasts, ground turkey, and ground beef from multiple states. Although this study revealed some association between PFGE profiles from raw poultry products and those of clinical isolates from the same geographical area, these results do not prove that all of those clinical isolates were from infections acquired through consumption or handling of poultry.

COVID-19 Surveillance and Investigations in Workplaces - Seattle & King County, Washington, June 15-November 15, 2020.

Workplace activities involving close contact with coworkers and customers can lead to transmission of SARS-CoV-2, the virus that causes COVID-19 (1,2). Information on the approach to and effectiveness of COVID-19 workplace investigations is limited. In May 2020, Public Health - Seattle & King County (PHSKC), King County, Washington established a COVID-19 workplace surveillance and response system to enhance COVID-19 contact tracing and identify outbreaks in workplaces. During June 15-November 15, 2020, a total of 2,881 workplaces in King County reported at least one case of COVID-19. Among 1,305 (45.3%) investigated workplaces,* 524 (40.3%) met the definition of a workplace outbreak.† Among 306 (58.4%) workplaces with complete data,§ an average of 4.4 employee COVID-19 cases¶ (median=three; range=1-65) were identified per outbreak, with an average attack rate among employees of 17.5%. PHSKC and the Washington State Department of Health optimized resources by establishing a classification scheme to prioritize workplace investigations as high, medium, or low priority based on workplace features observed to be associated with increased COVID-19 spread and workforce features associated with severe disease outcomes. High-priority investigations were significantly more likely than medium- and low-priority investigations to have two or more cases among employees (p<0.001), two or more cases not previously linked to the workplace (p<0.001), or two or more exposed workplace contacts not previously identified during case interviews (p = 0.002). Prioritization of workplace investigations allowed for the allocation of limited resources to effectively conduct workplace investigations to limit the potential workplace spread of COVID-19. Workplace investigations can also serve as an opportunity to provide guidance on preventing workplace exposures to SARS-CoV-2, facilitate access to vaccines, and strengthen collaborations between public health and businesses.

COVID-19 Outbreak Among Farmworkers - Okanogan County, Washington, May-August 2020.

Okanogan County, Washington, experienced increased community transmission of SARS-CoV-2, the virus that causes COVID-19, during summer 2020 (1). Multiple COVID-19 outbreaks occurred in agricultural settings, including a large outbreak among employees of a fruit grower during May-August. Because of this outbreak, Okanogan County Public Health and the Washington State Department of Health initiated one-time, on-site screening testing (2) of all orchard and warehouse employees in August 2020 and assessed risk factors for SARS-CoV-2 infection. Among 3,708 known orchard employees, a valid SARS-CoV-2 test result or information on COVID-19-like symptoms in the absence of a test was available for 3,013 (81%). Cumulative incidence of SARS-CoV-2 infection during approximately 3 months among tested orchard employees was 6%. Cumulative incidence was 12% in employees residing in the community, compared with 4% in employees residing in farmworker housing (p<0.001); point prevalence during the single screening testing event was 1% in both groups. Among 1,247 known warehouse employees, a valid result was available for 726 (58%). Cumulative incidence over approximately 3 months among tested warehouse employees was 23%, with substantial variation across job roles. Positive test results were received by 28% of employees who worked packing and sorting fruit, 24% of those in other roles in the packing and sorting area, 10% of forklift operators, 7% of employees in other warehouse roles, and 6% of office employees. Point prevalence among all warehouse workers was 1% at the screening testing event. Collaboration among employers, community groups, and public health authorities can reveal risk factors and help decrease farmworkers' risk for SARS-CoV-2 infection in the community and the workplace. Creation of a COVID-19 assessment and control plan by agricultural employers, with particular focus on indoor workers whose jobs limit physical distancing, could reduce workplace transmission.

The Essential Role of Nurse Practitioners and Midwives on Maternal Mortality Review Committees

Rates of maternal morbidity and mortality in the United States continue to rise, and three out of every five U.S. pregnancy-related deaths are preventable. A multiprong approach to addressing this public health crisis is needed, including the development and activation of maternal mortality review committees, which can systematically assess maternal deaths and recommend systemic-based interventions and policy changes to reverse this trend. Women’s health nurse practitioners and midwives are uniquely positioned to provide insight to maternal mortality review committees, given their holistic approach and person-centered philosophy of care. The Washington State Department of Health developed a robust committee that uses women’s health nurse practitioners and midwives in its review and may serve as a model for other state organizations.

Creating a Suicide Prevention Program for Farmers and Farmworkers

In 2018 the Washington State legislature passed Substitute House Bill 2671 to address suicide in the agriculture industry, and Washington State University Skagit County Extension was selected by the Washington State Department of Health to develop a suicide prevention pilot program for farmers and farmworkers. In the initial stage from March to September 2019, program efforts included collaborating with suicide prevention and behavioral health experts, building institutional capacity (bilingual English–Spanish material and website creation), and leveraging the Extension platform. We provide a roadmap for other Extension entities looking to create suicide prevention programs.

Long COVID guidelines need to reflect lived experience

Since May, 2020,1Garner P Covid-19 and fatigue—a game of snakes and ladders.BMJ Blogs. May 19, 2020; https://blogs.bmj.com/bmj/2020/05/19/paul-garner-covid-19-and-fatigue-a-game-of-snakes-and-ladders/Date accessed: December 10, 2020Google Scholar increasing attention has been given to the experiences of people with COVID-19 whose symptoms persist for 4 or more weeks. According to the Office for National Statistics (ONS), an estimated 186 000 people (95% CI 153 000–221 000) in private households in England currently have COVID-19 symptoms 5–12 weeks or longer after acute infection.2Office for National StatisticsThe prevalence of long COVID symptoms and COVID-19 complications.https://www.ons.gov.uk/news/statementsandletters/theprevalenceoflongcovidsymptomsandcovid19complicationsDate: Dec 16, 2020Date accessed: December 16, 2020Google Scholar The ONS estimate that one in five people have symptoms that persist after 5 weeks, and one in ten have symptoms for 12 weeks or longer after acute COVID-19 infection.2Office for National StatisticsThe prevalence of long COVID symptoms and COVID-19 complications.https://www.ons.gov.uk/news/statementsandletters/theprevalenceoflongcovidsymptomsandcovid19complicationsDate: Dec 16, 2020Date accessed: December 16, 2020Google Scholar Research on long COVID is growing, including into the underlying pathology, consequences, and sequelae, as well as rehabilitation for patients. Evidence suggests that a considerable proportion of people with long COVID have severe complications.3Greenhalgh T Knight M A’Court C Buxton M Husain L Management of post-acute covid-19 in primary care.BMJ. 2020; 370m3026Crossref PubMed Scopus (676) Google Scholar, 4Puntmann VO Carerj ML Wieters I et al.Outcomes of cardiovascular magnetic resonance imaging in patients recently recovered from coronavirus disease 2019 (COVID-19).JAMA Cardiol. 2020; 5: 1265-1273Crossref PubMed Scopus (1093) Google Scholar, 5Libby P Luscher T COVID-19 is, in the end, an endothelial disease.Eur Heart J. 2020; 41: 3038-3044Crossref PubMed Scopus (446) Google Scholar We have lived experiences of long COVID, with a range of symptoms lasting for more than 6 months. Staff in the UK National Health Service (NHS) have been variously supportive or disbelieving of our ongoing, often worsening, symptoms. Before our illness we were fit, healthy, and working in demanding roles, including as doctors, nurses, and other health professionals. Our symptoms of acute COVID-19 included dyspnoea, dry cough, fever, anosmia, and debilitating fatigue. Throughout 2020 we also experienced other symptoms and conditions, never experienced before our acute illnesses (panel). All of these conditions began during, or shortly after, acute COVID-19. We each are experiencing different patterns and varied severity of symptoms; we all share difficulties accessing adequate health-care services; some of us have received misguided assessment and treatment in some of the UK's recently established long COVID clinics and encountered dismissive behaviour from some health professionals.6Lokugamage A Taylor S Rayner C Patients’ experiences of “longcovid” are missing from the NHS narrative.BMJ Blog. July 10, 2020; https://blogs.bmj.com/bmj/2020/07/10/patients-experiences-of-longcovid-are-missing-from-the-nhs-narrative/Date accessed: December 10, 2020Google Scholar, 7Jensen L “Just stay at home” was lonely and terrifying.BMJ. 2020; 371m3807Crossref PubMed Scopus (3) Google Scholar, 8Lokugamage AU Bowen MA Blair J Long covid: doctors must assess and investigate patients properly.BMJ. 2020; 371m4583Crossref PubMed Scopus (7) Google Scholar We share these experiences with thousands of people we engage with in rapidly growing online support groups.PanelConditions experienced by members of the UK doctors #longcovid group•Myocarditis or pericarditis•Microvascular angina•Cardiac arrhythmias, including atrial flutter and atrial fibrillation•Dysautonomia, including postural orthostatic tachycardia syndrome•Mast cell activation syndrome•Interstitial lung disease•Thromboembolic disease (pulmonary emboli or cerebral venous thrombosis)•Myelopathy, neuropathy, and neurocognitive disorders•Renal impairment•New-onset diabetes and thyroiditis•Hepatitis and abnormal liver enzymes•New-onset allergies and anaphylaxis•Dysphonia •Myocarditis or pericarditis•Microvascular angina•Cardiac arrhythmias, including atrial flutter and atrial fibrillation•Dysautonomia, including postural orthostatic tachycardia syndrome•Mast cell activation syndrome•Interstitial lung disease•Thromboembolic disease (pulmonary emboli or cerebral venous thrombosis)•Myelopathy, neuropathy, and neurocognitive disorders•Renal impairment•New-onset diabetes and thyroiditis•Hepatitis and abnormal liver enzymes•New-onset allergies and anaphylaxis•Dysphonia We were encouraged by the announcement, on Oct 5, 2020, that the National Institute for Health and Care Excellence (NICE), the Scottish Intercollegiate Guidelines Network (SIGN), and the Royal College of General Practitioners (RCGP) were developing “a guideline on persistent effects of COVID-19 (long COVID) on patients”,9National Institute for Health and Care ExcellenceNICE & SIGN announce latest rapid Covid-19 guideline will address long Covid.https://www.nice.org.uk/news/article/nice-sign-announce-latest-rapid-covid-19-guideline-will-address-long-covidDate: Oct 5, 2020Date accessed: December 10, 2020Google Scholar consulting with a broad range of professional groups and some people with long COVID. The final NICE–SIGN–RCGP guideline, published on Dec 18, 2020,10National Institute for Health and Care ExcellenceRoyal College of General PractitionersHealthcare Improvement Scotland SIGNCOVID-19 rapid guideline: managing the long-term effects of COVID-19. National Institute for Health and Care Excellence, London2020www.nice.org.uk/guidance/ng188Date accessed: December 18, 2020Google Scholar should provide clear information on what is and is not known about the natural history of long COVID, provide guidance for health-care workers to identify cases, and inform clinical practice for the correct management of people with symptoms. Accurate assessment, diagnosis, treatment, and rehabilitation are especially important given the increasing evidence of organ pathology and impairment,11Iacobucci G Long Covid: damage to multiple organs presents in young, low risk patients.BMJ. 2020; 371m4470Crossref Google Scholar with preliminary findings from 201 patients in a prospective, longitudinal, observational study suggesting up to 66% of people with long COVID have organ damage and 25% have damage to multiple organs.12Dennis A Wamil M Kapur S Alberts J Badley AD Multi-organ impairment in low-risk individuals with long COVID.medRxiv. 2020; (published online Oct 16.) (preprint)https://doi.org/10.1101/2020.10.14.20212555Google Scholar In our view, the NICE guideline10National Institute for Health and Care ExcellenceRoyal College of General PractitionersHealthcare Improvement Scotland SIGNCOVID-19 rapid guideline: managing the long-term effects of COVID-19. National Institute for Health and Care Excellence, London2020www.nice.org.uk/guidance/ng188Date accessed: December 18, 2020Google Scholar does not do this sufficiently. We are disappointed that the guideline does not adequately address the following issues. First, the guideline needs to provide a more comprehensive description of the clinical features and physical nature of long COVID. Although we recognise that this is a “living guideline” that will evolve with increasing information on the condition, the clinical case definition of long COVID in the guideline does not adequately describe the varied symptoms experienced beyond the limited number of symptoms and signs listed in an annex towards the end of the guideline. Although the guideline notes that symptoms may fluctuate and often present as overlapping clusters, there is insufficient consideration of the apparent relapsing–remitting nature of the condition, which risks patients being discharged from clinics during a time of remittance of symptoms but before resolution of the condition. Although we value the holistic and multidisciplinary approach of the guideline, a greater emphasis on the broad range of symptoms would assist clinicians in the assessment, diagnosis, and treatment of physical complaints associated with long COVID,3Greenhalgh T Knight M A’Court C Buxton M Husain L Management of post-acute covid-19 in primary care.BMJ. 2020; 370m3026Crossref PubMed Scopus (676) Google Scholar, 13Ross JM Seiler J Meisner J et al.COVID-19 Literature Report Team: summary of COVID-19 long-term health effects: emerging evidence and ongoing investigation. Washington State Department of Health, 2020https://globalhealth.washington.edu/sites/default/files/COVID-19%20Long%20Term%20Effects%20Summary.pdfDate accessed: December 10, 2020Google Scholar, 14PAHOWHOEpidemiological alert: complications and sequelae of COVID-19.https://www.paho.org/en/documents/epidemiological-alert-complications-and-sequelae-covid-19-12-august-2020Date: Aug 12, 2020Date accessed: December 10, 2020Google Scholar and the need for ongoing monitoring and repeated investigations of symptoms. The guideline is overly focused on self-management, psychological support, and rehabilitation, resulting in the potential for “watered-down” versions of NHS long COVID clinics that do not provide thorough physical assessment of patients. Second, the guideline does not sufficiently describe what is known about the underlying pathology and the natural history of long COVID. There is no mention of the three theories of persistent virus in immune-privileged sites, aberrant immune response, or autoimmunity.15British Society for ImmunologyLong-term immunological health consequences of COVID-19.https://www.immunology.org/sites/default/files/BSI_Briefing_Note_August_2020_FINAL.pdfDate: Aug 13, 2020Date accessed: December 10, 2020Google Scholar In the guideline there are implicit assumptions about the nature of long COVID, which could result in some likening it to post-viral fatigue and may lead to providers over-emphasising a psychological component. At the very early stage of any new disease, it is unwise to presume parallels with other conditions. This approach risks mismanagement and missed pathology. Research into the natural history of long COVID is in its infancy, yet the guideline does not satisfactorily address what is known about the complexities of the disease course, including development of new symptoms and severe abnormalities months after the acute phase of COVID-19.16Paterson RW Brown RL Benjamin L et al.The emerging spectrum of COVID-19 neurology: clinical, radiological and laboratory findings.Brain. 2020; 143: 3104-3120Crossref PubMed Scopus (598) Google Scholar Instead, the guideline introduces new definitions and nomenclature for different phases of COVID-19 without any clear rationale, defining acute COVID-19 (signs and symptoms of COVID-19 for up to 4 weeks), ongoing symptomatic COVID-19 infection (signs and symptoms of COVID-19 from 4 to 12 weeks), and post-COVID-19 syndrome (signs and symptoms that develop during or after an infection consistent with COVID-19, continue for more than 12 weeks, and are not explained by an alternative diagnosis). This seemingly arbitrary construct implies a linear course and risks damaging patient care by creating barriers to services and investigations. Third, in developing the guideline we believe a more thorough participative and open process was needed to consider and determine appropriate terminology by involving a broad range of experts, including people with lived experience. Although the guideline acknowledges that “the term ‘long COVID’ is commonly used”, the use of new nomenclature in the NICE guideline, notably the use of the term post-COVID-19 syndrome, is in our view rooted in unfounded assumptions about the pathology and not grounded in evidence. When explaining the rationale for terms used in the guideline, no evidence is provided beyond vague assertions—eg, “most people's symptoms will resolve before 12 weeks”—and it does not engage with the fact that the term “post-COVID” does not accord with what is understood about the natural history of long COVID. Despite the explanation given for the choice of “post-COVID-19 syndrome”, some will interpret this new terminology as suggestive of some degree of recovery, and this is not borne out by what is currently known about the natural history of long COVID. We believe the guideline should have paused on introducing new nomenclature until WHO convenes an inclusive consultation process to ensure that terminology for illness beyond the 4-week acute period is scientifically, culturally, and politically accurate, and facilitates access to care for people with long-term symptoms. WHO is expected to update its guidance on the clinical management of COVID-19 to include long COVID, and this will be a timely opportunity to secure global agreement on the correct approach to clinical case definition and terminology.17The LancetFacing up to long COVID.Lancet. 2020; 3061861Summary Full Text Full Text PDF Scopus (106) Google Scholar We look forward to this “living guideline” taking into account future WHO guidance, including on clinical case definition and terminology, and fully incorporating the perspectives and expertise of the hundreds of thousands of people who are living with long COVID, many of whom have substantial clinical experience alongside lived experience. Only then can health-care providers deliver the best possible care, assessment, diagnosis, and treatment in partnership with the growing population of people living with long COVID. To tackle this new and complex condition optimally, we propose that all clinics caring for people with persisting symptoms after acute COVID-19 provide a thorough physical assessment by a consultant physician from a medical specialty, addressing first and foremost identification and management of any organ or multisystem dysfunction. Psychological aspects of disease should be managed as part of the recovery process, but not seen as the primary treatment focus for all. Individualised rehabilitation plans are crucial—not a one-model-fits-all approach. Long COVID health-care services are also needed for children and young people. There should be greater inclusion of people with long COVID in clinical trials for potential COVID-19 treatments, including early interventions in the acute phase to prevent long-term complications, and there is a need for more long-term cohort studies of long COVID. Additionally, a nationwide register should be established of people with long COVID, and governments should report the data from this register with COVID-19 outcome data. Guidelines must represent the complexity of long COVID, including the areas where evidence is still emerging. Hasty attempts to rename the condition or compare it to other conditions is a disservice to thousands of people, and could result in missed pathology to the detriment of the patient. Comprehensive long COVID guidelines are essential to prevent an epidemic of long-term, chronic disease as a result of early mismanagement of pathology, and the potential implications of such an epidemic for health systems and economies. RG is a member of the NHS Long Covid Taskforce, the Long Covid Support Group, and a Global Fund TRP Focal Point. NM receives funding from the National Institute for Health Research and is a member of the UK doctors #longcovid group. CR is a member of UK doctors #longcovid group, Long Covid Support Group, and the NHS Long Covid Taskforce. MO’H, SE, LA, NR, and CH are members of the Long Covid Support Group and the NHS Long Covid Taskforce; all were part of a stakeholder group that commented on the NICE long COVID draft guidance, as did RG, NM, and CR. WN is Honorary Assistant Professor at the London School of Hygiene & Tropical Medicine and a co-founder of PRePster, a not-for-profit advocacy group for PrEP access. UK guidelines for managing long-term effects of COVID-19Robin Gorna and colleagues1 state that people with lived experience should have been involved in developing the National Institute for Health and Care Excellence (NICE), the Scottish Intercollegiate Guidelines Network (SIGN), and the Royal College of General Practitioners (RCGP) guideline on managing the long-term effects of COVID-19. The expert advisory panel for developing the NICE–SIGN–RCGP guideline had 23 members who contributed substantial clinician and patient experience to discussions.2 Two stakeholder consultations were held and the guideline was adapted in response to feedback from patient-led, health, and care organisations. Full-Text PDF

Adding Life to Years: Adopting Age-Friendly Public Health in Washington State

Age-Friendly Public Health is an emerging concept and practice aiming to equip the public health infrastructure to more readily address aging issues. In 2019, the Washington State Department of Health (WA DOH), began operationalizing Age-Friendly Public Health within the agency. Work entailed bringing together a cross-agency workgroup on healthy aging and drawing on expertise from agency programs including environmental health, immunizations, falls prevention, emergency preparedness, chronic disease and many others. The workgroup conducted an internal assessment of ‘touch points’ regarding aging work within WA DOH. The Life Course Perspective was used as a theoretical framework to categorize current efforts, and existing research on social determinants of health in aging were used to identify potential areas for future impact. In addition, the Healthy Brain Initiative (HBI) Road Map for public health was used to identify current and potential approaches to addressing Alzheimer’s Disease and Related Dementias. This workgroup inventoried WA DOH’s current efforts that align with the HBI agenda, and identified 88 opportunities to promote healthy aging and brain health. This work contributes to the emerging field of Age-Friendly Public Health by demonstrating strengths and challenges of advancing healthy aging through state public health agencies.

Estimation of differential occupational risk of COVID-19 by comparing risk factors with case data by occupational group.

BackgroundThe disease burden of coronavirus disease 2019 (COVID‐19) is not uniform across occupations. Although healthcare workers are well‐known to be at increased risk, data for other occupations are lacking. In lieu of this, models have been used to forecast occupational risk using various predictors, but no model heretofore has used data from actual case numbers. This study assesses the differential risk of COVID‐19 by occupation using predictors from the Occupational Information Network (O*NET) database and correlating them with case counts published by the Washington State Department of Health to identify workers in individual occupations at highest risk of COVID‐19 infection.MethodsThe O*NET database was screened for potential predictors of differential COVID‐19 risk by occupation. Case counts delineated by occupational group were obtained from public sources. Prevalence by occupation was estimated and correlated with O*NET data to build a regression model to predict individual occupations at greatest risk.ResultsTwo variables correlate with case prevalence: disease exposure (r = 0.66; p = 0.001) and physical proximity (r = 0.64; p = 0.002), and predict 47.5% of prevalence variance (p = 0.003) on multiple linear regression analysis. The highest risk occupations are in healthcare, particularly dental, but many nonhealthcare occupations are also vulnerable.ConclusionsModels can be used to identify workers vulnerable to COVID‐19, but predictions are tempered by methodological limitations. Comprehensive data across many states must be collected to adequately guide implementation of occupation‐specific interventions in the battle against COVID‐19.